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Senate Engrossed |
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State of Arizona Senate Fifty-third Legislature Second Regular Session 2018
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SENATE BILL 1471 |
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AN ACT
Amending Title 20, chapter 1, article 1, Arizona Revised Statutes, by adding sections 20‑124 and 20‑125; relating to health care services.
(TEXT OF BILL BEGINS ON NEXT PAGE)
Be it enacted by the Legislature of the State of Arizona:
Section 1. Title 20, chapter 1, article 1, Arizona Revised Statutes, is amended by adding sections 20-124 and 20‑125, to read:
20-124. Health insurers; interactive mechanism for enrollees; out-of-pocket cost estimate; requirements; definitions
A. Beginning January 1, 2019, a health insurer that offers a health care plan in the individual or small group market in this state shall do all of the following:
1. Establish an interactive mechanism on its publicly accessible website that enables an enrollee to request and obtain from the health insurer information on the payments made by the health insurer to network health care facilities or health care providers for comparable health care services as well as quality data for those health care facilities or health care providers to the extent available. The interactive mechanism shall allow an enrollee seeking information about the cost of a particular health care service to compare allowed amounts among network health care facilities or health care providers, estimate out‑of‑pocket costs applicable to the enrollee's health care plan and learn the average payment made to network health care facilities or health care providers for the procedure or health care service under the enrollee's health care plan within a reasonable time frame not to exceed one year. The out-of-pocket cost estimate shall provide a good faith estimate of the amount the enrollee will be responsible to pay out of pocket for a proposed nonemergency procedure or health care service that is a medically necessary covered benefit from a health insurer's network health care facility or health care provider, including any copayment, deductible, coinsurance or other out‑of-pocket amount for any covered benefit, based on the information available to the health insurer at the time the enrollee makes the request. A health insurer may contract with a third‑party vendor to satisfy the requirements of this paragraph.
2. Notify an enrollee making a request under paragraph 1 of this subsection that these are estimated costs and that the actual total cost of care and total out‑of‑pocket costs may be more or less depending on the exact circumstances of the care and treatment provided, the enrollee's decisions and choices and unanticipated or unforeseen issues directly or indirectly related to the enrollee's medical condition.
3. Beginning with the next health insurance rate filing after the effective date of this section, attest to the department that the health insurer is complying with this section and thereafter attest annually to the department that the information the health insurer provides pursuant to paragraph 1 of this subsection remains current.
B. Subsection A of this section does not prohibit a health insurer from imposing cost sharing requirements disclosed in an enrollee's contract or policy for unforeseen health care services that arise out of the nonemergency procedure or service or for a procedure or service provided to an enrollee that was not included in the original out‑of‑pocket cost estimate.
C. A health insurer may submit to the department the reasons why the insurer believes that it is too difficult to provide any health care service information required in subsection A of this section. The department shall approve any exemption that includes an explanation. The information submitted by the health insurer pursuant to this section is public after the department has taken action.
D. A health insurer, annually at enrollment or renewal, shall provide notice about the availability of any interactive mechanism to compare allowed amounts among network health care facilities or health care providers to each enrollee who is enrolled in a health care plan that is eligible.
E. Beginning January 1, 2020, the department may expand the list of health care services that will be considered comparable health care services for the purposes of this section.
F. For the purposes of this section:
1. "Allowed amount" means the contractually agreed on amount paid by a health insurer to a health care provider or health care facility participating in the health insurer's network or the amount the health insurer is required to pay under the health care plan.
2. "Comparable health care services" means any covered nonemergency health care service or bundle of services, including at least the following:
(a) Physical and occupational therapy services.
(b) Obstetrical and gynecological services.
(c) Radiology and imaging services.
(d) Laboratory services.
(e) Infusion therapy.
(f) Inpatient and outpatient surgical procedures.
3. "Enrollee" means a person who is enrolled in a health care plan provided by a health insurer.
4. "Health care facility" has the same meaning prescribed in section 36‑437.
5. "Health care plan" means a policy, contract or evidence of coverage issued in the individual or small group market to an enrollee. Health care plan does not include limited benefit coverage as defined in section 20‑1137 or coverage offered through a medicare accountable care organization.
6. "Health care provider" has the same meaning prescribed in section 32‑3216.
7. "Health care service" means any health‑related service or treatment, to the extent that the service or treatment is allowed or not prohibited by law or regulation, that may be provided by a person or business that is otherwise allowed to offer the service or treatment.
8. "Health insurer" has the same meaning prescribed in section 20‑125.
9. "Total cost of care" means the combined cost of inpatient and outpatient covered health care services.
10. "Total out‑of‑pocket costs" means the sum of all copayments, coinsurance and deductibles and any other patient payment responsibility that is due under the terms of the health care plan.
20-125. Health insurers; shared savings programs; definitions
A. Beginning with the next health insurance rate filing after the effective date of this section, a health insurer that offers a health care plan in this state shall establish for all health care plans it offers in this state in the individual and small group market a shared savings program in which enrollees are directly incentivized to shop before and after the enrollee's out‑of‑pocket limit has been met for lower‑cost, high‑quality participating health care providers or health care facilities for comparable health care services. Incentives may include cash payments, gift cards or credits or reductions of premiums, copayments, coinsurance or deductibles.
B. A health insurer, annually at enrollment or renewal, shall provide notice about the availability of the shared savings program to each enrollee who is enrolled in a health care plan that is eligible for the program. An incentive made by a health insurer in accordance with this section is not an administrative expense of the health insurer for rate development or rate filing purposes.
C. Beginning January 1, 2020, the department may expand the list of health care services that will be considered comparable health care services for the purposes of this section.
D. For the purposes of this section:
1. "Health care facility" has the same meaning prescribed in section 20‑124.
2. "Health care plan" has the same meaning prescribed in section 20‑124.
3. "Health care provider" has the same meaning prescribed in section 20‑124.
4. "Health care services" has the same meaning prescribed in section 20‑124.
5. "Health insurer" means a disability insurer, group disability insurer, blanket disability insurer, health care services corporation, or hospital and medical service corporation.