Florida Senate - 2020 SB 1836
By Senator Bean
4-01734-20 20201836__
1 A bill to be entitled
2 An act relating to health insurance and prescription
3 drug coverage; amending s. 110.123, F.S.; requiring
4 the state group insurance program to allow enrollees
5 to obtain health care services and prescription drugs
6 from out-of-network providers and pharmacies if
7 certain conditions are met; providing for the payment
8 to be applied towards the enrollee’s deductible and
9 out-of-pocket maximum; providing notice requirements;
10 amending s. 110.12303, F.S.; revising provider
11 organizations included in benefit packages for the
12 state group insurance program; revising requirements
13 for the contracts between the Department of Management
14 Services and health insurers; requiring the department
15 to offer specified reimbursement as a voluntary
16 supplemental benefit option in the state group
17 insurance program; amending s. 110.12315, F.S.;
18 requiring the state employees’ prescription drug
19 program to allow members and members’ dependents to
20 obtain prescription drugs from out-of-network
21 pharmacies if certain conditions are met; providing
22 for the payment to be applied towards the deductible
23 and out-of-pocket maximum; providing notice
24 requirements; amending s. 110.1238, F.S.; requiring
25 state group health insurance plans to allow
26 participants to obtain health care services and
27 prescription drugs from out-of-network providers and
28 pharmacies if certain conditions are met; providing
29 for the payment to be applied towards the deductible
30 and out-of-pocket maximum; providing notice
31 requirements; creating s. 465.203, F.S.; defining the
32 term “covered individual”; prohibiting pharmacy
33 benefit managers from engaging in specified acts under
34 certain circumstances; creating s. 627.4435, F.S.;
35 defining the term “health insurer”; requiring health
36 insurers to apply certain payments toward deductibles
37 and out-of-pocket maximums within a specified
38 timeframe under certain circumstances; prohibiting
39 health insurers from engaging in specified acts under
40 certain circumstances; providing construction;
41 providing publication and notification requirements;
42 amending ss. 627.6387, 627.6648, and 641.31076, F.S.;
43 revising definitions; requiring, rather than
44 authorizing, health insurers and health maintenance
45 organizations to offer shared savings incentive
46 programs; revising duties of health insurers and
47 health maintenance organizations with respect to
48 shared savings incentive programs; providing an
49 effective date.
50
51 Be It Enacted by the Legislature of the State of Florida:
52
53 Section 1. Subsection (14) is added to section 110.123,
54 Florida Statutes, to read:
55 110.123 State group insurance program.—
56 (14) OUT-OF-NETWORK PROVIDERS.—
57 (a) The state group insurance program shall allow its
58 enrollees to obtain a covered health care service from an out
59 of-network provider at a cost that is the same or less than the
60 in-network average that an enrollee’s insurance plan pays for
61 that health care service. The state group insurance program
62 shall apply, within a reasonable timeframe not to exceed 1 year,
63 the payment made by, or required of, an enrollee for that health
64 care service toward the enrollee’s deductible and out-of-pocket
65 maximum as specified in the enrollee’s insurance plan as if the
66 health care service had been provided by an in-network provider.
67 (b) If an enrollee uses a pharmacy discount program, drug
68 manufacturer rebate, or other discount or rebate program,
69 including purchasing a prescription drug from a licensed
70 prescribing provider such as a direct primary care provider, and
71 such use results in a lower cost than would have been paid for a
72 covered prescription drug had the enrollee used the enrollee’s
73 insurance plan to purchase the prescription drug, the state
74 group insurance program shall apply, within a reasonable
75 timeframe not to exceed 1 year, the payment made by the enrollee
76 for that covered prescription drug toward the enrollee’s
77 deductible and out-of-pocket maximum as specified in the
78 enrollee’s insurance plan as if the prescription drug had been
79 purchased from an in-network pharmacy.
