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Senate
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319
-
Introduced
SENATE
FILE
319
BY
COMMITTEE
ON
HEALTH
AND
HUMAN
SERVICES
(SUCCESSOR
TO
SSB
1029)
A
BILL
FOR
An
Act
relating
to
certain
cost
controls
for
health
care
1
services.
2
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
3
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Section
1.
Section
507B.4,
subsection
3,
Code
2025,
is
1
amended
by
adding
the
following
new
paragraph:
2
NEW
PARAGRAPH
.
v.
Improper
denial
of
claims.
A
health
3
carrier
improperly
denying
claims
under
chapter
514M.
4
Sec.
2.
NEW
SECTION
.
514M.1
Short
title.
5
This
chapter
shall
be
known
and
may
be
cited
as
“The
6
Patient’s
Right
to
Save
Act”
.
7
Sec.
3.
NEW
SECTION
.
514M.2
Definitions.
8
As
used
in
this
chapter,
unless
the
context
otherwise
9
requires:
10
1.
“Average
allowed
amount”
means
the
average
of
all
11
contractually
agreed
upon
amounts
paid
by
a
health
benefit
12
plan
or
a
health
carrier
to
a
health
care
provider
or
other
13
entity
participating
in
the
health
carrier’s
network.
The
14
average
shall
be
calculated
according
to
payments
within
a
15
reasonable
amount
of
time
not
to
exceed
one
calendar
year.
The
16
commissioner
may
approve
methodologies
for
calculating
the
17
average
allowed
amount
that
are
based
on
any
of
the
following:
18
a.
A
specific
covered
person’s
health
plan.
19
b.
All
health
plans
offered
in
the
state
by
a
specific
20
health
carrier.
21
c.
Geographic
area.
22
2.
“Cost-sharing”
means
any
coverage
limit,
copayment,
23
coinsurance,
deductible,
or
other
out-of-pocket
expense
24
obligation
imposed
on
a
covered
person
by
a
policy,
contract,
25
or
plan
providing
for
third-party
payment
or
prepayment
of
26
health
or
medical
expenses.
27
3.
“Covered
benefits”
or
“benefits”
means
health
care
28
services
that
a
covered
person
is
entitled
to
under
the
terms
29
of
a
health
benefit
plan.
30
4.
“Covered
person”
means
a
policyholder,
subscriber,
31
enrollee,
or
other
individual
participating
in
a
health
benefit
32
plan.
33
5.
“Discounted
cash
price”
means
the
price
an
individual
34
pays
for
a
specific
health
care
service
if
the
individual
pays
35
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for
the
health
care
service
with
cash
or
a
cash
equivalent.
1
6.
“Health
benefit
plan”
means
a
policy,
contract,
2
certificate,
or
agreement
offered
or
issued
by
a
health
carrier
3
to
provide,
deliver,
arrange
for,
pay
for,
or
reimburse
any
of
4
the
costs
of
health
care
services.
5
7.
“Health
care
provider”
means
a
physician
or
other
6
health
care
practitioner
licensed,
accredited,
registered,
or
7
certified
to
perform
specified
health
care
services
consistent
8
with
state
law,
an
institution
providing
health
care
services,
9
a
health
care
setting,
including
but
not
limited
to
a
hospital
10
or
other
licensed
inpatient
center,
an
ambulatory
surgical
11
or
treatment
center,
a
skilled
nursing
center,
a
residential
12
treatment
center,
a
diagnostic,
laboratory,
and
imaging
center,
13
or
a
rehabilitation
or
other
therapeutic
health
setting.
14
8.
“Health
care
services”
means
services
for
the
diagnosis,
15
prevention,
treatment,
cure,
or
relief
of
a
health
condition,
16
illness,
injury,
or
disease.
17
9.
a.
“Health
carrier”
means
an
entity
subject
to
the
18
insurance
laws
and
regulations
of
this
state,
or
subject
19
to
the
jurisdiction
of
the
commissioner,
including
an
20
insurance
company
offering
sickness
and
accident
plans,
a
21
health
maintenance
organization,
a
nonprofit
health
service
22
corporation,
a
plan
established
pursuant
to
chapter
509A
23
for
public
employees,
or
any
other
entity
providing
a
plan
24
of
health
insurance,
health
care
benefits,
or
health
care
25
services.
