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1 **** BILL NO. ****
2 INTRODUCED BY ****
3
4 A BILL FOR AN ACT ENTITLED: “AN ACT REVISING HEALTH INSURANCE LAWS RELATING TO
5 CONSUMERS; CREATING THE PATIENT'S RIGHT TO SAVE ACT.”
6
7 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MONTANA:
8
9 NEW SECTION. Section 1. Short title. [Sections 1 through 3] may be cited as "The Patient's Right to
10 Save Act".
11
12
13 NEW SECTION. Section 2. Definitions. As used in [sections 1 through 3], unless the context
14 otherwise requires:
15 (1) “Collection action” means any of the following actions taken with respect to a debt for health
16 care services purchased from, or provided to a covered person by, a health care provider on a date on which
17 the health care provider was not in material compliance with this chapter:
18 (a) attempting to collect a debt from a covered person or a covered person’s guarantor by referring
19 the debt, directly or indirectly, to a debt collector, a collection agency, or other third-party retained by or on
20 behalf of the health care provider.
21 (b) suing a covered person or a covered person’s guarantor, or enforcing an arbitration or
22 mediation clause in a health care provider’s contract, agreement, statement, or bill.
23 (c) directly or indirectly causing a report to be made to a consumer reporting agency.
24 (2) “Collection agency” means a person that regularly collects or attempts to collect, directly or
25 indirectly, debts owed, due, or asserted to be owed or due; that takes assignment of debts for collection
26 purposes; or that directly or indirectly solicits for collection debts owed, due, or asserted to be owed or due.
27 (3) “Consumer reporting agency” means a person that for monetary fees, dues, or on a Commented [JW1]: This is defined in 33-18-604.
28 cooperative nonprofit basis, regularly engages in assembling or evaluating consumer credit information, or
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1 other consumer information, for the purpose of providing consumer reports to third parties, and that uses any
2 means or facility of interstate commerce for the purpose of preparing or furnishing consumer reports.
3 “Consumer reporting agency” does not include any person that only provides check verification or check
4 guarantee services.
5 (4) “Cost-sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-
6 pocket expense obligation imposed on a covered person by a policy, contract, or plan providing for third-party
7 payment or prepayment of health or medical expenses.
8 (5) “Covered person” means the same as provided in 33-22-1902.
9 (6) “Debt” means an obligation or alleged obligation of a consumer to pay money arising out of a
10 transaction, whether or not the obligation has been reduced to judgment. “Debt” does not include a consumer
11 debt incurred for business, investment, commercial, or agricultural purposes, or a debt incurred by a business.
12 (7) “Debt collector” means a person employed or engaged by a collection agency to perform debt
13 collection.
14 (8) “Deidentified minimum negotiated charge” means the lowest charge for a specific health care
15 service that a health care provider has negotiated with a health carrier.
16 (9) “Discounted cash price” means the price an individual pays for a specific health care service if
17 the individual pays for the health care service with cash or a cash equivalent.
18 (10) “Health benefit plan” means the same as defined in 33-22-1902.
19 (11) “Health care provider” means a physician or other health care practitioner licensed, accredited,
20 registered, or certified to perform specified health care services consistent with state law, an institution
21 providing health care services, a health care setting, including but not limited to a hospital or other licensed
22 inpatient center, an ambulatory surgical or treatment center, a skilled nursing center, a residential treatment
23 center, a diagnostic, laboratory and imaging center, or a rehabilitation or other therapeutic health setting.
24 (12) “Health care services” means the same as defined in 33-22-1703.
25 (13) “Health carrier” means the same as defined in section 33-1-801. Commented [JW2]: There is also a definition in 33-2-
2402 for “health carrier” - See which one you would
26 (14) “Pharmacist” means the same as defined in section 33-20-170. like.
27 (15) “Pharmacy” means the same as defined in section 33-2-2402.
