Senate File 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 TLSB 1498SV (3) 91 nls/ko
S.F. 319 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 Patients 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 carriers 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 persons 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 -1- LSB 1498SV (3) 91 nls/ko 1/ 13
S.F. 319 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. 35 -2- LSB 1498SV (3) 91 nls/ko 2/ 13
S.F. 319 (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. 35 -3- LSB 1498SV (3) 91 nls/ko 3/ 13
S.F. 319 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 35 -4- LSB 1498SV (3) 91 nls/ko 4/ 13
S.F. 319 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 persons 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 providers 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 providers discounted cash price under paragraph 28 b . 29 g. A covered persons out-of-pocket pricing for each 30 prescription drug on a health carriers 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 35 -5- LSB 1498SV (3) 91 nls/ko 5/ 13
S.F. 319 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 individuals 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 individuals deductible if the individual is a covered person. 10 2. Each health benefit plan shall disclose to the health 11 benefit plans covered persons the average allowed amount for 12 each health care service that is covered under the covered 13 persons 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 persons in-network cost-sharing as specified in the covered 21 persons 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 persons health 32 benefit plan, excluding any drug manufacturers rebate or 33 other discount from the average allowed amount, the health 34 benefit plan shall apply any payments made by the covered 35 -6- LSB 1498SV (3) 91 nls/ko 6/ 13
S.F. 319 person for the generic-brand covered prescription drug 1 to the covered persons cost-sharing as specified in the 2 covered persons health benefit plan as if the covered person 3 purchased the generic-brand prescription drug from a network 4 pharmacy using the covered persons 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 manufacturers rebate 9 or other discount from the average allowed amount, toward 10 the covered persons cost-sharing for health care services 11 that are covered or that are considered formulary under the 12 covered persons 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 manufacturers rebate or other discount 17 from the average allowed amount, toward the covered persons 18 cost-sharing for health care services that are not covered 19 or that are considered nonformulary under the covered 20 persons 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 carriers 30 health benefit plan materials and the health carriers 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 35 -7- LSB 1498SV (3) 91 nls/ko 7/ 13
S.F. 319 above the average allowed amount, the health benefit plan shall 1 credit the covered persons 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 carriers health benefit plan materials 18 and the health carriers internet site of the savings incentive 19 program and how the savings incentive program works. If a 20 covered person exceeds the covered persons annual deductible, 21 the covered persons 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 persons 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 persons 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 35 -8- LSB 1498SV (3) 91 nls/ko 8/ 13
S.F. 319 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 persons 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 35 -9- LSB 1498SV (3) 91 nls/ko 9/ 13
S.F. 319 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 explanations 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 Patients 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 35 -10- LSB 1498SV (3) 91 nls/ko 10/ 13
S.F. 319 the provider has with a carrier, or that prevents the provider 1 from disclosing the providers cash price to persons. 2 A persons out-of-pocket pricing for each drug on a 3 carriers 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 persons 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 plans covered persons the 15 average allowed amount for each service that is covered under 16 the persons 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 persons 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 persons 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 carriers health plan materials and 34 on the carriers internet site of the option and the process 35 -11- LSB 1498SV (3) 91 nls/ko 11/ 13
S.F. 319 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 persons 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 carriers 15 internet site of the savings incentive program and how the 16 savings incentive program works. If a person exceeds the 17 persons annual deductible, the persons plan shall notify the 18 person of the savings incentive program. A persons 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 persons 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 persons 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. 35 -12- LSB 1498SV (3) 91 nls/ko 12/ 13
S.F. 319 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. 10 -13- LSB 1498SV (3) 91 nls/ko 13/ 13