80 (c) At a minimum, the state group insurance program shall
81 inform enrollees on its website and in its benefit plan
82 materials of the options of obtaining covered health care
83 services from out-of-network providers and prescription drugs
84 from out-of-network pharmacies under paragraphs (a) and (b),
85 respectively, with the enrollees’ payments applied to
86 deductibles and out-of-pocket maximums. On its website and in
87 its benefit plan materials, the state group insurance program
88 shall also provide information on how to use the options under
89 paragraphs (a) and (b) if an enrollee is interested in doing so.
90 Section 2. Present paragraph (e) of subsection (3) and
91 present subsection (4) of section 110.12303, Florida Statutes,
92 are redesignated as subsections (4) and (5), respectively, a new
93 paragraph (e) is added to subsection (3) of that section, and
94 paragraph (e) of subsection (1), paragraph (a) of subsection
95 (2), paragraph (d) of subsection (3), and present subsection (4)
96 of that section are amended, to read:
97 110.12303 State group insurance program; additional
98 benefits; price transparency program; reporting.—
99 (1) In addition to the comprehensive package of health
100 insurance and other benefits required or authorized to be
101 included in the state group insurance program, the package of
102 benefits may also include products and services offered by:
103 (e) Provider organizations, including service networks,
104 group practices, professional associations, and other
105 incorporated organizations of providers, who sell service
106 contracts and arrangements for a specified amount and type of
107 health services, including direct primary or other medical care
108 provided on a subscription basis.
109 (2)(a) The department shall contract with at least one
110 entity that provides comprehensive pricing and inclusive
111 services for surgery and other medical procedures which may be
112 accessed at the option of the enrollee. The contract shall
113 require the entity to:
114 1. Have procedures and evidence-based standards to ensure
115 the inclusion of only high-quality health care providers.
116 2. Provide assistance to the enrollee in accessing and
117 coordinating care.
118 3. Provide cost savings to the state group insurance
119 program to be shared with both the state and the enrollee. Cost
120 savings payable to an enrollee may be:
121 a. Credited to the enrollee’s flexible spending account;
122 b. Credited to the enrollee’s health savings account;
123 c. Credited to the enrollee’s health reimbursement account;
124 or
125 d. Credited to the enrollee as a premium or out-of-pocket
126 cost reduction; or
127 e. Paid directly to the enrollee as cash or a cash
128 equivalent additional health plan reimbursements not exceeding
129 the amount of the enrollee’s out-of-pocket medical expenses.
130 4. Provide an educational campaign for enrollees to learn
131 about the services offered by the entity.
132 (3) The department shall contract with an entity that
133 provides enrollees with online information on the cost and
134 quality of health care services and providers, allows an
135 enrollee to shop for health care services and providers, and
136 rewards the enrollee by sharing savings generated by the
137 enrollee’s choice of services or providers. The contract shall
138 require the entity to:
139 (d) Identify the savings realized to the enrollee and state
140 if the enrollee chooses high-quality, lower-cost health care
141 services or providers, and facilitate a shared savings payment
142 to the enrollee. The amount of shared savings shall be
143 determined by a methodology approved by the department and shall
144 maximize value-based purchasing by enrollees. The amount payable
145 to the enrollee may be:
146 1. Credited to the enrollee’s flexible spending account;
147 2. Credited to the enrollee’s health savings account;
148 3. Credited to the enrollee’s health reimbursement account;
149 or
150 4. Credited to the enrollee as a premium or out-of-pocket
151 cost reduction; or
152 5. Paid directly to the enrollee as cash or a cash
153 equivalent additional health plan reimbursements not exceeding
154 the amount of the enrollee’s out-of-pocket medical expenses.
155 (e) Include infusion therapy in the shared savings
156 incentive program.
157 (5)(4) The department shall offer, as a voluntary
158 supplemental benefit option:,
159 (a) International prescription services that offer safe
160 maintenance medications at a reduced cost to enrollees and that
161 meet the standards of the United States Food and Drug
162 Administration personal importation policy.
163 (b) At a minimum, reimbursement of direct primary care
164 subscription fees.