28
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1
2 NEW SECTION. Section 3. Health care services -- cost control. (1) (a) All health care providers
3 shall establish and disclose the discounted cash price the health care provider will accept for specific health
4 care services. The disclosure must specify if the discounted cash price varies due to different circumstances,
5 including but not limited to the day or time a health care service is provided, the office or location at which the
6 health care service is provided, how quickly an individual pays the discounted cash price for a health care
7 service the individual received, the income level of the individual who received the health care service, or the
8 ancillary services or amenities provided to an individual at the same time the health care service is provided.
9 The discounted cash price shall be available to all covered persons and to all uninsured individuals.
10 (b) A health carrier shall post all discounted cash prices via a secure internet site that is easily
11 accessible to all covered persons. A health carrier shall update any change in a discounted cash price within
12 five calendar days of the change and shall review each discounted cash price at least annually.
13 (c) (i) During the appointment scheduling process, and any intake process prior to the provision of a
14 health care service, covered persons and uninsured individuals shall be informed of their right to pay for the
15 health care service via the discounted cash price.
16 (ii) During the appointment scheduling process, and any intake process prior to the provision of a
17 health care service, a covered person shall be advised that they qualify for a deductible credit if they have not
18 exceeded their deductible to date, and all of the following are true:
19 (A) the covered person pays the discounted cash price for the health care service.
20 (B) the discounted cash price is below the deidentified minimum negotiated charge for the specific
21 health care service that the covered person will receive.
22 (d) a health carrier may not enter into a contract that prevents the health carrier from offering a
23 discounted cash price below the contracted rates the health carrier has with other commercial or public payors,
24 or that prevents the health carrier from disclosing the health carrier’s discounted cash price under subsection
25 (1)(b).
26 (e) a covered person’s out-of-pocket pricing for each prescription drug on a health carrier’s
27 formulary shall be available to a health care provider via an easily accessible and secure internet site hosted by
28 the health carrier at the point the health care provider prescribes prescription drugs to the covered person.
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1 (2) Each health benefit plan shall disclose to the health benefit plan’s covered persons the
2 deidentified minimum negotiated charge for each health care service that is covered under the covered
3 person’s health benefit plan. If a health benefit plan fails to disclose each deidentified minimum negotiated
4 charge, a covered person may substitute a benchmark selected by the commissioner for the deidentified
5 minimum negotiated charge.
6 (3) A covered person who elects to receive a covered health care service at a discounted cash
7 price that is below the deidentified minimum negotiated charge shall receive credit toward the covered person’s
8 cost-sharing as specified in the covered person’s health benefit plan, as if the health care service is provided by
9 an in-network health care provider.
10 (4) A health benefit plan may not discriminate in the form of payment for any covered in-network
11 health care service solely on the basis that the covered person was referred for the health care service by an
12 out-of-network health care provider.
13 (5) (a) If a covered person elects to use a pharmacy discount program, a drug manufacturer’s rebate,
14 or other discount or rebate program that results in a lower cost for a covered prescription drug than if the
15 covered person uses their health benefit plan, the health benefit plan shall apply any payments made by the
16 covered person for the covered prescription drug to the covered person’s cost-sharing as specified in the
17 covered person’s health benefit plan as if the covered person purchased the prescription drug from a network
18 pharmacy using the covered person’s health benefit plan. The health benefit plan shall credit the value of the
19 rebate or other discount toward the covered person’s cost-sharing for health care services that are covered or
20 that are considered formulary under the covered person’s health benefit plan. The health benefit plan may
21 credit the value of the rebate or other discount toward the covered person’s cost-sharing for health care
22 services that are not covered or that are considered nonformulary under the covered person’s health benefit
23 plan. This subsection may not be construed to restrict a health benefit plan from requiring a preauthorization or
24 other precertification normally required by the health benefit plan.
25 (b) A health benefit plan shall provide a downloadable or interactive online form for a covered
26 person to submit proof of payment under subsection (5)(a) and shall annually inform covered persons of their
27 options under this subsection.
