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1 HOUSE BILL NO. 689
2 INTRODUCED BY B. MERCER
3
4 A BILL FOR AN ACT ENTITLED: “AN ACT PROVIDING FOR PRICING TRANSPARENCY REQUIREMENTS
5 FOR HOSPITALS; REQUIRING THE PUBLISHING OF STANDARD CHARGES AND CHARGES FOR
6 SHOPPABLE SERVICES; PROVIDING FOR REQUIRED REPORTING TO THE DEPARTMENT OF PUBLIC
7 HEALTH AND HUMAN SERVICES; PROVIDING FOR ENFORCEMENT BY THE DEPARTMENT OF
8 JUSTICE; PROVIDING FOR A PRIVATE RIGHT OF ACTION; PROVIDING NOTICE AND DISCLOSURE
9 REQUIREMENTS FOR FACILITY FEES; REQUIRING REPORTING TO THE LEGISLATURE; PROHIBITING
10 COLLECTION ACTIONS OF DEBT BY NONCOMPLIANT HOSPITALS; PROVIDING RULEMAKING
11 AUTHORITY; AND PROVIDING DEFINITIONS.”
12
13 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MONTANA:
14
15 NEW SECTION. Section 1. As used in [sections 1 through 12], unless the context
16 clearly indicates otherwise, the following definitions apply:
17 (1) "Ancillary service" means a hospital item or service that a hospital customarily provides as part
18 of a shoppable service.
19 (2) "Chargemaster" means the list of all hospital items or services maintained by a hospital for
20 which the hospital has established a charge.
21 (3) "Deidentified maximum negotiated charge" means the highest charge that a hospital has
22 negotiated with all third-party payors for a hospital item or service.
23 (4) "Deidentified minimum negotiated charge" means the lowest charge that a hospital has
24 negotiated with all third-party payors for a hospital item or service.
25 (5) "Department" means the department of public health and human services provided for in 2-15-
26 2201.
27 (6) "Discounted cash price" means the charge that applies to an individual who pays cash or a
28 cash equivalent for a hospital item or service. ****
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1 (7) "Facility fee" means a fee charged or billed by a hospital for outpatient services provided in an
2 off-campus health care facility, regardless of the modality through which the health care service is provided,
3 that is:
4 (a) intended to compensate the health system or hospital for health care expenses; and
5 (b) separate and distinct from a professional fee.
6 (8) "Gross charge" means the charge for a hospital item or service that is reflected on the
7 hospital's chargemaster, absent any discount.
8 (9) "Health system" means two or more health care facilities, with at least one being a hospital,
9 that are owned by a common legal entity or that have entered into an affiliation agreement to combine or
10 coordinate delivery of health care services under a common organizational name.
11 (10) "Hospital" has the same meaning as provided in 50-5-101.
12 (11) "Item or service" means an item or service, including a package of individual items or services,
13 that could be provided by a hospital to a patient in connection with an inpatient admission or an outpatient
14 department visit for which the hospital has established a standard charge, and may include the following:
15 (a) a supply or procedure;
16 (b) room and board;
17 (c) the use of a hospital or other item;
18 (d) the service of a health care practitioner; or
19 (e) any other item or service for which a hospital has established a standard charge.
20 (12) "Machine-readable format" means a digital representation of information in a file that can easily
21 be imported or read into a computer system for further processing without any additional preparation.
22 (13) "Payor-specific negotiated charge" means a charge that a hospital has negotiated with a third-
23 party payor for a hospital item or service.
24 (14) "Professional fee" means a fee charged by a health care practitioner for medical services.
25 (15) "Shoppable service" means a service that may be scheduled by an individual in advance.
26 (16) "Standard charge" means the regular rate established by a hospital for a hospital item or
27 service provided to a specific group of paying patients. The term includes the following:
28 (a) the gross charge; ****
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1 (b) the payor-specific negotiated charge;
2 (c) the deidentified minimum negotiated charge;
3 (d) the deidentified maximum negotiated charge; and
4 (e) the discounted cash price.
5 (17) "Third-party payor" means an entity that is legally responsible for payment of a claim for a
6 hospital item or service.
