Amends TCA Title 8; Title 56 and Title 71.
As described below, this bill makes changes to the Tennessee Right to Shop Act.<br /> <br /> OUT-OF-POCKET PAYMENTS<br /> <br /> This bill provides that an individual who is insured under a healthcare plan ("covered person") may choose to pay out-of-pocket for a nonemergency medical service, including a prescription drug or device ("service"). If a covered person negotiates for a lower cost for the service than the average allowed amount paid by the carrier to network providers for a comparable service, and the covered person pays for the service out-of-pocket, then the healthcare entity must send documentation to the carrier that provides the following:<br /> <br /> (1) What service the covered person received;<br /> <br /> (2) The negotiated cost of the service received; and <br /> <br /> (3) A statement that the covered person paid out-of-pocket for the service received, and the healthcare entity is not making a claim against the carrier for payment for the service provided to the covered person.<br /> <br /> If a carrier receives such documentation from a healthcare entity, then this bill requires the carrier to count the full amount that the covered person paid out-of-pocket toward the covered person's deductible, coinsurance, copayment, or other cost-sharing amount:<br /> <br /> (1) If the service is included under the covered person's insurance plan; <br /> <br /> (2) The covered person negotiated for a lower cost for the service than the average allowed amount paid by the carrier to network providers for that comparable service; and <br /> <br /> (3) Regardless of whether the healthcare entity belongs to the provider network in the healthcare plan.<br /> <br /> This bill provides that the amount counted toward a covered person's out-of-pocket deductible, coinsurance, copayment, or other cost-sharing amount must not exceed the total amount that the covered person is required to pay out-of-pocket during a contractually agreed upon period of time for services that are included under the covered person's insurance plan, and does not carry over once a new contract or agreement period for the insurance plan begins.<br /> <br /> INCENTIVES<br /> <br /> Present law requires a carrier offering a health plan in this state to implement a shopping and decision support program that provides shopping capabilities and decision support services for enrollees in a health plan. Present law authorizes a carrier to provide incentives for enrollees who elect to receive a comparable healthcare service from a network provider that is covered by the health plan and that is paid less than the average allowed amount paid by that carrier to network providers for that comparable healthcare service before and after an enrollee's out-of-pocket limit has been met. Incentives may be calculated as a percentage of the difference between the amount actually paid by the carrier for a given comparable healthcare service and the average allowed amount for that healthcare service. Incentives may be provided as a cash payment to the enrollee; a credit toward the enrollee's annual in-network deductible and out-of-pocket limit; or a credit or reduction of a premium, a copayment, cost sharing, or a deductible.<br /> <br /> This bill clarifies that these provisions are in addition to the provisions above concerning a covered person choosing to pay for healthcare services out-of-pocket. <br /> <br /> CAP ON INCENTIVES<br /> <br /> Present law prohibits the total value of incentives offered to any one enrollee from exceeding $599 in any year. This bill clarifies that this monetary limit on incentives does not apply to the provisions above concerning a covered person choosing to pay for healthcare services out-of-pocket.<br /> <br /> APPLICABILITY<br /> <br /> This bill applies to healthcare plans issued, delivered, entered into, amended, or renewed on or after July 1, 2023.<br /> <br /> ON MARCH 6, 2023, THE HOUSE ADOPTED AMENDMENT #1 AND PASSED HOUSE BILL 1213, AS AMENDED.<br /> <br /> AMENDMENT #1 rewrites this bill to amend the Tennessee Right to Shop Act, as described below. <br /> <br /> OUT-OF-POCKET PAYMENTS<br /> <br /> Present law generally requires the Tennessee advisory commission on intergovernmental relations (“TACIR”) to perform a study of any cost savings realized by enrollees with health plans, including private health plans and state funded health plans, in states that have adopted legislation or programs that require carriers offering health plans in those states to offer incentive programs to enrollees for shopping for healthcare services at lower costs, commonly referred to as “Right to Shop” legislation or programs. The study must include, at a minimum, an examination of savings realized by such programs in Maine, New Hampshire, Florida, Arizona, and Kentucky. All appropriate state departments and agencies must provide assistance to TACIR, which must report its findings to the general assembly