28 (6) Annually at enrollment or renewal, a health carrier shall provide notice to covered persons via
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1 the health carrier’s health benefit plan materials and the health carrier’s internet site of the option, and the
2 process, to receive a covered health care service at a discounted cash price below the deidentified minimum
3 negotiated charge.
4 (7) If a covered person pays a discounted cash price that is above the deidentified minimum
5 negotiated charge, the health benefit plan shall credit the covered person’s cost-sharing an amount equal to the
6 discounted cash price.
7 (8) (a) If a health carrier denies a claim submitted by a covered person pursuant to this chapter, the
8 health carrier shall notify the commissioner and provide evidence to support the denial to the covered person
9 and to the commissioner.
10 (b) A covered person may appeal a claim denial to the commissioner within sixty calendar days of
11 the denial. The appeal shall be adjudicated within thirty calendar days of the covered person’s request for an
12 appeal. If the commissioner determines that the health carrier improperly denied the covered person’s claim,
13 the health carrier shall pay the covered person’s costs and attorney fees associated with the appeal, shall
14 accept the covered person’s claim, and shall provide cash compensation to the covered person in an amount
15 equal to the amount of the claim.
16 (c) If a health carrier denies twenty or more claims in any one quarter, the commissioner shall
17 have the authority to investigate the denials. If the commissioner finds that a health carrier has improperly
18 denied claims under this chapter, or committed an unfair or deceptive act or practice under Title 33, chapter 18.
19 (10) (a) For costs that exceed a covered person’s deductible, the covered person shall have access to
20 a program that directly rewards the covered person with a savings incentive for medically necessary covered
21 health care services received from health care providers that offer a discounted cash price below the
22 deidentified minimum negotiated charge. If a covered person exceeds the covered person’s annual deductible,
23 the covered person’s health benefit plan shall notify the covered person of the savings incentive program and
24 how the savings incentive program works.
25 (b) A covered person’s savings incentive for a specific health care service shall be calculated as
26 the difference between the discounted cash price and the deidentified minimum negotiated charge. A savings
27 incentive shall be divided equally between the covered person and the covered person’s health benefit plan,
28 and may include a cash payment to the covered person.
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1 (c) Savings incentives under this subsection may not be an administrative expense of the health
2 benefit plan for rate development or rate filing purposes.
3 (10) (a) A health care provider may not initiate or pursue a collection action against a covered person,
4 or a covered person’s guarantor, for a debt owed for a health care service unless the health care provider is in
5 material compliance with this chapter on the date that the health care provider provided the health care service
6 to the covered person.
7 (b) If a health care provider initiates or pursues a collection action in violation of this subsection
8 (10)(a), the covered person or the covered person’s guarantor may file for a declaratory judgment with a court
9 of competent jurisdiction and the health care provider may not continue the collection action against the
10 covered person, or the covered person’s guarantor, while the lawsuit is pending. If the court finds in favor of the
11 covered person, or the covered person’s guarantor, the court shall order the health care provider to do all of the
12 following:
13 (i) refund a payor any amount the payor paid for the debt that is the subject of the lawsuit.
14 (ii) pay a penalty to the covered person, or the covered person’s guarantor, in an amount equal to
15 the total amount of the debt that is the subject of the lawsuit.
16 (iii) dismiss with prejudice, or cause to be dismissed with prejudice, any court action related to the
17 collection action or the lawsuit.
18 (iv) pay any attorney fees and costs incurred by the covered person, or the covered person’s
19 guarantor, related to the collection action or the lawsuit.
20 (v) remove or cause to be removed from the covered person’s or the covered person’s guarantor’s
21 credit report any report made to a consumer reporting agency related to the debt that is the subject of the
22 lawsuit.
23 (11) Provided that a health care provider does not initiate or pursue a collection action in violation of
24 this chapter, this chapter may not be construed to prohibit a health care provider from billing a covered person,
25 a covered person’s guarantor, or a third-party payor including a health insurer, for health care services provided
26 to a covered person; or to require a health care provider to refund any payment made to the health care
27 provider for a health care service provided to a covered person.
28 (12) If a provision of this chapter or its a