AN ACT to establish fair pricing for low-complexity, routine medical care.

 § 1. Fair Pricing for Certain Services

   1. Definitions. As used in this section:

    (a) “Applicable services” means outpatient or ambulatory items or services that can be provided safely and appropriately across ambulatory care settings; including:

          (i) the services, as identified by Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes, contained within the sixty-six ambulatory payment classifications (APCs) identified by the Medicare Payment Advisory Commission (MedPAC) in its June 2023 Report to Congress recommending a site-neutral payment policy, and any subsequent APCs or services so designated by MedPAC;

          (ii) any outpatient or ambulatory item or service recommended or required to be paid on a site-neutral basis by federal or [state] statute, the U.S. Department of Health & Human Services, or the Medicare Payment Advisory Commission (MedPAC), including without limitation,  evaluation and management office visits, wellness visits, physical therapy, occupational therapy, speech language pathology, and mammography (screening and diagnostic);

          (iii) any other outpatient or ambulatory items or services as designated by the [Department/Commissioner/Secretary] as safe and appropriate to be provided in lower-cost settings.

[Comment: Accompanying FAQ will describe applicable services in more detail. For definitions (b) through (m), states may reference their own definitions for these terms, rendering new definitions unnecessary. “Department” refers the state’s department of health, “Commissioner” refers to the state’s Commissioner of Insurance, and “Secretary” refers to the state’s Secretary of health and human services. States can decide which authority in which to vest these powers and modify the terms to reflect the state-specific titles and authorities, accordingly.]

    (b) “Health benefit plan” means a plan, policy, contract, certificate, or agreement entered into, offered, or issued by a health insurance carrier or third-party administrator acting on behalf of a plan sponsor to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services and includes nonfederal governmental plans as defined in 29 U.S.C. § 1002(32). Health benefit plan does not include any plans, programs of coverage, or benefits administered under 42 U.S.C. § 1395 et seq. (Medicare).

    (c) “Plan sponsor” means:

          (i) the employer in the case of a benefit plan established or maintained by a single employer;

          (ii) the employee organization in the case of a benefit plan established or maintained by an employee organization, provided that “employee organization” shall mean any labor union or any organization of any kind, or any agency or employee representation committee, association, group, or plan, in which employees participate and that exists for the purpose, in whole or in part, of dealing with employers concerning an employee benefit plan, or other matters incidental to employment relationships, or any employees’ beneficiary association organized for the purpose in whole or in part, of establishing such a plan; or

          (iii) in the case of a benefit plan established or maintained by two or more employers or jointly by one or more employers and one or more employee organizations, the association, committee, joint board of trustees, or other similar group of representatives of the parties who establish or maintain the benefit plan.

    (d) “Health care contract” means a contract, agreement, or understanding, either orally or in writing, entered into, amended, restated, or renewed between a health care provider and a health insurance carrier, one or more third-party administrators, a plan sponsor or its contractors or agents for the delivery of health care services to an enrollee of a health benefit plan.

    (e) “Health care provider” means an individual, entity, corporation, person, or organization, whether for profit or nonprofit, operating under [state licensing statute] that furnishes, bills or is paid for health care service delivery in the normal course of business, and includes hospitals, hospital extension clinics, diagnostic and treatment centers, physician offices, or urgent care clinics, as well any affiliated provider or entity billing for health care goods or services delivered at the health care provider’s facility as an employee, contractor, a clinical faculty member, or otherwise.

[Comment: States could exclude certain facility or provider types from the legislation, such as critical access hospitals, rural hospitals, FQHCs, etc.]

    (f) “Health insurance carrier” means an entity licensed under [insurance licensing statute] and regulations of this state or subject to the jurisdiction of the [state insurance commissioner] that offers health insurance, health benefits, or contracts for health care services, prescription drug coverage, to large groups, small groups, or individuals on or outside the [state’s ACA Marketplace].

    (g) “Health system” means:

          (i) a parent corporation of one or more hospitals and any entity affiliated with such parent corporation through ownership, governance, membership or other means; or

          (ii) a hospital and any entity affiliated with such hospital through ownership, governance, membership or other means.

    (h) “Hospital-based facility” means a facility that is owned or operated, in whole or in part, by a hospital where hospital or professional medical services are provided, including without limitation, an outpatient department of the hospital.

    (i) “Medicare non-hospital rate” means the amount paid by Medicare for those same services pursuant to the Medicare Physician Fee Schedule, set forth under 42 U.S.C. § 1395w-4, or the Ambulatory Surgical Center (ASC) Payment System, set forth under 42 U.S.C. § 1395l(i)(2)(D), according to the site of service recommended by MedPAC as the reference rate where applicable.

    (j) “Participating provider” means a provider under contract with a health benefit plan, or one of its delegates, who has agreed under such contract to provide health care services to the health benefit plan’s beneficiaries with an expectation of receiving payment, other than coinsurance, copayments, or deductibles from the beneficiary, only from the health care entity under the terms of the contract.

    (k) “Site-neutral payment policy” means the policy of reimbursing health care providers the same amount for a similar service, regardless of the site or setting of the service.

    (l) “Third-party administrator” means a health plan administrator who acts on behalf of a plan sponsor to administer a health benefit plan.