Section
1 Purpose
The purpose of this Rule is to provide consumers with access
to information concerning health care prices, health care quality, and other
information necessary to empower consumers, including uninsured consumers, to
make economically sound and medically appropriate decisions.
Section 2 Authority
This Rule is issued pursuant to the authority vested in the
Commissioner by law, including but not limited to
18 V.S.A. §
9410(a)(2),
8 V.S.A.
§ 15(a), and 18 V.S.A. § 9404(d).
Section 3 Definitions
As used in this Rule:
(1) "Brand Name Drug" means a drug marketed
under a proprietary, trademark-protected name.
(2) "Charge" means the amount sought as
payment by a Health Care Facility, Health Care Provider, or seller of
prescription drugs, durable medical equipment, or medical supplies for a health
care service or product before the application of any discount, write-off,
contract or plan adjustment or allowance, or other reduction to such
amount.
(3) "Commissioner" means
the Commissioner of the Department.
(4) "Consumer Information Plan" means the
Consumer Information Plan filed by a Health Insurer for the benefit of the
Health Insurer's Members, and approved by the Commissioner under Section
4
of this Rule.
(5) "Department"
means the Vermont Department of Banking, Insurance, Securities and Health Care
Administration.
(6) "Diagnostic
Related Group" or "DRG" means any of the diagnostic categories which Medicare
accepts that can be used to classify a patient's inpatient service for
reimbursement purposes.
(7)
"Generic Drug" means a drug which has been approved by the Food and Drug
Administration as a generic drug to be equivalent to a Brand Name Drug in
dosage, safety, strength, how it is taken, quality, performance, and intended
use.
(8) "Health Care Facility"
means all institutions, whether public or private, proprietary or nonprofit,
which offer diagnosis, treatment, inpatient or ambulatory care to two or more
unrelated persons, and the buildings in which those services are offered. The
term shall not apply to any facility operated by religious groups relying
solely on spiritual means through prayer or healing, but includes all
institutions included in subdivision
9432(7)
of Title 18, except health maintenance organizations.
(9) "Health Care Provider" means a person,
partnership or corporation, other than a facility or institution, licensed or
certified or authorized by law to provide professional health care service in
this state to an individual during that individual's medical care, treatment or
confinement, and, except in connection with the requirements of Section
6 of this
Rule, practicing under a participating provider agreement with a Health
Insurer.
(10) " Health Care
Provider Practice" means an organization of Health Care Providers whose
financial information is reported annually by a Hospital pursuant to 18 V.S.A.
Chapter 221, subchapter 7
(11)
"Health Insurer" means:
(A) any health
insurance company, nonprofit hospital and medical services corporation, or
health maintenance organization with at least five percent of the lives covered
in the insured market in Vermont, as reported by the Department for the prior
calendar year. The requirements of this Rule apply to:
(i) a Health Insurer in connection with its
insured plans;
(ii) a Health
Insurer, or the controlled affiliate of a Health Insurer, acting as a
third-party administrator for a health benefit plan, and
(iii) the agents or affiliates of the Health
Insurer who contract to administer the benefits covered or administered by the
Health Insurer, such as pharmacy benefit managers and mental health services
review agents licensed under
8 V.S.A. §
4089a; and
(B) the employee health benefit plan offered
by the State of Vermont, or any agency or instrumentality of the state;
and
(C) Medicaid, VHAP, SCHIP and
any other health benefit plan offered or administered by the Vermont Office of
Health Access, to the extent permitted by federal law or authority.
(12) "Hospital" means an acute
care hospital licensed under chapter 43 of Title 18, Vermont Statutes
Annotated, and except for purposes of Section
6 of this
Rule, any out of state hospital with more than 1,000 annual inpatient
discharges of Vermont residents. The Department shall publish annually a list
of hospitals that satisfy the criteria of this subdivision.
(13) "Member" means an individual or
dependent covered by the health benefit plan of a Health Insurer.
(14) "Physician" means a physician practicing
under a participating provider agreement with a Health Insurer, except in
connection with the requirements of Section
6 of this
Rule.
(15) "Price" means the amount
due to a Health Care Facility, Health Care Provider, or seller of durable
medical equipment, or medical supplies for a health care service or product
after the application of any discount, write-off, contract or plan adjustment
or allowance, or other reduction to the Charge amount, and before the
application of any individual Member cost-sharing, including deductibles,
co-payments, co-insurance, and out-of-pocket maximums. The "Price" of
prescription drugs means the amount due to the pharmacy or other entity for the
delivery of prescription drugs to the Health Insurer's Members, or the
pharmacy's or other entity's usual and customary charge, whichever is lower;
provided that the Health Insurer may, but is not required to disclose the lower
usual and customary charge.
(16)
"Primary Care Physician" means a Physician who provides primary care services,
and who is designated as a primary care physician by the Health
Insurer.
(17) "Rule" means the
administrative rule adopted herein.
(18) "Therapeutic Equivalent Drug" means drug
products classified as therapeutically equivalent by the Food and Drug
Administration that can be substituted with the full expectation that the
substituted product will produce the same clinical effect and safety profile as
the prescribed product.