7
8 NEW SECTION. Section 2. A hospital shall publish the
9 following on the hospital's publicly accessible internet website and provide hard copies on request:
10 (1) a digital file in a machine-readable format and printable format that contains a list of all
11 standard charges for all hospital items or services as provided in [section 3]; and
12 (2) a consumer-friendly and printable list of standard charges for a limited set of shoppable
13 services as provided in [section 4].
14
15 NEW SECTION. Section 3.
16 (1) A hospital has the following duties:
17 (a) maintain a list of all standard charges for all hospital items or services in accordance with
18 [sections 1 through 7]; and
19 (b) ensure that the list is always available to the public, including publishing the list electronically in
20 the manner specified under [section 2].
21 (2) The standard charges contained in the list under subsection (1)(a) must reflect the standard
22 charges applicable to the location of the hospital, regardless of whether the hospital operates in more than one
23 location or operates under the same license as another hospital.
24 (3) A hospital shall include the following information in the list under subsection (1)(a):
25 (a) a description of each hospital item or service provided by the hospital;
26 (b) the following charges for each individual hospital item or service when provided in either an
27 inpatient setting or an outpatient department setting, as applicable, including:
28 (i) the gross charge; ****
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1 (ii) the deidentified minimum negotiated charge;
2 (iii) the deidentified maximum negotiated charge;
3 (iv) the discounted cash price;
4 (v) the payor-specific negotiated charge, including all payors and all plans accepted by the hospital
5 in a manner clearly associated with the name of the third-party payor and specific plan and delineated by the
6 name of the third-party payor and plan associated with the charge; and
7 (vi) a code used by the hospital for the purpose of accounting or billing for the hospital item or
8 service, which may include the current procedural terminology code, the health care common procedure coding
9 system, the diagnosis-related group code, the national drug code, or another common identifier.
10 (4) A hospital shall publish the information contained in the list under subsection (1) in a single
11 digital file that is in a machine-readable format.
12 (5) (a) A hospital shall display the list under subsection (1) by posting the list in a prominent
13 location on the home page of the hospital's publicly accessible internet website or by making the list accessible
14 by a dedicated link that is prominently displayed on the home page of the hospital's publicly accessible internet
15 website.
16 (b) If the hospital operates multiple locations and maintains a single internet website, the hospital
17 shall post the list for each location that the hospital operates in a manner that clearly associates the list with the
18 applicable location of the hospital and includes charges specific to each individual hospital location.
19 (6) (a) A hospital shall ensure that the list under subsection (1) is:
20 (i) available free of charge;
21 (ii) accessible to a common commercial operator of an internet search engine to the extent
22 necessary for the search engine to index the list and display the list in response to a search query of a user of
23 the search engine;
24 (iii) formatted in a manner specified under [section 2] and this section and required by the
25 department in administrative rule;
26 (iv) digitally searchable and printable by service description, billing code, and third-party payor; and
27 (v) in a format and identified by a naming convention specified by the department in administrative
28 rule. ****
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1 (b) The department shall ensure the list under subsection (1) does not require any of the following:
2 (i) the establishment of a user account or password or other information of the user;
3 (ii) the submission of personal identifying information; or
4 (iii) any other impediment, including entering a code to access the list.
5 (7) In determining the format of the list under subsection (1), the department shall develop a
6 template that each hospital shall use in formatting the list. In developing the template required under this
7 subsection (7), the department shall:
8 (a) take into consideration applicable federal guidelines for formatting similar lists required by
9 federal law and ensure that the design of the template enables an individual to compare the charges contained
10 in the lists maintained by each hospital; and
11 (b) design the template to be substantially like the template used by the centers for medicare and
12 medicaid services for the purposes specified in [sections 2 through 7].
13 (8) A hospital shall update the list under subsection (1) no less than once a year. The hospital shall
14 clearly indicate the date when the list was most recently updated, either on the list or in a manner that is clearly
15 associated with the list. The hospital shall make available no less than the three most recent versions of the list.
16
17 NEW SECTION. Section 4.
18 (1) Except as provided under subsection (3), a hospital shall maintain and
19 make publicly available a list of standard charges for each of at least 300 shoppable services provided by the
20 hospital with charges specific to that individual hospital location. The hospital may select the shoppable
21 services to be included in the list, except that the list must include the 70 services specified as shoppable
22 services by the centers for medicare and medicaid services. If the hospital does not provide all the shoppable
23 services specified by the centers for medicare and medicaid services, the hospital shall include all the
24 shoppable services provided by the hospital.