165 Section 3. Subsection (11) is added to section 110.12315,
166 Florida Statutes, to read:
167 110.12315 Prescription drug program.—The state employees’
168 prescription drug program is established. This program shall be
169 administered by the Department of Management Services, according
170 to the terms and conditions of the plan as established by the
171 relevant provisions of the annual General Appropriations Act and
172 implementing legislation, subject to the following conditions:
173 (11)(a) If a member or a member’s dependent uses a pharmacy
174 discount program, drug manufacturer rebate, or other discount or
175 rebate program, including purchasing a prescription drug from a
176 licensed prescribing provider such as a direct primary care
177 provider, and such use results in a lower cost than would have
178 been paid for a covered prescription drug had the member or
179 member’s dependent used the state group health insurance plan or
180 a pharmacy participating in the state employees’ prescription
181 drug program to purchase the prescription drug, the department
182 must apply the payments made by the member or member’s dependent
183 for that covered prescription drug toward the member’s
184 deductible and out-of-pocket maximum as specified in the state
185 group health insurance plan or state employees’ prescription
186 drug program as if the prescription drug had been purchased from
187 a pharmacy participating in the state employees’ prescription
188 drug program.
189 (b) At a minimum, the department, on its website and in its
190 materials, shall inform the program’s members on the program
191 benefits of the option of obtaining prescription drugs from
192 nonparticipating pharmacies under paragraph (a) and shall
193 provide information on how to use such option to a member or a
194 member’s dependent.
195 Section 4. Section 110.1238, Florida Statutes, is amended
196 to read:
197 110.1238 State group health insurance plans; refunds with
198 respect to overcharges by providers; out-of-network providers.—
199 (1) A participant in a state group health insurance plan
200 who discovers that he or she was overcharged by a health care
201 provider shall receive a refund of 50 percent of any amount
202 recovered as a result of such overcharge, up to a maximum of
203 $1,000.
204 (2) A state group health insurance plan shall allow its
205 participants to obtain a covered health care service from an
206 out-of-network provider at a cost that is the same or less than
207 the in-network average that the state group health insurance
208 plan pays for that health care service. The state group health
209 insurance plan shall apply, within a reasonable timeframe not to
210 exceed 1 year, the payment made by, or required of, a
211 participant for that health care service toward the
212 participant’s deductible and out-of-pocket maximum as specified
213 in the state group health insurance plan as if the health care
214 service had been provided by an in-network provider.
215 (3) If a participant uses a pharmacy discount program, drug
216 manufacturer rebate, or other discount or rebate program,
217 including purchasing a prescription drug from a licensed
218 prescribing provider such as a direct primary care provider, and
219 such use results in a lower cost than would have been paid for a
220 covered prescription drug had the participant used the state
221 group health insurance plan to purchase the prescription drug,
222 the state group health insurance plan must apply the payment
223 made by the participant for that covered prescription drug
224 toward the participant’s deductible and out-of-pocket maximum as
225 specified in the state group health insurance plan as if the
226 prescription drug had been purchased from an in-network
227 pharmacy.
228 (4) At a minimum, a state group health insurance plan shall
229 inform participants on its website and in its benefit plan
230 materials of the options of obtaining covered health care
231 services from out-of-network providers and prescription drugs
232 from out-of-network pharmacies under subsections (2) and (3),
233 respectively, with the participants’ payments applied to
234 deductibles and out-of-pocket maximums. On its website and in
235 its benefit plan materials, a state group health insurance plan
236 shall also provide information on how to use the options under
237 subsections (2) and (3) if a participant is interested in doing
238 so.
239 Section 5. Section 465.203, Florida Statutes, is created to
240 read:
241 465.203 Pharmacy benefit managers; prohibited acts.—
242 (1) As used in this section, the term “covered individual”
243 means a member, a participant, an enrollee, a contract holder, a
244 policyholder, or a beneficiary of a health plan, health plan
245 sponsor, health plan provider, health insurer, health
246 maintenance organization, or any other payor that uses pharmacy
247 benefit management services in this state.
248 (2) A pharmacy benefit manager may not impose on a covered
249 individual a copayment or any other charge that exceeds the
250 claim cost of a prescription drug. If information related to a
251 covered individual’s out-of-pocket cost, the clinical efficacy
252 of a prescription drug, or alternative medication is available
253 to a pharmacy provider, a pharmacy benefit manager may not
254 penalize the pharmacy provider for providing that information to
255 the covered individual.