26
b.
For
purposes
of
this
chapter,
“health
carrier”
does
not
27
include
an
entity
providing
any
of
the
following:
28
(1)
Coverage
for
accident-only,
or
disability
income
29
insurance.
30
(2)
Coverage
issued
as
a
supplement
to
liability
insurance.
31
(3)
Liability
insurance,
including
general
liability
32
insurance
and
automobile
liability
insurance.
33
(4)
Workers’
compensation
or
similar
insurance.
34
(5)
Automobile
medical-payment
insurance.
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(6)
Credit-only
insurance.
1
(7)
Coverage
for
on-site
medical
clinic
care.
2
(8)
Other
similar
insurance
coverage,
specified
in
3
federal
regulations,
under
which
benefits
for
medical
care
4
are
secondary
or
incidental
to
other
insurance
coverage
or
5
benefits.
6
c.
For
purposes
of
this
chapter,
“health
carrier”
does
not
7
include
an
entity
providing
benefits
under
a
separate
policy
8
including
any
of
the
following:
9
(1)
Limited
scope
dental
or
vision
benefits.
10
(2)
Benefits
for
long-term
care,
nursing
home
care,
home
11
health
care,
or
community-based
care.
12
(3)
Any
other
similar
limited
benefits
as
provided
by
the
13
commissioner
by
rule.
14
d.
For
purposes
of
this
chapter,
“health
carrier”
does
not
15
include
an
entity
providing
benefits
offered
as
independent
16
noncoordinated
benefits
including
any
of
the
following:
17
(1)
Coverage
only
for
a
specified
disease
or
illness.
18
(2)
A
hospital
indemnity
or
other
fixed
indemnity
19
insurance.
20
e.
For
purposes
of
this
chapter,
“health
carrier”
does
21
not
include
an
entity
providing
a
Medicare
supplemental
22
health
insurance
policy
as
defined
under
section
1882(g)(1)
23
of
the
federal
Social
Security
Act,
coverage
supplemental
to
24
the
coverage
provided
under
10
U.S.C.
ch.
55,
and
similar
25
supplemental
coverage
provided
to
coverage
under
group
health
26
insurance
coverage.
27
f.
For
purposes
of
this
chapter,
“health
carrier”
does
not
28
include
any
of
the
following:
29
(1)
The
department
of
health
and
human
services.
30
(2)
A
policy
or
contract
providing
a
prescription
drug
31
benefit
pursuant
to
42
U.S.C.
ch.
7,
subch.
XVIII,
part
D.
32
(3)
A
plan
offered
or
maintained
by
a
multiple
employer
33
welfare
arrangement
established
under
chapter
513D
before
34
January
1,
2022.
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10.
“Pharmacist”
means
the
same
as
defined
in
section
1
155A.3.
2
11.
“Pharmacy”
means
the
same
as
defined
in
section
155A.3.
3
Sec.
4.
NEW
SECTION
.
514M.3
Health
care
services
——
cost
4
controls.
5
1.
a.
All
health
care
providers
shall
disclose
the
6
discounted
cash
price
for
each
specific
health
care
service
for
7
which
the
health
care
provider
will
accept
cash
payment.
The
8
disclosure
shall
specify
if
the
discounted
cash
price
varies
9
due
to
different
circumstances,
including
but
not
limited
to
10
the
day
or
time
a
health
care
service
is
provided,
the
office
11
or
location
at
which
the
health
care
service
is
provided,
how
12
quickly
an
individual
pays
the
discounted
cash
price
for
a
13
health
care
service
the
individual
received,
the
income
level
14
of
the
individual
who
received
the
health
care
service,
or
15
the
ancillary
services
or
amenities
provided
to
an
individual
16
at
the
same
time
the
health
care
service
is
provided.
The
17
discounted
cash
price
shall
be
available
to
all
covered
persons
18
and
to
all
uninsured
individuals.
A
health
care
provider
may
19
satisfy
the
requirements
of
this
paragraph
by
complying
with
20
the
centers
for
Medicare
and
Medicaid
services
of
the
United
21
States
department
of
health
and
human
services
hospital
price
22
transparency
regulations
in
45
C.F.R.
pt.
