(1) In addition to the comprehensive package of health insurance and other benefits required or authorized to be included in the state group insurance program, the package of benefits may also include products and services offered by:(a) Prepaid limited health service organizations authorized pursuant to part I of chapter 636.
(b) Discount medical plan organizations authorized pursuant to part II of chapter 636.
(c) Prepaid health clinics licensed under part II of chapter 641.
(d) Licensed health care providers, including hospitals and other health care facilities, health care clinics, and health professionals, who sell service contracts and arrangements for a specified amount and type of health services.
(e) Provider organizations, including service networks, group practices, professional associations, and other incorporated organizations of providers, who sell service contracts and arrangements for a specified amount and type of health services.
(f) Entities that provide specific health services in accordance with applicable state law and sell service contracts and arrangements for a specified amount and type of health services.
(g) Entities that provide health services or treatments through a bidding process.
(h) Entities that provide health services or treatments through the bundling or aggregating of health services or treatments.
(i) Entities that provide international prescription services.
(j) Entities that provide optional participation in a Medicare Advantage Prescription Drug Plan.
(k) Entities that provide other innovative and cost-effective health service delivery methods.
(2)(a) The department shall contract with at least one entity that provides comprehensive pricing and inclusive services for surgery and other medical procedures which may be accessed at the option of the enrollee. The contract shall require:1. The entity to have procedures and evidence-based standards to ensure the inclusion of only high-quality health care providers.
2. The entity to provide assistance to the enrollee in accessing and coordinating care.
3. The entity to provide cost savings to the state group insurance program to be shared with both the state and the enrollee. Cost savings to an enrollee must, unless prohibited by first-dollar coverage rules under applicable tax law, include a waiver of enrollee cost-sharing liability for surgery and other medical procedures. Cost savings may additionally include amounts payable to an enrollee or beneficiary as follows:a. Credited to the enrollee’s flexible spending account;
b. Credited to the enrollee’s health savings account;
c. Credited to the enrollee’s health reimbursement account; or
d. Paid as additional health plan reimbursements.
4. The entity, in conjunction with the department, to provide an educational campaign for enrollees to learn about the services offered by the entity.
(b) On or before January 15 of each year, the department shall report to the Governor, the President of the Senate, and the Speaker of the House of Representatives on the participation level and cost-savings to both the enrollee and the state resulting from the contract or contracts described in this subsection.
(3) The department shall contract with an entity that provides enrollees with online information on the cost and quality of health care services and providers, allows an enrollee to shop for health care services and providers, and rewards the enrollee by sharing savings generated by the enrollee’s choice of services or providers. The contract shall require the entity to:(a) Establish an Internet-based, consumer-friendly platform that educates and informs enrollees about the price and quality of health care services and providers, including the average amount paid in each county for health care services and providers. The average amounts paid for such services and providers may be expressed for service bundles, which include all products and services associated with a particular treatment or episode of care, or for separate and distinct products and services.
(b) Allow enrollees to shop for health care services and providers using the price and quality information provided on the Internet-based platform.
(c) Permit a certified bargaining agent of state employees to provide educational materials and counseling to enrollees regarding the Internet-based platform.
(d) Identify the savings realized to the enrollee and state if the enrollee chooses high-quality, lower-cost health care services or providers, and facilitate a shared savings payment to the enrollee. The amount of shared savings shall be determined by a methodology approved by the department and shall maximize value-based purchasing by enrollees. The amount payable to the enrollee may be:1. Credited to the enrollee’s flexible spending account;
2. Credited to the enrollee’s health savings account;
3. Credited to the enrollee’s health reimbursement account; or
4. Paid as additional health plan reimbursements not exceeding the amount of the enrollee’s out-of-pocket medical expenses.
(4) The department shall offer, as a voluntary supplemental benefit option, international prescription services that offer safe maintenance medications at a reduced cost to enrollees and that meet the standards of the United States Food and Drug Administration personal importation policy.
(5)(a) Effective January 1, 2025, the department shall require all contracted state group health insurance plans and HMOs to provide coverage and payment, without imposing a deductible, copayment, coinsurance, or any other cost-sharing requirement on the covered individual, for annual skin cancer screenings performed by a dermatologist licensed under chapter 458 or chapter 459, or by a physician assistant licensed under chapter 458 or chapter 459 or an advanced practice registered nurse licensed under chapter 464 who is under the supervision of a dermatologist licensed under chapter 458 or chapter 459. Payment for such screenings must be consistent with how the state group health insurance plan or HMO pays for other preventive screenings as defined by the American Medical Association’s Current Procedural Terminology codes.
(b) A state group health insurance plan or HMO participating under this section may not bundle a payment for skin cancer screenings performed under this section with any other procedure or service, including, but not limited to, an evaluation and management visit which is performed during the same office visit or a subsequent office visit.
(6)(a) For state group health insurance plan policies issued on or after January 1, 2025, the department shall provide coverage of biomarker testing for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of an enrollee’s disease or condition to guide treatment decisions if medical and scientific evidence indicates that the biomarker testing provides clinical utility to the enrollee. Such medical and scientific evidence includes, but is not limited to:1. A labeled indication for a test approved or cleared by the United States Food and Drug Administration;
2. An indicated test for a drug approved by the United States Food and Drug Administration;
3. A national coverage determination made by the Centers for Medicare and Medicaid Services or a local coverage determination made by the Medicare Administrative Contractor; or
4. A nationally recognized clinical practice guideline. As used in this subparagraph, the term “nationally recognized clinical practice guideline” means an evidence-based clinical practice guideline developed by independent organizations or medical professional societies using a transparent methodology and reporting structure and with a conflict-of-interest policy. Guidelines developed by such organizations or societies establish standards of care informed by a systematic review of evidence and an assessment of the benefits and costs of alternative care options and include recommendations intended to optimize patient care.
(b) As used in this subsection, the term:1. “Biomarker” means a defined characteristic that is measured as an indicator of normal biological processes, pathogenic processes, or responses to an exposure or intervention, including therapeutic interventions. The term includes, but is not limited to, molecular, histologic, radiographic, or physiologic characteristics but does not include an assessment of how a patient feels, functions, or survives.
2. “Biomarker testing” means an analysis of a patient’s tissue, blood, or other biospecimen for the presence of a biomarker. The term includes, but is not limited to, single analyte tests, multiplex panel tests, protein expression, and whole exome, whole genome, and whole transcriptome sequencing performed at a participating in-network laboratory facility that is certified pursuant to the federal Clinical Laboratory Improvement Amendment (CLIA) or that has obtained a CLIA Certificate of Waiver by the United States Food and Drug Administration for the tests.
3. “Clinical utility” means the test result provides information that is used in the formulation of a treatment or monitoring strategy that informs a patient’s outcome and impacts the clinical decision.
(c) Each state group health insurance plan shall provide a clear and convenient process for providers to request authorization for biomarker testing. Such process shall be made readily accessible to all enrollees and participating providers online.
(d) This subsection does not require coverage of biomarker testing for screening purposes.