256 Section 6. Section 627.4435, Florida Statutes, is created
257 to read:
258 627.4435 Coverage for out-of-network providers and
259 prescription drugs.—
260 (1) DEFINITION.—As used in this section, the term “health
261 insurer” has the same meaning as provided in s. 408.07.
262 (2) HEALTH CARE SERVICES FROM OUT-OF-NETWORK PROVIDERS.
263 Beginning on January 1, 2021, upon approval of a health
264 insurer’s rate filings:
265 (a) If an insured obtains a covered health care service
266 from an out-of-network provider at a cost that is the same or
267 less than the in-network average that the health insurer pays
268 for that health care service, the health insurer must apply,
269 within a reasonable timeframe not to exceed 1 year, the payment
270 made by, or required of, an insured for that health care service
271 toward the insured’s deductible and out-of-pocket maximum as
272 specified in the insured’s health insurance policy, plan, or
273 contract as if the health care service had been provided by an
274 in-network provider.
275 (b) A health insurer may not deny payment for any in
276 network health care service covered under an insured’s health
277 insurance policy, plan, or contract based solely on the basis
278 that the insured’s referral was made by an out-of-network
279 provider. The health insurer may not apply a deductible,
280 coinsurance, or copayment greater than the applicable
281 deductible, coinsurance, or copayment that would apply to the
282 same health care service if the health care service was referred
283 by an in-network provider.
284 (3) PRESCRIPTION DRUGS.—
285 (a) A health insurer or a pharmacy benefit manager on
286 behalf of a health insurer may not impose on an insured a
287 copayment or other charge that exceeds the claim cost of a
288 prescription drug. If information related to an insured’s out
289 of-pocket cost, the clinical efficacy of a prescription drug, or
290 alternative medication is available to a pharmacy provider, a
291 health insurer or a pharmacy benefit manager on behalf of a
292 health insurer may not penalize the pharmacy provider for
293 providing that information to the insured.
294 (b) If an insured uses a pharmacy discount program, drug
295 manufacturer rebate, or other discount or rebate program,
296 including purchasing a prescription drug from a licensed
297 prescribing provider such as a direct primary care provider, and
298 such use results in a lower cost than would have been paid for a
299 covered prescription drug had the insured used the health
300 insurance policy, plan, or contract to purchase the prescription
301 drug, the health insurer or the pharmacy benefit manager on
302 behalf of a health insurer shall apply the payment made by the
303 insured for that covered prescription drug toward the insured’s
304 deductible and out-of-pocket maximum as specified in the
305 insured’s health insurance policy, plan, or contract as if the
306 prescription drug had been purchased from an in-network
307 pharmacy.
308 (c) This section does not restrict a health insurer from
309 requiring standard preauthorization or other precertification
310 requirements, such as the use of a formulary, that would
311 otherwise be required under the insured’s health insurance
312 policy, plan, or contract.
313 (4) NOTIFICATION TO INSUREDS.—
314 (a) At a minimum, a health insurer shall inform insureds on
315 its website and in its benefit policy, plan, or contract
316 materials of the options of obtaining health care services from
317 out-of-network providers and prescription drugs from out-of
318 network pharmacies under subsections (2) and (3), respectively,
319 with the insureds’ payments applied to deductibles and out-of
320 pocket maximums. On its website and in its benefit policy, plan,
321 or contract materials, the health insurer shall also inform
322 insureds on the process to obtain information on the average
323 amount paid to an in-network provider or in-network pharmacy for
324 a procedure, service, or prescription drug. The health insurer
325 shall provide on its website a downloadable or interactive form
326 for insureds to submit proof of payment to an out-of-network
327 provider or out-of-network pharmacy.
