Fair Pricing for Routine Medical Care
Table of Contents
This act establishes fair pricing for low-complexity, routine medical care.
§ 1.Fair Pricing for Certain Services
Definitions
As used in this section:
Applicable services
“Applicable services” means outpatient or ambulatory items and services that can be provided safely and appropriately across various care settings. This includes:
- The services identified by Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes within the sixty-six ambulatory payment classifications (APCs) recommended by the Medicare Payment Advisory Commission (MedPAC) in its June 2023 Report to Congress. This also includes any subsequent APCs or services MedPAC designates.
- any outpatient or ambulatory item or service recommended or required for site-neutral payment by federal or state law, the U.S.Department of Health & Human Services,or MedPAC. Examples include evaluation and management office visits, wellness visits, physical therapy, occupational therapy, speech language pathology, and mammography (screening and diagnostic).
- Other outpatient or ambulatory items and services designated by the Department/Commissioner/Secretary as safe and appropriate for lower-cost settings.
[Comment: A detailed FAQ will further describe applicable services. For definitions (b) through (m), states may reference existing definitions, making new ones unnecessary. “Department” refers to the state’s department of health, “commissioner” to the state’s Commissioner of Insurance, and “Secretary” to the state’s Secretary of health and human services.States can adjust these terms to match their specific titles and authorities.]
Health Benefit Plan
A “health benefit plan” is any plan, policy, contract, certificate, or agreement entered into, offered, or issued by a health insurance carrier or third-party administrator. It provides, delivers, arranges for, pays for, or reimburses health care costs. This includes nonfederal governmental plans as defined in 29 U.S.C. § 1002(32), but doesn’t include plans, programs, or benefits administered under 42 U.S.C. § 1395 et seq. (Medicare).
Plan Sponsor
This refers to…
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