25 (2) In selecting a shoppable service for the purpose of inclusion in the list under subsection (1), a
26 hospital shall:
27 (a) consider how frequently the hospital provides the service and the hospital's billing rate for the
28 service; and ****
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1 (b) prioritize the selection of services that are among the services most frequently provided by the
2 hospital.
3 (3) If the hospital providers fewer than 300 shoppable services, the hospital shall include in the list
4 under subsection (1) the total number of shoppable services that the hospital provides in a manner that
5 otherwise complies with the requirements of subsection (1).
6 (4) A hospital shall include all of the following information in the list of shoppable services under
7 subsection (1):
8 (a) a plain-language description of each shoppable service included on the list;
9 (b) the payor-specific negotiated charge that applies to each shoppable service included on the list
10 and any ancillary service delineated by the name of the third-party payor and plan associated with the charge
11 and displayed in a manner that clearly associates the charge with the third-party payor and plan;
12 (c) the discounted cash price that applies to each shoppable service included on the list and any
13 ancillary service or, if the hospital does not offer a discounted cash price for a shoppable service or an ancillary
14 service on the list, the gross charge for the shoppable service or ancillary service;
15 (d) the deidentified minimum negotiated charge that applies to each shoppable service included on
16 the list and any ancillary service;
17 (e) the deidentified maximum negotiated charge that applies to each shoppable service included
18 on the list and any ancillary service;
19 (f) a code used by the hospital for the purposes of accounting or billing for each shoppable service
20 included on the list and any ancillary service, including the current procedural terminology code, the health care
21 common procedure coding system code, the diagnosis-related group code, the national drug code, or another
22 common identifier;
23 (g) if applicable, each location where the hospital provides a shoppable service and whether the
24 standard charges included in the list apply to the provision of the shoppable service in an inpatient setting or an
25 outpatient department setting at the location; and
26 (h) if applicable, an indication if a shoppable service specified by the centers for medicare and
27 medicaid services is not provided by the hospital.
28 (5) (a) A hospital shall ensure that the list under subsection (1) is: ****
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1 (i) available free of charge;
2 (ii) accessible to a common commercial operator of an internet search engine to the extent
3 necessary for the search engine to index the list and display the list in response to a search query of a user of
4 the search engine;
5 (iii) formatted in a manner specified under [section 2] and this section and required by
6 administrative rule;
7 (iv) digitally searchable and printable by service description, billing code, and third-party payor; and
8 (v) in a format and identified by a naming convention specified by the department in administrative
9 rule.
10 (b) Nothing in this section may preclude a hospital from using a price estimator tool as provided for
11 in 45 CFR 180.60 in addition to the list of shoppable services.
12 (c) The department shall ensure that the list under subsection (1) does not require any of the
13 following:
14 (i) the establishment of a user account or password or other information of the user;
15 (ii) the submission of personal identifying information; or
16 (iii) any other impediment, including entering a code to access the list.
17 (6) In determining the format of the list under subsection (1), the department shall develop a
18 template that each hospital shall use in formatting the list. In developing the template required under this
19 subsection (6), the department shall:
20 (a) take into consideration applicable federal guidelines for formatting similar lists required by
21 federal law and ensure that the design of the template enables an individual to compare the charges contained
22 in the lists maintained by each hospital; and
23 (b) design the template to be substantially like the template used by the centers for medicare and
24 medicaid services for the purposes specified in [sections 2 through 7].
25 (7) A hospital shall update the list under subsection (1) no less than once a year. The hospital shall
26 clearly indicate the date when the list was most recently updated, either on the list or in a manner that is clearly
27 associated with the list. The hospital shall make available no less than the three most recent versions of the list.
28 ****
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1 NEW SECTION. Section 5. (1) Each time a hospital
2 creates or updates a list as required under [sections 3 and 4], the hospital shall submit the list, along with a
3 report on the list, to the department. The department shall specify the form of the report in administrative rule.
4 (2) To be considered in compliance, a list received by the department must include a minimum of
5 95% of all values required under [sections 3 and 4].