180.
This
paragraph
23
shall
not
require
disclosure
of
a
discounted
cash
price
for
24
health
care
services
not
provided
by
a
health
care
provider.
25
b.
A
health
care
provider
shall
review
each
discounted
cash
26
price
under
paragraph
“a”
at
least
annually.
27
c.
Prior
to
the
provision
of
a
scheduled
health
care
service
28
that
has
a
discounted
cash
price,
a
health
care
provider
shall
29
inform
all
covered
persons
and
uninsured
individuals
of
the
30
right
of
the
covered
person
or
uninsured
individual
to
pay
31
for
a
health
care
service
via
the
discounted
cash
price.
The
32
notice
may
be
provided
electronically,
verbally,
in
writing,
or
33
posted
at
the
physical
location
of
the
health
care
provider.
34
The
notice
shall
include
a
statement
that
a
discounted
cash
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price
may
not
be
less
expensive
than
a
rate
negotiated
by
a
1
health
carrier,
and
that
a
covered
person
may
compare
the
rates
2
by
contacting
the
covered
person’s
health
carrier.
3
d.
To
encourage
a
direct
patient
to
health
care
provider
4
relationship,
a
health
care
provider
may
grant
a
discounted
5
cash
price
for
a
health
care
service
when
payment
for
the
6
health
care
service
is
made
promptly
within
the
time
limit
7
prescribed
by
the
health
care
provider
or
health
care
facility
8
rendering
the
health
care
service.
A
health
care
provider
9
offering
a
discounted
cash
price
shall
not
be
considered
in
10
violation
of
a
contract
provision
that
prohibits
different
11
prices
from
being
offered
to
different
individuals.
A
health
12
care
provider
that
offers
discounted
cash
prices
shall
not
13
permit
a
health
carrier
to
recover
a
past
payment
to
the
health
14
care
provider
based
on
a
price
difference
unless
the
past
15
health
care
service
violates
other
contract
provisions.
16
e.
A
health
care
provider
shall
not
enter
into
a
contract
17
that
prohibits
the
health
care
provider
from
offering
a
18
discounted
cash
price
below
the
contracted
rates
the
health
19
care
provider
has
with
a
health
carrier,
or
that
prohibits
the
20
health
care
provider
from
disclosing
the
health
care
provider’s
21
discounted
cash
price
under
paragraph
“b”
.
22
f.
A
health
carrier
shall
not
enter
into
a
contract
with
a
23
health
care
provider
that
prohibits
the
health
care
provider
24
from
offering
a
discounted
cash
price
below
the
contracted
25
rates
the
health
care
provider
has
with
a
health
carrier,
or
26
that
prohibits
the
health
care
provider
from
disclosing
the
27
health
care
provider’s
discounted
cash
price
under
paragraph
28
“b”
.
29
g.
A
covered
person’s
out-of-pocket
pricing
for
each
30
prescription
drug
on
a
health
carrier’s
formulary
shall
be
31
available
to
a
pharmacist
via
an
easily
accessible
and
secure
32
internet
site
hosted
by
the
health
carrier
at
the
point
the
33
pharmacist
fills
a
prescription
drug
to
the
covered
person.
34
h.
A
health
care
provider
shall
provide
an
individual
with
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an
itemized
list
of
all
health
care
services
provided
to
the
1
individual,
a
statement
that
the
individual
paid
out-of-pocket
2
for
the
health
care
services,
a
statement
that
the
health
care
3
provider
will
not
make
a
claim
against
a
health
carrier
for
4
payment
for
the
health
care
services
provided
to
the
individual
5
if
the
individual
is
a
covered
person,
and
a
statement
that
the
6
individual
may
contact
the
individual’s
health
benefit
plan
to
7
determine
if
the
individual
qualifies
for
a
deductible
credit,
8
and
for
instructions
on
applying
a
deductible
credit
to
the
9
individual’s
deductible
if
the
individual
is
a
covered
person.
10
2.