328 (b) If an insured who is in a group health insurance
329 policy, plan, or contract has paid for a health care service and
330 the paid contracted rate for the provider was in the highest
331 third for in-network providers for that insured’s group health
332 insurance policy, plan, or contract, the health insurer must
333 inform the insured, by mail, electronic transmission, or
334 telephone, that the insured has overpaid for the health care
335 service, and the health insurer must also inform the insured of
336 tools or methods the insured could use next time to elect a
337 lower-cost option if the insured is interested in doing so.
338 Section 7. Paragraphs (c), (d), and (e) of subsection (2)
339 and subsection (3) of section 627.6387, Florida Statutes, are
340 amended to read:
341 627.6387 Shared savings incentive program.—
342 (2) As used in this section, the term:
343 (c) “Shared savings incentive” means a voluntary and
344 optional financial incentive that a health insurer provides may
345 provide to an insured for choosing certain shoppable health care
346 services under a shared savings incentive program and may
347 include, but is not limited to, the incentives described in s.
348 626.9541(4)(a).
349 (d) “Shared savings incentive program” means an a voluntary
350 and optional incentive program established by a health insurer
351 pursuant to this section.
352 (e) “Shoppable health care service” means a lower-cost,
353 high-quality nonemergency health care service for which a shared
354 savings incentive is available for insureds under a health
355 insurer’s shared savings incentive program. Shoppable health
356 care services may be provided within or outside this state and
357 include, but are not limited to:
358 1. Clinical laboratory services.
359 2. Infusion therapy.
360 3. Inpatient and outpatient surgical procedures.
361 4. Obstetrical and gynecological services.
362 5. Inpatient and outpatient nonsurgical diagnostic tests
363 and procedures.
364 6. Physical and occupational therapy services.
365 7. Radiology and imaging services.
366 8. Prescription drugs.
367 9. Services provided through telehealth.
368 10. Any additional services identified by the Florida
369 Center for Health Information and Transparency which commonly
370 have a wide price variation.
371 (3) A health insurer shall may offer a shared savings
372 incentive program to provide incentives to an insured when the
373 insured obtains a shoppable health care service from the health
374 insurer’s shared savings list. An insured may not be required to
375 participate in a shared savings incentive program. A health
376 insurer that offers a shared savings incentive program must:
377 (a) Establish the program as a component part of the policy
378 or certificate of insurance provided by the health insurer and
379 notify the insureds and the office at least 30 days before
380 program termination.
381 (a)(b) File a description of the program on a form
382 prescribed by commission rule. The office must review the filing
383 and determine whether the shared savings incentive program
384 complies with this section.
385 (b)(c) Notify an insured annually and at the time of
386 renewal, and an applicant for insurance at the time of
387 enrollment, of the availability of the shared savings incentive
388 program and the procedure to participate in the program.
389 (c)(d) Publish on a webpage easily accessible to insureds
390 and to applicants for insurance a list of shoppable health care
391 services and health care providers and the shared savings
392 incentive amount applicable for each service. A shared savings
393 incentive may not be less than 25 percent of the savings
394 generated by the insured’s participation in any shared savings
395 incentive offered by the health insurer. The baseline for the
396 savings calculation is the average in-network amount paid for
397 that service in the most recent 12-month period or some other
398 methodology established by the health insurer and approved by
399 the office. The health insurer must also offer a toll-free
400 telephone number that an insured may call to compare services
401 that qualify for a shared savings incentive.
402 (d)(e) At least quarterly, credit or deposit the shared
403 savings incentive amount to the insured’s account as a return or
404 reduction in premium, or credit the shared savings incentive
405 amount to the insured’s flexible spending account, health
406 savings account, or health reimbursement account, or reward the
407 insured directly with cash or a cash equivalent such that the
408 amount does not constitute income to the insured.
409 (e)(f) Submit an annual report to the office within 90
410 business days after the close of each plan year. At a minimum,
411 the report must include the following information:
412 1. The number of insureds who participated in the program
413 during the plan year and the number of instances of
414 participation.
415 2. The total cost of services provided as a part of the
416 program.
417 3. The total value of the shared savings incentive payments
418 made to insureds participating in the program and the values
419 distributed as premium reductions, credits to flexible spending
420 accounts, credits to health savings accounts, or credits to
421 health reimbursement accounts.