6 (3) By July 1 of each year, a hospital shall report to the department on facility fees charged or
7 billed during the preceding calendar year. The department shall specify the form of the report in administrative
8 rule. The report must include:
9 (a) the name and location of each health care facility owned or operated by the hospital that
10 provides services for which a facility fee is charged or billed;
11 (b) the number of patient visits at each health care facility for which a facility fee was charged or
12 billed;
13 (c) the number, total amount, and types of allowable facility fees paid at each health care facility by
14 medicare, medicaid, and private insurance;
15 (d) for each health care facility, the total number of facility fees charged and the total amount of
16 revenue received by the hospital or health system derived from facility fees;
17 (e) the total amount of facility fees charged and the total amount of revenue received by the
18 hospital or health system from all health care facilities derived from facility fees;
19 (f) the 10 most frequent procedures or services, identified by category I current procedural
20 terminology codes, provided by the hospital that generated the largest amount of facility fee gross revenue,
21 including:
22 (i) the volume of each procedure or service;
23 (ii) the gross and net revenue totals for each procedure or service; and
24 (iii) the total net amount of revenue received by the hospital or health system derived from facility
25 fees for each procedure or service;
26 (g) the 10 most frequent procedures or services, based on patient volume and identified by
27 category I current procedural terminology codes, provided by the hospital for which facility fees were billed or
28 charged, including the gross and net revenue totals received for each procedure or service; and ****
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1 (h) any other information related to facility fees the department may require.
2 (4) An authorized executive of the hospital or health system shall issue an unsworn written
3 declaration, following the requirements of 1-6-105, stating that any report or list submitted to the department is
4 complete and accurate to the best of the authorized executive's knowledge and belief.
5 (5) The department shall make all reports and lists available on its publicly accessible internet
6 website within 60 days of receipt of each report.
7 (6) A health system may make the report for each hospital that it owns or operates, provided that
8 each hospital has its own separate report.
9
10 NEW SECTION. Section 6. For the purposes of [sections
11 2 through 7], a hospital shall meet the following conditions when providing digital files in a machine-readable
12 format:
13 (1) the file must be formatted without additional rows or spacing between data;
14 (2) the file must be readily usable without additional instructions; and
15 (3) the file must be in a machine-readable format that is widely used by other hospitals for cross-
16 comparison purposes, including a spreadsheet format that an individual with average computer skills can open,
17 read, and comprehend.
18
19 NEW SECTION. Section 7. (1) A health care facility affiliated
20 with or owned by a hospital that charges a facility fee shall disclose to a patient at the time an appointment is
21 scheduled, and at the time medical services are rendered, that a facility fee may be charged.
22 (2) Disclosure of facility fees must occur on a plain language notice as determined in
23 administrative rule. The notice must include:
24 (a) the dollar amount of the patient's potential financial liability for a facility fee if a diagnosis and
25 extent of medical treatment is known;
26 (b) an estimated range in dollars of the patient's potential financial liability for a facility fee if the
27 diagnosis and extent of medical treatment is unknown; and
28 (c) if applicable, a statement that the patient may incur a financial liability to the health care facility ****
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1 that the patient would not incur if the patient was receiving medical services and treatment on the campus of
2 the hospital.
3
4 NEW SECTION. Section 8. The department shall establish an electronic form for
5 individuals to submit complaints for alleged violations of [sections 2 through 7]. The department shall post the
6 electronic form on its publicly accessible internet website. The department shall also accept complaints via a
7 department customer service telephone number.
8
9 NEW SECTION. Section 9. (1) A violation
10 of the provisions of [sections 2 through 7] is an unlawful practice under 30-14-103.
11 (2) A hospital that violates the provisions of [sections 2 through 7] is subject to any investigative or
12 enforcement action available under Title 30, chapter 14, parts 1 and 2, including investigative demands,
13 remedies, penalties, and the right to bring an individual action under 30-14-133.
14 (3) A person who suffers an injury caused by a violation of [sections 2 through 7] has a private
15 right of action to seek damages, subject to the following conditions:
16 (a) the person reports the violation to the noncompliant hospital;
17 (b) the hospital fails to cure the violation; and
18 (c) at least 30 days have passed since the person reported the violation to the noncompliant
19 hospital.
20 (4) A person who brings an action for damages under subsection (3) and prevails is entitled to
21 attorney fees.
22
23 NEW SECTION. Section 10. The department shall adopt rules necessary to
24 implement [sections 1 through 8].