Each
health
benefit
plan
shall
disclose
to
the
health
11
benefit
plan’s
covered
persons
the
average
allowed
amount
for
12
each
health
care
service
that
is
covered
under
the
covered
13
person’s
health
benefit
plan.
If
a
health
benefit
plan
fails
14
to
disclose
the
average
allowed
amount
for
a
health
care
15
service,
a
covered
person
may
substitute
a
benchmark
selected
16
by
the
commissioner.
17
3.
A
covered
person
who
elects
to
receive
a
covered
health
18
care
service
at
a
discounted
cash
price
that
is
below
the
19
average
allowed
amount
shall
receive
credit
toward
the
covered
20
person’s
in-network
cost-sharing
as
specified
in
the
covered
21
person’s
health
benefit
plan,
as
if
the
health
care
service
is
22
provided
by
an
in-network
health
care
provider.
23
4.
A
health
benefit
plan
shall
not
discriminate
in
the
24
form
of
payment
for
any
covered
in-network
health
care
service
25
solely
on
the
basis
that
the
covered
person
was
referred
for
26
the
health
care
service
by
an
out-of-network
health
care
27
provider.
28
5.
If
a
covered
person
elects
to
pay
cash
price
for
a
29
generic-brand
covered
prescription
drug
that
results
in
a
30
lower
cost
than
the
average
allowed
amount
for
the
name-brand
31
covered
prescription
drug
under
the
covered
person’s
health
32
benefit
plan,
excluding
any
drug
manufacturer’s
rebate
or
33
other
discount
from
the
average
allowed
amount,
the
health
34
benefit
plan
shall
apply
any
payments
made
by
the
covered
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person
for
the
generic-brand
covered
prescription
drug
1
to
the
covered
person’s
cost-sharing
as
specified
in
the
2
covered
person’s
health
benefit
plan
as
if
the
covered
person
3
purchased
the
generic-brand
prescription
drug
from
a
network
4
pharmacy
using
the
covered
person’s
health
benefit
plan.
The
5
health
benefit
plan
shall
credit
half
the
difference
in
the
6
cash
price
for
the
generic-brand
covered
prescription
drug
7
and
the
average
allowed
amount
for
the
name-brand
covered
8
prescription
drug,
excluding
any
drug
manufacturer’s
rebate
9
or
other
discount
from
the
average
allowed
amount,
toward
10
the
covered
person’s
cost-sharing
for
health
care
services
11
that
are
covered
or
that
are
considered
formulary
under
the
12
covered
person’s
health
benefit
plan.
The
health
benefit
13
plan
may
credit
half
the
difference
in
the
cash
price
for
14
the
generic-brand
covered
prescription
drug
and
the
average
15
allowed
amount
for
the
name-brand
covered
prescription
drug,
16
excluding
any
drug
manufacturer’s
rebate
or
other
discount
17
from
the
average
allowed
amount,
toward
the
covered
person’s
18
cost-sharing
for
health
care
services
that
are
not
covered
19
or
that
are
considered
nonformulary
under
the
covered
20
person’s
health
benefit
plan.
This
paragraph
shall
not
be
21
construed
to
restrict
a
health
benefit
plan
from
requiring
a
22
preauthorization
or
other
precertification
normally
required
by
23
the
health
benefit
plan.
24
6.
A
health
benefit
plan
shall
provide
a
downloadable
or
25
interactive
online
form
for
a
covered
person
to
submit
proof
of
26
payment
under
this
section,
and
shall
annually
inform
covered
27
persons
of
their
options
under
this
section.
28
7.
Annually
at
enrollment
or
renewal,
a
health
carrier
shall
29
provide
notice
to
covered
persons
via
the
health
carrier’s
30
health
benefit
plan
materials
and
the
health
carrier’s
internet
31
site
of
the
option,
and
the
process,
to
receive
a
covered
32
health
care
service
at
a
discounted
cash
price
and
to
receive
a
33
deductible
credit.
34
8.
If
a
covered
person
pays
a
discounted
cash
price
that
is
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above
the
average
allowed
amount,
the
health
benefit
plan
shall
1
credit
the
covered
person’s
cost-sharing
an
amount
equal
to
2
the
lesser
of
the
discounted
cash
price
or
the
average
allowed
3
amount.
