Budget Amendment ID: FY2024-S3-441
EHS 441
Patients Right to Save
Mr. Tarr moved that the proposed new text be amended by inserting after SECTION _ the following sections:-
"SECTION_. (A). Notwithstanding any general or special law to the contrary all health care entities and providers licensed by the commonwealth shall set and disclose the discounted cash price(s) they would accept for items and services in a machine-readable format. Said disclosure shall specify when the discounted cash price varies for reasons such as, but not limited to, the time of day the item and service is provided, day of service, office location, if the patient is filling a last minute cancelled appointment, or the promptness of the payment, if items and services are billed individually or by a service package, or if the price varies by income level, or for any ancillary services or amenities provided during the service.
(B). Such discounted cash price shall be available to all patients regardless of insurance plan or insurance status.
(D) . Health care entities shall publish such information on their website, if they have one, and/or provide a link to a third-party that provides patients free access to discounted cash prices for items and services, including those offered through that entity.
(E) Patients shall be informed of their ability to access discounted cash prices during any intake process to make an appointment, or when checking in for a service.
Said disclosure should inform the patient or potential patient insured on a plan regulated under chapter 176J that the patient would quality under this section for deductible credit if they have not exceeded their deductible to date if:
(a). The patient were to pay the discounted cash price and
(b).The discounted cash price is below the de-identified minimum negotiated
charge
(F). Discounted cash pricing information shall be updated at least annually, or within 10 days of pricing changes.
(G). Limit on contractual obligations to avoid disclosure:
(i).Health care entities licensed in the state may not sign contracts that prevent them from offering a discounted cash price below other contracted rates with either commercial and public payers, or that prevents the health entity from disclosing their discounted cash price to patients. Such a clause of any current contract that does so is void and shall be stricken from subsequent versions of the contract.
(ii) A health insurance plan or pharmacy benefits manager may not impose on an enrollee a copayment or other charge that exceeds the claim cost of a prescription drug. If information related to an enrollee's out-of-pocket cost or the clinical efficacy of a prescription drug or alternative medication is available to a pharmacy provider, a carrier or pharmacy benefits manager may not penalize a pharmacy provider for providing that information to an enrollee. Out-of-pocket pricing shall be displayed via an interface to prescribers at the point of prescribing with the patient.
SECTION _. (A). Notwithstanding any general or special law to the contrary beginning upon approval of the next health insurance rate filing after enactment, an enrollee covered under chapter 176J that elects to receive medically necessary covered items or services at a discounted cash priced that is below the de-identified minimum negotiated charge shall receive credit toward the enrollee’s deductible and out-of-pocket maximum as specified in the enrollee’s health plan as if the health care services had been provided by a network provider.
(B). Health plans licensed under chapter 176j shall disclose to the enrollee the de-identified minimum negotiated charge for their particular health plan. If health care entities do not disclose the de-identified minimum negotiated charge, then enrollees can reference a benchmark selected by the health policy commission in consultation with the division of insurance as a substitute for the minimum negotiated charge, which may be drawn from a third-party.
(C). A health plan may not discriminate in the form of payment for any network health care item or service covered under an enrollee's health plan based solely on the basis that the enrollee's referral was made by a provider who is not a member of the carrier's provider network.
(D).If an enrollee elects to utilize a pharmacy discount program, drug manufacturer rebate, or other discount or rebate program from a U.S.-based seller, including purchasing from a licensed prescribing provider such as a direct primary care provider, that results in a lower cost than the de-identified minimum negotiated charge would have been paid for a covered prescription medication had the enrollee utilized their health insurance policy to purchase the drug, the health plan shall apply the payments made by the enrollee for that covered prescription medication toward the enrollee’s deductible and out-of-pocket maximum as specified in the enrollee’s health plan as if the prescription medication had been purchased from a network pharmacy utilizing the enrollee’s health plan. The insurer may recognize the value of a discount or coupon towards a patient’s deductible. Nothing in this section shall be construed to restrict a health plan from requiring standard preauthorization or other precertification requirements that are currently required.
(E). The health plan shall provide a downloadable or interactive online form for the purpose of submitting proof of payment, and inform enrollees of their options under this section annually.
(F). Annually at enrollment or renewal, a carrier shall provide notice to enrollees in plan benefit material and on their website of the availability of the program with a description of how they may utilize the program.
(G). To ensure maximum enrollee choice but protect health plans, if the enrollee utilizes a discounted cash price option that is above the de-identified minimum negotiated charge, then the health plan shall only give credit toward the enrollee deductible and out-of-pocket responsibility equal to the discounted cash price or de-identified minimum negotiated charge, whichever is lowest.
(I). If a carrier denies a claim submitted by an enrollee pursuant to this act, the carrier must notify the division of insurance and provide supporting evidence for the denial to the enrollee and the division of insurance. An enrollee may appeal any denial of a claim submitted pursuant to this act to the division of insurance within 60 days of such denial. Such appeal shall be adjudicated within 30 days. If the division of insurance determines that the carrier improperly denied a claim, the carrier must pay enrollee’s costs and attorney’s fees associated with the appeal, must accept the filed claim, and must provide cash compensation equal to the amount of the claim to the enrollee.
(J). If a carrier denies more than twenty claims in one quarter under this act, the division of insurance shall notify the office of the attorney general. The Attorney General shall have authority to investigate any unfair trade practices in denying claims under this act. Should the Attorney General find that the carrier is wrongly denying claims under this act on an unreasonable basis, the Attorney General’s office may prosecute improper denials as an unfair trade practice under chapter 93A.