no later than December 2020. <br /> <br /> This amendment deletes these provisions and provides that an individual may choose to pay for a nonemergency service for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease, including a prescription drug or device (“service”) out-of-pocket from an out-of-network provider. If an enrollee negotiates for a lower cost for the service than the average allowed amount paid by the carrier to network providers for a comparable healthcare service, and the enrollee pays for the service out-of-pocket, then the enrollee may send documentation to the carrier that provides the following:<br /> <br /> (1) The healthcare service the enrollee or patient received and the healthcare provider’s name and contact information;<br /> <br /> (2) The order from the healthcare provider given to the enrollee or patient and the final bill or statement for the healthcare service; <br /> <br /> (3) The average payments made by the carrier to network entities or providers for comparable healthcare services if this information is made available to the enrollee; <br /> <br /> (4) The negotiated cost of the healthcare service that the enrollee received; and <br /> <br /> (5) A statement that the enrollee paid out-of-pocket for the healthcare services received and the healthcare entity is not making a claim against the carrier for payment for the healthcare service provided to the enrollee or patient. <br /> <br /> If a carrier receives such documentation from an enrollee, then this amendment requires the carrier to count the full amount that the enrollee paid out-of-pocket toward the enrollee’s deductible, coinsurance, copayment, or other cost-sharing amount:<br /> <br /> (1) If the service is included under the enrollee's insurance plan; and <br /> <br /> (2) The enrollee negotiated for a lower cost for the service than the average allowed amount paid by the carrier to network providers for that comparable service. <br /> <br /> This amendment prohibits the amount counted toward an enrollee's out-of-pocket deductible, coinsurance, copayment, or other cost-sharing amount from exceeding the total amount that the enrollee is required to pay out-of-pocket during a contractually agreed upon period of time for services that are included under the enrollee's insurance plan. Such amount does not carry over once a new contract or agreement period for the insurance plan begins.<br /> <br /> INCENTIVES<br /> <br /> Present law requires a carrier offering a health plan in this state to implement a shopping and decision support program that provides shopping capabilities and decision support services for enrollees in a health plan. Present law authorizes a carrier to provide incentives for enrollees who elect to receive a comparable healthcare service from a network provider that is covered by the health plan and that is paid less than the average allowed amount paid by that carrier to network providers for that comparable healthcare service before and after an enrollee's out-of-pocket limit has been met. Incentives may be calculated as a percentage of the difference between the amount actually paid by the carrier for a given comparable healthcare service and the average allowed amount for that healthcare service. Incentives may be provided as a cash payment to the enrollee; a credit toward the enrollee's annual in-network deductible and out-of-pocket limit; or a credit or reduction of a premium, a copayment, cost sharing, or a deductible.<br /> <br /> This amendment clarifies that these provisions are in addition to the provisions above concerning an enrollee choosing to pay for healthcare services out-of-pocket. <br /> <br /> CAP ON INCENTIVES<br /> <br /> Present law prohibits the total value of incentives offered to any one enrollee from exceeding $599 in any year. This amendment clarifies that this monetary limit on incentives does not apply to the provisions above concerning an enrollee choosing to pay for healthcare services out-of-pocket.<br /> <br /> INTERACTIVE MEMBER PORTAL<br /> <br /> Present law requires a carrier to make available an interactive member portal or a toll-free phone number that enables an enrollee to request and obtain from the carrier information on out-of-pocket costs to the enrollee for the comparable healthcare services or on the average payments made by the carrier to network entities or providers for comparable healthcare services, as well as quality data for those providers, to the extent available. In addition, the member portal or toll-free phone number must allow an enrollee seeking information about the cost of a particular healthcare service to estimate out-of-pocket costs applicable to that enrollee and compare the average allowed amount paid to a network provider for the procedure or service under the enrollee's health plan within a reasonable timeframe not to exceed one year.<br /> <br /> This amendment lowers the reasonable timeframe to not exceed 30 days.<br />