4
9.
a.
If
a
health
carrier
denies
proof
of
payment
5
submitted
by
a
covered
person
pursuant
to
this
chapter,
the
6
health
carrier
shall
notify
the
commissioner
and
provide
7
evidence
to
support
the
denial
to
the
covered
person
and
to
the
8
commissioner.
9
b.
A
covered
person
may
appeal
a
denial
of
a
proof
of
10
payment
pursuant
to
chapter
514J.
11
10.
a.
A
covered
person
shall
have
access
to
a
program
that
12
directly
rewards
the
covered
person
with
a
savings
incentive
13
for
medically
necessary
covered
health
care
services
received
14
from
health
care
providers
that
offer
a
discounted
cash
price
15
below
the
average
allowed
amount.
Annually
at
enrollment
or
16
renewal,
a
health
carrier
shall
provide
notice
to
covered
17
persons
via
the
health
carrier’s
health
benefit
plan
materials
18
and
the
health
carrier’s
internet
site
of
the
savings
incentive
19
program
and
how
the
savings
incentive
program
works.
If
a
20
covered
person
exceeds
the
covered
person’s
annual
deductible,
21
the
covered
person’s
health
benefit
plan
shall
notify
the
22
covered
person
of
the
savings
incentive
program
and
how
the
23
savings
incentive
program
works.
24
b.
A
covered
person’s
savings
incentive
for
a
specific
25
health
care
service
shall
be
calculated
as
the
difference
26
between
the
discounted
cash
price
and
the
average
allowed
27
amount.
A
savings
incentive
shall
be
divided
equally
between
28
the
covered
person
and
the
covered
person’s
health
benefit
29
plan,
and
may
include
a
cash
payment
to
the
covered
person.
If
30
a
third
party
helps
facilitate
a
covered
person
in
utilizing
31
a
discounted
cash
price
that
saves
money
for
the
covered
32
person,
the
covered
person
may
share
a
portion
of
their
savings
33
incentive
with
the
third
party.
34
c.
Savings
incentives
under
this
subsection
shall
not
be
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an
administrative
expense
of
the
health
benefit
plan
for
rate
1
development
or
rate
filing
purposes.
2
11.
This
chapter
shall
not
be
construed
to
prohibit
a
3
health
care
provider
from
billing
a
covered
person,
a
covered
4
person’s
guarantor,
or
a
third-party
payor
including
a
health
5
carrier,
for
health
care
services
provided
to
a
covered
person;
6
to
require
a
health
care
provider
to
refund
any
payment
made
7
to
the
health
care
provider
for
a
health
care
service
provided
8
to
a
covered
person;
or
to
require
a
health
care
provider
to
9
order
or
provide
medically
unnecessary
health
care
services,
10
regardless
of
if
the
covered
person
was
provided
with
a
cash
11
discount
price
for
a
specific
health
care
service.
12
12.
If
a
provision
of
this
chapter
or
its
application
to
13
any
person
or
circumstance
is
held
invalid,
the
invalidity
does
14
not
affect
other
provisions
or
applications
of
this
chapter
15
which
can
be
given
effect
without
the
invalid
provision
or
16
application.
17
13.
a.
Except
as
provided
in
paragraph
“b”
,
this
section
18
applies
to
third-party
payment
provider
policies,
contracts,
or
19
plans
delivered,
issued
for
delivery,
continued,
or
renewed
in
20
this
state
on
or
after
January
1,
2026.
21
b.
This
section
applies
to
third-party
payment
provider
22
policies,
contracts,
or
plans
established
pursuant
to
chapter
23
509A
delivered,
issued
for
delivery,
continued,
or
renewed
in
24
this
state
on
or
after
the
2027
state
employee
health
insurance
25
open
enrollment
period.
26
Sec.
5.
SAVINGS
INCENTIVE
PROGRAM
AND
DEDUCTIBLE
CREDIT
27
PROGRAM
FOR
STATE
EMPLOYEES.
28
1.
Before
August
1,
2026,
the
department
of
administrative
29
services
shall
conduct
an
analysis
of
the
cost-effectiveness
of
30
offering
a
savings
incentive
program
and
deductible
credit
for
31
state
employees
and
retirees.
