This bill requires defined network plans, such as health maintenance
organizations, and certain preferred provider plans and self-insured governmental
plans that cover benefits or services provided in either an emergency department of
a hospital or independent freestanding emergency department to cover emergency
medical services without requiring a prior authorization determination and without
regard to whether the health care provider providing the emergency medical services
is a participating provider or facility. If the emergency medical services for which
coverage is required are provided by a nonparticipating provider, the plan must 1)
not impose a prior authorization requirement or other limitation that is more
restrictive than if the service was provided by a participating provider; 2) not impose
cost sharing on an enrollee that is greater than the cost sharing required if the
service was provided by a participating provider; 3) calculate the cost-sharing
amount to be equal to the amount that would have been charged if the service was
provided by a participating provider; 4) provide, within 30 days of the provider’s or
facility’s bill, an initial payment or denial notice to the provider or facility and then
pay a total amount to the provider or facility that is equal to the amount by which
the provider’s or facility’s rate exceeds the amount it received in cost sharing from
the enrollee; and 5) count any cost-sharing payment made by the enrollee for the emergency medical services toward any in-network deductible or out-of-pocket
maximum as if the cost-sharing payment was made for services provided by a
participating provider or facility. The provider or facility may not bill or hold liable
an enrollee of the plan for any amount for the emergency medical service that is more
than the cost-sharing amount that is calculated as described in the bill for the
emergency medical service.

This bill requires a defined network plan or preferred provider plan to make
available a current directory of health care providers in the plan’s network of
providers to anyone considering enrollment in the plan and to the plan’s enrollees at
least annually. Defined network plans and preferred provider plans are types of
managed care organizations that provide health care benefits to their enrollees. The
bill requires the plan to maintain a current provider directory on its website, to
ensure that the directory on the site is updated at least quarterly, and to ensure that
the public may view the provider directory on the site without creating or accessing
an account or entering a policy or contract number. A plan is also required by the bill
to provide information in each electronic and print directory on providers for each of
the plan’s covered services, to prominently indicate in each electronic and print
directory which providers are accepting new patients at the time the directory is
updated, and to accommodate with each electronic and print directory the
communication needs of persons with disabilities and persons with limited English
proficiency.

Regulation of pharmacy benefit managers, fiduciary and disclosure requirements on pharmacy benefit managers, and application of prescription drug payments to health insurance cost-sharing requirements.

Price transparency in hospitals and providing a penalty. This bill creates several requirements for hospitals to provide cost information
for certain items and services provided by the hospital. Under the bill, each hospital
must make publicly available a digital file in a machine-readable format that
contains a list of standard charges for certain items and services provided by the
hospital and a consumer-friendly list of standard charges for certain shoppable
services. “Standard charge” is defined to mean the regular rate established by the
hospital for an item or service provided to a specific group of paying patients and
includes certain price information, including the gross charge, the payor-specific
negotiated charge, and the discounted cash price. “Shoppable service” is defined to
mean a service that may be scheduled by a health care consumer in advance. If the
Department of Health Services determines that a hospital is not in compliance with
any of the price transparency requirements specified in the bill, the bill requires DHS
to take certain actions, including providing a written notice to the hospital,
requesting a corrective action plan from the hospital, or imposing a penalty. The bill
establishes escalating penalties for violations of the hospital price transparency
requirements specified in the bill based on the hospital’s bed count, from $600 for
each day in which a hospital with 30 beds or fewer violates the hospital price
transparency requirements under the bill up to $10,000 for each day in which a
hospital with greater than 550 beds violates the hospital price transparency
requirements under the bill.

Price transparency in hospitals and providing a penalty. This bill creates several requirements for hospitals to provide cost information
for certain items and services provided by the hospital. Under the bill, each hospital
must make publicly available a digital file in a machine-readable format that
contains a list of standard charges for certain items and services provided by the
hospital and a consumer-friendly list of standard charges for certain shoppable
services. “Standard charge” is defined to mean the regular rate established by the
hospital for an item or service provided to a specific group of paying patients and
includes certain price information, including the gross charge, the payor-specific
negotiated charge, and the discounted cash price. “Shoppable service” is defined to
mean a service that may be scheduled by a health care consumer in advance. If the
Department of Health Services determines that a hospital is not in compliance with
any of the price transparency requirements specified in the bill, the bill requires DHS
to take certain actions, including providing a written notice to the hospital,
requesting a corrective action plan from the hospital, or imposing a penalty. The bill
establishes escalating penalties for violations of the hospital price transparency
requirements specified in the bill based on the hospital’s bed count, from $600 for
each day in which a hospital with 30 beds or fewer violates the hospital price
transparency requirements under the bill up to $10,000 for each day in which a
hospital with greater than 550 beds violates the hospital price transparency
requirements under the bill.

Creating a Prescription Drug Affordability Review Board, funding for an office of prescription drug affordability, crediting certain amounts to the general program operations account of the office of the commissioner of insurance, granting rulemaking authority, and making an appropriation.

Cost-sharing cap on insulin. This bill prohibits every health insurance policy and governmental self-insured health plan that cover insulin and impose cost sharing on prescription drugs from imposing cost sharing on insulin in an amount that exceeds $35 for a one-month supply. The bill’s cost-sharing limitation on insulin supersedes the specification that the exclusions, limitations, deductibles, and coinsurance are the same as for other coverage.

Cost-sharing cap on insulin. This bill prohibits every health insurance policy and governmental self-insured health plan that cover insulin and impose cost sharing on prescription drugs from imposing cost sharing on insulin in an amount that exceeds $35 for a one-month supply. The bill’s cost-sharing limitation on insulin supersedes the specification that the exclusions, limitations, deductibles, and coinsurance are the same as for other coverage.

Application of prescription drug payments to health insurance cost-sharing requirements. Health insurance policies and plans often apply deductibles and out-of-pocket
maximum amounts to the benefits covered by the policy or plan. A deductible is an
amount that an enrollee in a policy or plan must pay out of pocket before attaining
the full benefits of the policy or plan. An out-of-pocket maximum amount is a limit
specified by a policy or plan on the amount that an enrollee pays, and, once that limit
is reached, the policy or plan covers the benefit entirely. This bill generally requires
health insurance policies that offer prescription drug benefits, self-insured health
plans, and pharmacy benefit managers acting on behalf of policies or plans to apply
amounts paid by or on behalf of an individual covered under the policy or plan for
brand name prescription drugs to any cost-sharing requirement or to any
calculation of an out-of-pocket maximum amount of the policy or plan. Health
insurance policies are referred to in the bill as disability insurance policies.

Application of prescription drug payments to health insurance cost-sharing requirements. Health insurance policies and plans often apply deductibles and out-of-pocket
maximum amounts to the benefits covered by the policy or plan. A deductible is an
amount that an enrollee in a policy or plan must pay out of pocket before attaining
the full benefits of the policy or plan. An out-of-pocket maximum amount is a limit
specified by a policy or plan on the amount that an enrollee pays, and, once that limit
is reached, the policy or plan covers the benefit entirely. This bill generally requires
health insurance policies that offer prescription drug benefits, self-insured health
plans, and pharmacy benefit managers acting on behalf of policies or plans to apply
amounts paid by or on behalf of an individual covered under the policy or plan for
brand name prescription drugs to any cost-sharing requirement or to any
calculation of an out-of-pocket maximum amount of the policy or plan. Health
insurance policies are referred to in the bill as disability insurance policies.