422 4. An inventory of the shoppable health care services
423 offered by the health insurer.
424 Section 8. Paragraphs (c), (d), and (e) of subsection (2)
425 and subsection (3) of section 627.6648, Florida Statutes, are
426 amended to read:
427 627.6648 Shared savings incentive program.—
428 (2) As used in this section, the term:
429 (c) “Shared savings incentive” means a voluntary and
430 optional financial incentive that a health insurer provides may
431 provide to an insured for choosing certain shoppable health care
432 services under a shared savings incentive program and may
433 include, but is not limited to, the incentives described in s.
434 626.9541(4)(a).
435 (d) “Shared savings incentive program” means an a voluntary
436 and optional incentive program established by a health insurer
437 pursuant to this section.
438 (e) “Shoppable health care service” means a lower-cost,
439 high-quality nonemergency health care service for which a shared
440 savings incentive is available for insureds under a health
441 insurer’s shared savings incentive program. Shoppable health
442 care services may be provided within or outside this state and
443 include, but are not limited to:
444 1. Clinical laboratory services.
445 2. Infusion therapy.
446 3. Inpatient and outpatient surgical procedures.
447 4. Obstetrical and gynecological services.
448 5. Inpatient and outpatient nonsurgical diagnostic tests
449 and procedures.
450 6. Physical and occupational therapy services.
451 7. Radiology and imaging services.
452 8. Prescription drugs.
453 9. Services provided through telehealth.
454 10. Any additional services identified by the Florida
455 Center for Health Information and Transparency which commonly
456 have a wide price variation.
457 (3) A health insurer shall may offer a shared savings
458 incentive program to provide incentives to an insured when the
459 insured obtains a shoppable health care service from the health
460 insurer’s shared savings list. An insured may not be required to
461 participate in a shared savings incentive program. A health
462 insurer that offers a shared savings incentive program must:
463 (a) Establish the program as a component part of the policy
464 or certificate of insurance provided by the health insurer and
465 notify the insureds and the office at least 30 days before
466 program termination.
467 (a)(b) File a description of the program on a form
468 prescribed by commission rule. The office must review the filing
469 and determine whether the shared savings incentive program
470 complies with this section.
471 (b)(c) Notify an insured annually and at the time of
472 renewal, and an applicant for insurance at the time of
473 enrollment, of the availability of the shared savings incentive
474 program and the procedure to participate in the program.
475 (c)(d) Publish on a webpage easily accessible to insureds
476 and to applicants for insurance a list of shoppable health care
477 services and health care providers and the shared savings
478 incentive amount applicable for each service. A shared savings
479 incentive may not be less than 25 percent of the savings
480 generated by the insured’s participation in any shared savings
481 incentive offered by the health insurer. The baseline for the
482 savings calculation is the average in-network amount paid for
483 that service in the most recent 12-month period or some other
484 methodology established by the health insurer and approved by
485 the office. The health insurer must also offer a toll-free
486 telephone number that an insured may call to compare services
487 that qualify for a shared savings incentive.
488 (d)(e) At least quarterly, credit or deposit the shared
489 savings incentive amount to the insured’s account as a return or
490 reduction in premium, or credit the shared savings incentive
491 amount to the insured’s flexible spending account, health
492 savings account, or health reimbursement account, or reward the
493 insured directly with cash or a cash equivalent such that the
494 amount does not constitute income to the insured.
495 (e)(f) Submit an annual report to the office within 90
496 business days after the close of each plan year. At a minimum,
497 the report must include the following information:
498 1. The number of insureds who participated in the program
499 during the plan year and the number of instances of
500 participation.
501 2. The total cost of services provided as a part of the
502 program.
503 3. The total value of the shared savings incentive payments
504 made to insureds participating in the program and the values
505 distributed as premium reductions, credits to flexible spending
506 accounts, credits to health savings accounts, or credits to
507 health reimbursement accounts.
508 4. An inventory of the shoppable health care services
509 offered by the health insurer.
