H.F. No. 638 Summary

• Each health plan company must offer a shared savings incentive program to enrollees beginning January 1, 2020, providing incentives when enrollees receive covered comparable health care services from providers charging less than the average allowed amount.

• Program must provide enrollees at least 50 percent of saved costs for comparable services including physical/occupational therapy, obstetrical/gynecological, radiology, laboratory, infusion therapy, surgical procedures, and diagnostic tests.

• Health plan companies must establish interactive mechanisms allowing enrollees to request cost information, receive good faith estimates of out-of-pocket costs, and compare average allowed amounts paid to in-network providers.

• Enrollees may receive services from out-of-network providers at lower costs with payments applied toward deductibles and out-of-pocket maximums as if provided in-network, subject to proof of payment submission.

• Health plan companies must file annual reports with the commissioner beginning March 1, 2021, detailing total incentive payments, service utilization by category, average payment amounts, total savings achieved, and percentage of enrollee participation.