Disclosure of information by health care providers, insurers, and governmental self-insured plans; requiring acceptance by a health care provider of a payment amount in certain circumstances; and requiring the exercise of rule-making authority

Under the bill, if a patient is recommended, referred for service, or prescribed a health care service (including any applicable course of treatment), diagnostic test, or procedure for which the charge exceeds $500 or any higher amount that the Department of Health Services (DHS) promulgates by rule (the minimum cost), the health care provider must provide an estimate of the charge to the patient, whether insured or uninsured, or the patient's agent who requests it. The estimate of the charge must be provided at the time of scheduling of the health care service, diagnostic test, procedure, or course of treatment, or within ten business days of the request, whichever is later. The bill specifies numerous requirements for the estimate of charge, except that, in lieu of several of the requirements, a health care provider may provide to the patient or his or her agent an estimate of charge that is a single fixed-price estimate of the total cost of the health care service, diagnostic test, or procedure.

The bill requires DHS, by rule, biennially to adjust the dollar amount that is specified for minimum cost and specifies a procedure, using the consumer price index, by which the adjusted dollar amount must be calculated. DHS may promulgate the amount as an emergency rule without providing a finding of emergency or complying with certain other standards for promulgating emergency rules.

The bill requires a self-insured health plan of the state or a county, city, village, town, or school district, or an insurer that provides health care coverage under a health care plan, including a defined network plan or a sickness care plan operated by a cooperative association, to provide to an insured under the health care plan or an enrollee under the self-insured health plan, any of the following if requested by the insured or enrollee: 1) a description of the coverage, including benefits and cost-sharing requirements, under the health care plan or self-insured health plan;

2) a description of any pre-certification or other requirements that an insured or enrollee must complete before any care is approved by the insurer or self-insured health plan; and 3) a summary of the insured's or enrollee's coverage with respect to a specific medical service or course of treatment. The summary of coverage is based on information relating to an estimate of a charge for a medical service or course of treatment that was provided by a provider or group of providers to the insured or enrollee and must include an estimate of the total out-of-pocket costs that the insured or enrollee may incur, an estimate of the amount that the insurer or self-insured health plan has paid to the provider or providers, any limits on what the insurer or self-insured health plan will pay if the service or course of treatment is received from a nonparticipating or out-of-network provider, and any discounts that the insurer or self-insured health plan is willing to offer the insured or enrollee if the service or course of treatment is received from a different provider.