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REFERENCE TITLE: estimated costs; insurers; health providers |
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State of Arizona Senate Fifty-third Legislature Second Regular Session 2018
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SB 1471 |
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Introduced by Senator Barto
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AN ACT
Amending Title 20, chapter 1, article 1, Arizona Revised Statutes, by adding sections 20‑124 and 20‑125; Amending Title 32, chapter 32, article 1, Arizona Revised Statutes, by adding section 32‑3216.01; Amending Title 36, chapter 4, article 3, Arizona Revised Statutes, by adding section 36‑437.01; 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 care systems; interactive mechanism for enrollees; out-of-pocket cost estimate; requirements; definitions
A. Beginning January 1, 2019, a health care system that offers a health care plan 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 care system information on the payments made by the health care system 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 a network health care facility or health care provider for the procedure or health care facilities 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 facility or health care service that is a medically necessary covered benefit from a health care system'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 care system at the time the enrollee makes the request. A health care system 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. On or before January 1, 2019, attest to the department that the health care system is complying with this section and thereafter attest annually to the department that the information the health care system provides pursuant to paragraph 1 of this subsection remains current.
B. Subsection A of this section does not prohibit a health care system 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. For the purposes of this section:
1. "Enrollee" means a person who is enrolled in a health care plan provided by a health care system.
2. "Health care facility" has the same meaning prescribed in section 36‑437.
3. "Health care plan" means a policy, contract or evidence of coverage issued to an enrollee. Health care plan does not include limited benefit coverage as defined in section 20‑1137.
4. "Health care provider" has the same meaning prescribed in section 32‑3216.
5. "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.
6. "health care system" means any public or private entity whose function or purpose is to manage, process and enroll individuals for or pay for, in full or in part, health care services, health care data or health care information for its enrollees.
7. "Total cost of care" means the combined cost of inpatient and outpatient covered health care services, including pharmacy costs for a period beginning on the day of the procedure until ninety days after the procedure.
8. "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 January 1, 2019, a health insurer that offers a health care plan in this state and that contracts with the Arizona health care cost containment system administration or the department of administration benefits division shall establish for all health care plans it offers in this state a shared savings program in which enrollees are directly incentivized to shop 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 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. 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.
Sec. 2. Title 32, chapter 32, article 1, Arizona Revised Statutes, is amended by adding section 32-3216.01, to read:
32-3216.01. Health care providers; estimated costs; nonemergency services; definition
A. At a patient's request, a health care provider shall provide to the patient an estimate of the current procedural terminology or other billing codes for a procedure or service for the patient that is scheduled to occur at least forty‑eight hours after the time of the request. A health care provider may decline to give this information to a patient with whom the provider has not established a health care provider‑patient relationship or for a procedure or service that is unrelated to the primary purpose of the patient's outpatient visit.
B. A health care provider shall notify A patient who makes a request pursuant to subsection A of this section that the billing codes provided are an estimate and that the actual codes for a procedure or service that the patient will be responsible to pay for may vary due to unforeseen services that arise out of the proposed nonemergency procedure or service.
C. This section does not apply to a patient who is seen while in an acute care hospital.
D. If a patient makes a complaint related to a health care provider's failure to comply with this section, the applicable health profession regulatory board may issue, after appropriate and usual investigation, an advisory letter to the health care provider. An advisory letter issued pursuant to this subsection may not be used either alone or in conjunction with any other health profession regulatory board complaint as justification, in whole or in part, for additional health profession regulatory board action against the health care provider.
E. For the purposes of this section, "health care provider" has the same meaning prescribed in section 32‑3216.
Sec. 3. Title 36, chapter 4, article 3, Arizona Revised Statutes, is amended by adding section 36-437.01, to read:
36-437.01. Health care facilities; estimated costs; nonemergency services; definition
A. At a patient's request, a health care facility shall provide to the patient an estimate of the current procedural terminology or diagnosis-related group or other billing codes for a procedure or service for the patient that is scheduled to occur at least forty‑eight hours but less than forty‑five days after the time of the request.
B. A health care facility shall notify A patient who makes a request pursuant to subsection A of this section that the billing codes provided are an estimate and that the actual codes for a procedure or service that the patient will be responsible to pay for may vary due to unforeseen services that arise out of the proposed nonemergency procedure or service.
C. If a patient makes a complaint related to a health care facility's failure to comply with this section, the department may issue, after appropriate and usual investigation, an advisory letter to the health care facility. An advisory letter issued pursuant to this subsection may not be used either alone or in conjunction with any other department complaint as justification, in whole or in part, for additional department action against the health care facility.
D. For the purposes of this section, "health care facility" has the same meaning prescribed in section 36‑437.