As described below, this bill makes changes to the Tennessee Right to Shop Act.<br /> <br /> OUT-OF-POCKET PAYMENTS<br /> <br /> This bill provides that an individual who is insured under a healthcare plan ("covered person") may choose to pay out-of-pocket for a nonemergency medical service, including a prescription drug or device ("service"). If a covered person negotiates for a lower cost for the service than the average allowed amount paid by the carrier to network providers for a comparable service, and the covered person pays for the service out-of-pocket, then the healthcare entity must send documentation to the carrier that provides the following:<br /> <br /> (1) What service the covered person received;<br /> <br /> (2) The negotiated cost of the service received; and <br /> <br /> (3) A statement that the covered person paid out-of-pocket for the service received, and the healthcare entity is not making a claim against the carrier for payment for the service provided to the covered person.<br /> <br /> If a carrier receives such documentation from a healthcare entity, then this bill requires the carrier to count the full amount that the covered person paid out-of-pocket toward the covered person's deductible, coinsurance, copayment, or other cost-sharing amount:<br /> <br /> (1) If the service is included under the covered person's insurance plan; <br /> <br /> (2) The covered person negotiated for a lower cost for the service than the average allowed amount paid by the carrier to network providers for that comparable service; and <br /> <br /> (3) Regardless of whether the healthcare entity belongs to the provider network in the healthcare plan.<br /> <br /> This bill provides that the amount counted toward a covered person's out-of-pocket deductible, coinsurance, copayment, or other cost-sharing amount must not exceed the total amount that the covered person is required to pay out-of-pocket during a contractually agreed upon period of time for services that are included under the covered person's insurance plan, and does not carry over once a new contract or agreement period for the insurance plan begins.<br /> <br /> INCENTIVES<br /> <br /> Present law requires a carrier offering a health plan in this state to implement a shopping and decision support program that provides shopping capabilities and decision support services for enrollees in a health plan. Present law authorizes a carrier to provide incentives for enrollees who elect to receive a comparable healthcare service from a network provider that is covered by the health plan and that is paid less than the average allowed amount paid by that carrier to network providers for that comparable healthcare service before and after an enrollee's out-of-pocket limit has been met. Incentives may be calculated as a percentage of the difference between the amount actually paid by the carrier for a given comparable healthcare service and the average allowed amount for that healthcare service. Incentives may be provided as a cash payment to the enrollee; a credit toward the enrollee's annual in-network deductible and out-of-pocket limit; or a credit or reduction of a premium, a copayment, cost sharing, or a deductible.<br /> <br /> This bill clarifies that these provisions are in addition to the provisions above concerning a covered person choosing to pay for healthcare services out-of-pocket. <br /> <br /> CAP ON INCENTIVES<br /> <br /> Present law prohibits the total value of incentives offered to any one enrollee from exceeding $599 in any year. This bill clarifies that this monetary limit on incentives does not apply to the provisions above concerning a covered person choosing to pay for healthcare services out-of-pocket.<br /> <br /> APPLICABILITY<br /> <br /> This bill applies to healthcare plans issued, delivered, entered into, amended, or renewed on or after July 1, 2023.<br /> <br /> ON MARCH 6, 2023, THE HOUSE ADOPTED AMENDMENT #1 AND PASSED HOUSE BILL 1213, AS AMENDED.<br /> <br /> AMENDMENT #1 rewrites this bill to amend the Tennessee Right to Shop Act, as described below. <br /> <br /> OUT-OF-POCKET PAYMENTS<br /> <br /> Present law generally requires the Tennessee advisory commission on intergovernmental relations (“TACIR”) to perform a study of any cost savings realized by enrollees with health plans, including private health plans and state funded health plans, in states that have adopted legislation or programs that require carriers offering health plans in those states to offer incentive programs to enrollees for shopping for healthcare services at lower costs, commonly referred to as “Right to Shop” legislation or programs. The study must include, at a minimum, an examination of savings realized by such programs in Maine, New Hampshire, Florida, Arizona, and Kentucky. All appropriate state departments and agencies must provide assistance to TACIR, which must report its findings to the general assembly no later than December 2020. <br /> <br /> This amendment deletes these provisions and provides that an individual may choose to pay for a nonemergency service for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease, including a prescription drug or device (“service”) out-of-pocket from an out-of-network provider. If an enrollee negotiates for a lower cost for the service than the average allowed amount paid by the carrier to network providers for a comparable healthcare service, and the enrollee pays for the service out-of-pocket, then the enrollee may send documentation to the carrier that provides the following:<br /> <br /> (1) The healthcare service the enrollee or patient received and the healthcare provider’s name and contact information;<br /> <br /> (2) The order from the healthcare provider given to the enrollee or patient and the final bill or statement for the healthcare service; <br /> <br /> (3) The average payments made by the carrier to network entities or providers for comparable healthcare services if this information is made available to the enrollee; <br /> <br /> (4) The negotiated cost of the healthcare service that the enrollee received; and <br /> <br /> (5) A statement that the enrollee paid out-of-pocket for the healthcare services received and the healthcare entity is not making a claim against the carrier for payment for the healthcare service provided to the enrollee or patient. <br /> <br /> If a carrier receives such documentation from an enrollee, then this amendment requires the carrier to count the full amount that the enrollee paid out-of-pocket toward the enrollee’s deductible, coinsurance, copayment, or other cost-sharing amount:<br /> <br /> (1) If the service is included under the enrollee's insurance plan; and <br /> <br /> (2) The enrollee negotiated for a lower cost for the service than the average allowed amount paid by the carrier to network providers for that comparable service. <br /> <br /> This amendment prohibits the amount counted toward an enrollee's out-of-pocket deductible, coinsurance, copayment, or other cost-sharing amount from exceeding the total amount that the enrollee is required to pay out-of-pocket during a contractually agreed upon period of time for services that are included under the enrollee's insurance plan. Such amount does not carry over once a new contract or agreement period for the insurance plan begins.<br /> <br /> INCENTIVES<br /> <br /> Present law requires a carrier offering a health plan in this state to implement a shopping and decision support program that provides shopping capabilities and decision support services for enrollees in a health plan. Present law authorizes a carrier to provide incentives for enrollees who elect to receive a comparable healthcare service from a network provider that is covered by the health plan and that is paid less than the average allowed amount paid by that carrier to network providers for that comparable healthcare service before and after an enrollee's out-of-pocket limit has been met. Incentives may be calculated as a percentage of the difference between the amount actually paid by the carrier for a given comparable healthcare service and the average allowed amount for that healthcare service. Incentives may be provided as a cash payment to the enrollee; a credit toward the enrollee's annual in-network deductible and out-of-pocket limit; or a credit or reduction of a premium, a copayment, cost sharing, or a deductible.<br /> <br /> This amendment clarifies that these provisions are in addition to the provisions above concerning an enrollee choosing to pay for healthcare services out-of-pocket. <br /> <br /> CAP ON INCENTIVES<br /> <br /> Present law prohibits the total value of incentives offered to any one enrollee from exceeding $599 in any year. This amendment clarifies that this monetary limit on incentives does not apply to the provisions above concerning an enrollee choosing to pay for healthcare services out-of-pocket.<br /> <br /> INTERACTIVE MEMBER PORTAL<br /> <br /> Present law requires a carrier to make available an interactive member portal or a toll-free phone number that enables an enrollee to request and obtain from the carrier information on out-of-pocket costs to the enrollee for the comparable healthcare services or on the average payments made by the carrier to network entities or providers for comparable healthcare services, as well as quality data for those providers, to the extent available. In addition, the member portal or toll-free phone number must allow an enrollee seeking information about the cost of a particular healthcare service to estimate out-of-pocket costs applicable to that enrollee and compare the average allowed amount paid to a network provider for the procedure or service under the enrollee's health plan within a reasonable timeframe not to exceed one year.<br /> <br /> This amendment lowers the reasonable timeframe to not exceed 30 days.<br />
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