510 Section 9. Paragraphs (c), (d), and (e) of subsection (2)
511 and subsection (3) of section 641.31076, Florida Statutes, are
512 amended to read:
513 641.31076 Shared savings incentive program.—
514 (2) As used in this section, the term:
515 (c) “Shared savings incentive” means a voluntary and
516 optional financial incentive that a health maintenance
517 organization provides may provide to a subscriber for choosing
518 certain shoppable health care services under a shared savings
519 incentive program and may include, but is not limited to, the
520 incentives described in s. 641.3903(15).
521 (d) “Shared savings incentive program” means an a voluntary
522 and optional incentive program established by a health
523 maintenance organization pursuant to this section.
524 (e) “Shoppable health care service” means a lower-cost,
525 high-quality nonemergency health care service for which a shared
526 savings incentive is available for subscribers under a health
527 maintenance organization’s shared savings incentive program.
528 Shoppable health care services may be provided within or outside
529 this state and include, but are not limited to:
530 1. Clinical laboratory services.
531 2. Infusion therapy.
532 3. Inpatient and outpatient surgical procedures.
533 4. Obstetrical and gynecological services.
534 5. Inpatient and outpatient nonsurgical diagnostic tests
535 and procedures.
536 6. Physical and occupational therapy services.
537 7. Radiology and imaging services.
538 8. Prescription drugs.
539 9. Services provided through telehealth.
540 10. Any additional services identified by the Florida
541 Center for Health Information and Transparency which commonly
542 have a wide price variation.
543 (3) A health maintenance organization shall may offer a
544 shared savings incentive program to provide incentives to a
545 subscriber when the subscriber obtains a shoppable health care
546 service from the health maintenance organization’s shared
547 savings list. A subscriber may not be required to participate in
548 a shared savings incentive program. A health maintenance
549 organization that offers a shared savings incentive program
550 must:
551 (a) Establish the program as a component part of the
552 contract of coverage provided by the health maintenance
553 organization and notify the subscribers and the office at least
554 30 days before program termination.
555 (a)(b) File a description of the program on a form
556 prescribed by commission rule. The office must review the filing
557 and determine whether the shared savings incentive program
558 complies with this section.
559 (b)(c) Notify a subscriber annually and at the time of
560 renewal, and an applicant for coverage at the time of
561 enrollment, of the availability of the shared savings incentive
562 program and the procedure to participate in the program.
563 (c)(d) Publish on a webpage easily accessible to
564 subscribers and to applicants for coverage a list of shoppable
565 health care services and health care providers and the shared
566 savings incentive amount applicable for each service. A shared
567 savings incentive may not be less than 25 percent of the savings
568 generated by the subscriber’s participation in any shared
569 savings incentive offered by the health maintenance
570 organization. The baseline for the savings calculation is the
571 average in-network amount paid for that service in the most
572 recent 12-month period or some other methodology established by
573 the health maintenance organization and approved by the office.
574 The health maintenance organization must also offer a toll-free
575 telephone number that a subscriber may call to compare services
576 that qualify for a shared savings incentive.
577 (d)(e) At least quarterly, credit or deposit the shared
578 savings incentive amount to the subscriber’s account as a return
579 or reduction in premium, or credit the shared savings incentive
580 amount to the subscriber’s flexible spending account, health
581 savings account, or health reimbursement account, or reward the
582 subscriber directly with cash or a cash equivalent such that the
583 amount does not constitute income to the subscriber.
584 (e)(f) Submit an annual report to the office within 90
585 business days after the close of each plan year. At a minimum,
586 the report must include the following information:
587 1. The number of subscribers who participated in the
588 program during the plan year and the number of instances of
589 participation.
590 2. The total cost of services provided as a part of the
591 program.
592 3. The total value of the shared savings incentive payments
593 made to subscribers participating in the program and the values
594 distributed as premium reductions, credits to flexible spending
595 accounts, credits to health savings accounts, or credits to
596 health reimbursement accounts.
597 4. An inventory of the shoppable health care services
598 offered by the health maintenance organization.
599 Section 10. This act shall take effect January 1, 2021.