Reimbursement Requirements for Health Insurers

The bill sets the reimbursement rates that a health insurance carrier (carrier) may reimburse a health-care provider (provider) for covered services for the state employee group benefit plans (state group benefit plans) and for small employer group benefit plans (small group plans).

The bill prohibits a provider that is subject to the reimbursement limitations from billing or collecting payment from a person covered under a state group benefit plan or small group plan for any outstanding balance for covered services that is not reimbursed by the carrier, except for the applicable in-network coinsurance, copayment, or deductible amounts.

The bill requires a carrier to provide cost and quality of care information to the commissioner of insurance (commissioner) in the case of small group plans and to the director of the department of personnel (director) in the case of state group benefit plans, at the request of the commissioner or director, as applicable, and prohibits a carrier from entering into an agreement with a provider or third party that would restrict the carrier from providing the information.

By September 1, 2027, and by September 1 each year thereafter, the director is required to provide a report to the governor's office, the state treasurer's office, and the joint budget committee that states the amount of calculated savings in general fund expenditures (calculated savings), if any, for health plan reimbursement for the prior fiscal year as a result of the reimbursement limits for state group benefit plans. The director is also required to include in the report the cost to the department in determining the calculated savings. By September 15, 2027, and by September 15 each year thereafter, of the money from the calculated savings, the state treasurer is required to transfer an amount equal to the department's costs in determining the calculated savings to the group benefit plans expenditure savings cash fund (expenditure savings cash fund), which is created in the bill, and specified percentages of the calculated savings from the general fund to the primary care fund and to the expenditure savings cash fund.

The bill also requires the executive director of the department of health care policy and financing (state department) to conduct a study, in collaboration with specified state agencies, to determine the feasibility of establishing a similar reimbursement limit for group benefit plans offered to school district, higher education, and local government employees. The executive director is required to complete the study and report the findings to the general assembly on or before January 1, 2028. The bill allocates $500,000 from the calculated savings to a health care reimbursement feasibility study cash fund created in the bill and authorizes the state department to use the money to conduct the study.

(Note: This summary applies to this bill as introduced.)