32
2.
On
or
before
September
1,
2026,
the
department
of
33
administrative
services
shall
submit
a
report
to
the
general
34
assembly
that
contains
an
explanation
as
to
the
decision
to
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implement,
or
not
implement,
a
savings
incentive
program
and
1
deductible
credit
program.
2
3.
Any
savings
incentive
program
or
deductible
credit
found
3
to
be
cost-effective
shall
be
implemented
for
the
2027
state
4
employee
health
insurance
open
enrollment
period.
5
EXPLANATION
6
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
7
the
explanation’s
substance
by
the
members
of
the
general
assembly.
8
This
bill
relates
to
certain
cost
controls
for
health
care
9
services
and
may
be
cited
as
“The
Patient’s
Right
to
Save
Act”.
10
Under
the
bill,
all
health
care
providers
(providers)
are
11
required
to
disclose
the
discounted
cash
price
(cash
price)
12
the
provider
will
accept
for
each
specific
health
care
service
13
(service)
for
which
the
provider
will
accept
cash
payment.
14
“Discounted
cash
price”
is
defined
in
the
bill
as
the
price
15
an
individual
pays
for
a
specific
service
if
the
individual
16
pays
with
cash
or
a
cash
equivalent.
The
cash
price
shall
be
17
available
to
all
covered
persons
(persons)
and
to
all
uninsured
18
individuals.
A
provider
may
satisfy
the
requirements
of
the
19
bill
by
complying
with
the
United
States
centers
for
medicare
20
and
medicaid
services
hospital
price
transparency
regulations
21
in
45
C.F.R.
pt.
180.
A
provider
shall
review
each
discounted
22
cash
price
at
least
annually.
23
Prior
to
the
provision
of
a
scheduled
service
that
has
a
24
discounted
cash
price,
persons
and
uninsured
individuals
shall
25
be
informed
of
their
right
to
pay
for
the
service
via
the
26
cash
price,
and
that
a
discounted
cash
price
may
not
be
less
27
expensive
than
a
rate
negotiated
by
a
health
carrier
(carrier),
28
and
that
a
person
may
compare
the
rates
by
contacting
the
29
carrier.
A
provider
may
grant
a
discounted
cash
price
for
a
30
service
when
payment
is
promptly
made.
A
provider
shall
not
31
permit
a
carrier
to
recover
a
past
payment
based
on
a
price
32
difference.
33
A
provider
shall
not
enter
into
a
contract
that
prevents
the
34
provider
from
offering
a
cash
price
below
the
contracted
rates
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the
provider
has
with
a
carrier,
or
that
prevents
the
provider
1
from
disclosing
the
provider’s
cash
price
to
persons.
2
A
person’s
out-of-pocket
pricing
for
each
drug
on
a
3
carrier’s
formulary
shall
be
available
to
a
pharmacist
via
4
an
easily
accessible
and
secure
internet
site
hosted
by
the
5
carrier
at
the
point
the
pharmacist
fills
a
prescription
drug
6
to
the
person.
7
A
provider
shall
provide
an
individual
with
an
itemized
list
8
of
all
services
provided
to
the
individual,
a
statement
that
9
the
individual
paid
out-of-pocket
for
the
services,
and
if
the
10
individual
is
a
covered
person,
a
statement
that
the
provider
11
will
not
make
a
claim
against
the
person’s
carrier
for
payment
12
for
the
services
provided,
and
a
statement
that
the
person
may
13
contact
their
plan
regarding
deductible
credit.
14
Each
plan
shall
disclose
to
the
plan’s
covered
persons
the
15
average
allowed
amount
for
each
service
that
is
covered
under
16
the
person’s
plan.
If
a
plan
fails
to
disclose
each
average
17
allowed
amount,
a
person
may
substitute
a
benchmark
selected
18
by
the
commissioner
of
insurance
(commissioner).
A
person
who
19
elects
to
receive
service
at
a
cash
price
that
is
below
the
20
average
allowed
amount
shall
receive
credit
toward
the
person’s
21
cost-sharing
as
if
the
service
had
been
provided
by
a
network
22
provider.
“Average
allowed
amount”
is
defined
in
the
bill.
