THE PATIENT RIGHT TO SHOP ACT: would require health care entities to disclose, within two working days, the allowed amount or charge of a patient or prospective patient’s admission, procedure, or service if the patient so requests. If the health care entity were not able to predict a specific code, it would still be required to disclose the maximum allowed amount.
SB172 would also require health carriers establish a toll-free phone number and a website that enables its insureds to request and obtain carrier information on the average price paid to a participating provider for a proposed admission, procedure, or service in each provider network area established b the carrier and an estimated cost. The carrier would be required to respond to an insured’s request with a binding estimate for the maximum allowed amount or charge within two business days—and would include facility fees, copayments, deductibles, coinsurances, and other out-of-pocket amounts.
If an insured were to elect to receive health care services from a participating provider that cost less than the average cost for a particular admission, procedure or service, a carrier would have to pay to an insured 50% of the saved cost except that a carrier would not required to make such payment if the saved cost is $25 or less. If an insured were to elect to receive health care services from an out-of- network provider that costs less than the average cost for a particular admission, procedure or service, a carrier would have to apply the insured’s share of the cost of those health care services as specified in the insured’s health benefit plan toward the insured’s out-of-pocket limit as if the health care services were provided by a participating provider.