SCS/SB 122 - Under this act, if the co-payment applied by a HMO or health insurer exceeds the usual and customary retail price of a prescription drug, the enrollee shall only be required to pay the usual and customary retail price of the prescription drug and there will be no further charge to the enrollee or plan sponsor for the prescription (Sections 354.535 and 376.387). Under this act, health carriers are required, by July 1, 2012, to utilize a web-based estimating system or other mechanism, by which covered individuals, or their parents or guardians, will be able to enter, provide, or select from menus, the procedures, tests, or services the individual is considering having, and based upon the individual's benefit plan and the health carrier's internal data, receive estimates of the total cost and total out-of-pocket cost of the procedures, test, or services specific to all available contracted providers or facilities for which such estimates are requested. The estimates shall take into account any known unmet deductible obligation and shall be based upon assumptions of typical utilization and an assumption that, in the provision of the procedures, tests, or services, no complications or unexpected events would occur necessitating other expenses. The estimates shall include related estimates of typically needed and expected ancillary costs such as those for radiology, pathology, or anesthesiology services, and shall indicate when no contracted providers of such services are available under the individual's benefit plan at a selected health care facility or provider. Any estimate given shall not be a guarantee of coverage and the health carrier shall not be held liable for differences between the estimated costs and the ultimate charges to the individual. The provision of estimates under this act shall not be construed as violating any provider contract provisions with a health carrier that prohibits disclosure of a provider's fee schedule to third parties (Section 376.475).
Provisions in this act are identical to SB 153 (2011).
STEPHEN WITTE