23
A
plan
shall
not
discriminate
in
the
form
of
payment
for
any
24
in-network
covered
service
solely
on
the
basis
that
the
person
25
was
referred
for
the
service
by
an
out-of-network
provider.
If
26
a
person
elects
to
pay
cash
price
for
a
generic-brand
drug
that
27
results
in
a
lower
cost
than
the
average
allowed
amount
for
the
28
name-brand
drug
under
the
person’s
plan,
the
plan
shall
apply
29
any
payments
made
by
the
person
for
the
generic-brand
drug
as
30
detailed
in
the
bill.
A
plan
is
required
to
provide
an
online
31
form
for
the
purpose
of
a
person
submitting
proof
of
payment.
32
Annually
at
enrollment
or
renewal,
a
carrier
shall
provide
33
notice
to
persons
via
the
carrier’s
health
plan
materials
and
34
on
the
carrier’s
internet
site
of
the
option
and
the
process
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to
receive
a
covered
service
at
a
discounted
cash
price
and
to
1
receive
a
deductible
credit.
If
a
person
pays
a
discounted
2
cash
price
that
is
above
the
average
allowed
amount,
the
plan
3
shall
give
the
person
credit
toward
the
person’s
cost-sharing
4
in
an
amount
equal
to
the
cash
price.
5
If
a
carrier
denies
a
proof
of
payment
submitted
by
a
person
6
pursuant
to
the
bill,
the
carrier
shall
notify
the
commissioner
7
and
provide
evidence
to
support
the
denial
to
the
person
and
8
the
commissioner.
A
person
may
appeal
a
denial
of
a
proof
of
9
payment
pursuant
to
Code
chapter
514J.
10
A
person
shall
have
access
to
a
program
that
rewards
the
11
person
with
a
savings
incentive
for
medically
necessary
12
services
received
from
providers
that
offer
a
cash
price
below
13
the
average
allowed
amount.
Annually
at
enrollment
or
renewal,
14
a
carrier
shall
provide
notice
to
persons
via
the
carrier’s
15
internet
site
of
the
savings
incentive
program
and
how
the
16
savings
incentive
program
works.
If
a
person
exceeds
the
17
person’s
annual
deductible,
the
person’s
plan
shall
notify
the
18
person
of
the
savings
incentive
program.
A
person’s
savings
19
incentives
for
a
service
shall
be
calculated
as
the
difference
20
between
the
cash
price
and
the
average
allowed
amount.
A
21
savings
incentive
shall
be
divided
equally
between
the
person
22
and
the
person’s
plan,
and
may
include
a
cash
payment
to
the
23
person
and
a
third
party
as
described
in
the
bill.
24
The
bill
shall
not
be
construed
to
prohibit
a
provider
from
25
billing
a
person,
a
person’s
guarantor,
or
a
third-party
payor,
26
including
a
health
carrier,
for
a
service
provided
to
the
27
person,
to
require
a
provider
to
refund
any
payment
made
to
the
28
provider
for
a
service
provided
to
the
person,
or
to
require
a
29
provider
to
order
or
provide
medically
unnecessary
services.
30
If
a
provision
of
the
bill
or
its
application
to
any
person
31
or
circumstance
is
held
invalid,
the
invalidity
does
not
affect
32
other
provisions
or
applications
of
the
bill
which
can
be
given
33
effect
without
the
invalid
provision
or
application.
34
Applicability
of
the
bill
is
detailed
in
the
bill.
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The
bill
directs
the
department
of
administrative
services
1
(DAS)
to
conduct
an
analysis
of
the
cost-effectiveness
of
2
offering
a
savings
incentive
program
and
deductible
credit
for
3
state
employees
and
retirees.
DAS
shall
submit
a
report
to
the
4
general
assembly
on
or
before
September
1,
2026,
containing
5
an
explanation
as
to
the
decisions
to
implement,
or
not
to
6
implement,
a
savings
incentive
program
and
deductible
credit
7
program.
Any
savings
incentive
program
or
deductible
credit
8
program
found
to
be
cost-effective
shall
be
implemented
for
the
9
2027
state
employee
health
insurance
open
enrollment
period.
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