25
26 NEW SECTION. Section 11. The department shall report annually by
27 September 1 to the children, families, health, and human services interim committee in accordance with 5-11-
28 222 regarding the department's efforts under [sections 1 through 10]. ****
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1
2 NEW SECTION. Section 12.
3 (1) Except as provided under subsection (4), a hospital may not initiate or pursue a
4 collection action against a patient or patient guarantor for a debt owed for an item or service if the hospital is in
5 violation of the requirements under [sections 2 through 7] on the date when the item or service is purchased by
6 or provided to the patient.
7 (2) If a patient believes that a hospital is in violation of the requirements under [sections 2 through
8 7] on the date when an item or service is purchased by or provided to the patient and the hospital takes a
9 collection action against the patient or patient guarantor, the patient or patient guarantor may initiate a civil
10 action in the district court to determine if the hospital is in violation of [sections 2 through 7] and the
11 noncompliance is related to the item or service. The hospital may not take a collection action against the patient
12 or patient guarantor or submit a report to the patient's or patient guarantor's credit report while the civil action is
13 pending.
14 (3) A hospital that has been determined to be in violation of the requirements under [sections 2
15 through 7] shall:
16 (a) refund the payor an amount of the debt the payor has paid and pay a penalty to the patient or
17 patient guarantor in an amount equal to the total amount of debt;
18 (b) dismiss or cause to be dismissed a civil action under subsection (2) with prejudice and pay any
19 attorney fees and costs incurred by the patient or patient guarantor relating to the action; and
20 (c) remove or cause to be removed from the patient's or patient guarantor's credit report a report
21 made to a consumer reporting agency relating to the debt.
22 (4) Nothing in this section may be construed to:
23 (a) prohibit a hospital from billing a patient, patient guarantor, or third-party payor, including a
24 health insurer, for an item or service provided to the patient in a manner that is not in violation of this section; or
25 (b) require a hospital to refund a payment made to the hospital for an item or service provided to
26 the patient if no collection action is taken in violation of [sections 2 through 7].
27 (5) As used in this section, the following definitions apply:
28 (a) "Collection action" means any of the following actions taken with respect to a debt for an item ****
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1 or service that was purchased from or provided to a patient by a hospital on a date during which the hospital
2 was not in material compliance with [sections 2 through 7]:
3 (i) attempting to collect a debt from a patient or patient guarantor by referring the debt, directly or
4 indirectly, to a debt collector, a collection agency, or other third-party retained by or on behalf of the hospital;
5 (ii) bringing a civil legal action against the patient or patient guarantor or enforcing an arbitration or
6 mediation clause in a hospital document, including any contract, agreement, statement, or bill; or
7 (iii) directly or indirectly causing a report to be made to a consumer reporting agency.
8 (b) "Collection agency" means any of the following:
9 (i) a person who engages in a business for the principal purpose of collecting debts;
10 (ii) a person who regularly collects or attempts to collect, directly or indirectly, debts owed or due
11 or asserted to be owed or due to another; or
12 (iii) a person who directly or indirectly solicits for collection debts owed or due or asserted to be
13 owed or due to another.
14 (c) (i) "Consumer reporting agency" means a person who, for monetary fees, dues, or on a
15 cooperative nonprofit basis, regularly engages in the practice of assembling or evaluating consumer credit
16 information or other information on consumers for the purpose of furnishing consumer reports to third parties.
17 The term includes "consumer reporting agency" as defined in 15 USC 1681a(f).
18 (ii) The term does not include a business entity that only provides check verification or check
19 guarantee services.
20 (d) (i) "Debt" means an obligation or alleged obligation of a consumer to pay money arising out of a
21 transaction, whether or not the obligation has been reduced to judgment.
22 (ii) The term does not include a debt for business, investment, commercial, or agricultural
23 purposes or a debt incurred by a business.
24 (e) "Debt collector" means a person employed or engaged by a collection agency to perform the
25 collection of debts owed or due, or asserted to be owed or due, to another.
26
27 NEW SECTION. Section 13. [Sections 1 through 12] are intended to be
28 codified as a new part in Title 30, chapter 14, and the provisions of Title 30, chapter 14, apply to [sections 1 ****
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1 through 12].
2 - END -