(19)
"Uninsured Consumer Information Plan" means the Uninsured Consumer Information
Plan filed by a Hospital or by a Health Care Provider Practice and approved by
the Commissioner under Section
6 of this
Rule.
Section 4 Health
Insurer Consumer Price and Quality Information Plans
(a) General. Each Health Insurer shall
establish, maintain and administer a Consumer Information Plan approved by the
Commissioner.
(b) Filing and
Approval. On or before January 1, 2009, on or before January 1, 2011, and if
required thereafter under subdivision (c)(4) of this Section, each Health
Insurer shall file in writing with the Commissioner a Consumer Information Plan
that complies with the requirements of this Rule. The Consumer Information Plan
shall be deemed approved unless the Commissioner, within 30 calendar days of
filing, approves, disapproves, or approves the Consumer Information Plan
subject to such conditions as the Commissioner may prescribe as necessary to
ensure that the Consumer Information Plan is consistent with the provisions of
this Rule, and with the provisions of
18 V.S.A. §
9410(a)(2). The Commissioner
may extend the time period to review and act upon the Plan for one additional
30 day period if necessary. The Commissioner shall not disapprove a Consumer
Information Plan unless the Commissioner finds that it is in noncompliance with
one or more of the requirements of this Rule. The Consumer Information Plan
shall take effect and be implemented six months after approval, unless the
Health Insurer demonstrates and the Commissioner finds that a later effective
date is needed to avoid undue financial or administrative burden. The Consumer
Information Plan of a Health Insurer as defined by Section
3(11)(C)
shall be deemed approved upon filing; however the Department may offer guidance
to Plans filed by the Vermont Office of Health Access as is necessary and
appropriate to carry out the purposes of this Rule.
(c) Phased-In Consumer Information Plan Price
Information.
(1) First Phase. On and after
October 1, 2008, each Health Insurer shall provide Members with a link on the
Health Insurer's website to, or information on how to access, at least the
information identified or described in the Department's Act 53 Hospital
Community Report website for hospital quality and Charge information, and free
care and discount policies.
(2)
Second Phase. A Consumer Information Plan filed with the Commissioner on or
before January 1, 2009 shall describe how the Health Insurer will provide
consumers with Price information concerning at least the information identified
or described in subdivisions (A) through (E), below.
(A) The in-patient, out-patient diagnostic
and other procedures and services provided by each Hospital, as identified in
the Act 53 Hospital Community Report pursuant to
18 V.S.A. §
9405b(c).
(B) The following procedures or services
provided by individual Physicians or Physician practices:
(i) the list of procedures and services
identified in Appendix A; or
(ii)
an alternative list filed with the Commissioner, if the Commissioner determines
that the alternative list will accomplish the purposes of this Rule. Such
alternative list may include for Physician services and procedures a list
approved by the Commissioner of "examination and management" codes, plus the
code for routine obstetrical care;
(C) The 100 prescription drugs most
frequently prescribed to the Health Insurer's Members, not including
prescription drugs administered by a Health Care Provider in the office
environment. Price information shall permit Price comparison of the list of
most frequently prescribed drugs with those Brand Name Drugs, Therapeutic
Equivalent Drugs, and Generic Drugs, which can be prescribed for a specific
illness or condition, or for a category of illnesses or conditions. In counting
the 100 most frequently prescribed drugs, a Brand Name Drug and its Generic
Drug equivalent shall be counted as one drug, and different dosages of the same
drug shall be counted as one drug. If a Health Insurer's Price for prescription
drugs does not vary from pharmacy to pharmacy, the Health Insurer may disclose
to Members that one Price applies for all pharmacies, and the Health Insurer
need not list Price for individual pharmacies;
(D) The 20 items of durable medical equipment
most frequently purchased or leased by the Health Insurer's Members;
and
(E) The 10 items of medical
supplies such as diabetic supplies, excluding any items obtained through the
Health Insurer's pharmacy benefit manager's website most frequently purchased
by the Health Insurer's Members.
(3) Third Phase. A Consumer Information Plan
filed with the Commissioner on or before January 1, 2011 shall describe how the
Health Insurer will provide consumers with Price information concerning at
least the information identified or described in subdivisions (A) through (E)
below.
(A) The in-patient, out-patient,
diagnostic and other procedures and services provided by each Hospital, as
identified in the Act 53 Hospital Community Report pursuant to
18 V.S.A. §
9405b(c).
(i) Where applicable to, and feasible for a
specific Hospital in connection with inpatient procedures and services, Price
information shall be aggregated for Hospital and Physician Price information
for procedures and services typically associated with Diagnostic Related Group
codes in a manner approved by the Commissioner upon consideration of the
recommendations of the Act 53 Financial Workgroup.
(ii) Where applicable to, and feasible for a
specific Hospital in connection with outpatient procedures and services, Price
information shall be aggregated for Hospital and Physician Price information in
a manner approved by the Commissioner upon consideration of the recommendations
of the Act 53 Financial Workgroup.
(iii) The Health Insurer shall disclose to
Members the methodology used to derive the Price for the Diagnostic Related
Group.
(B) The following
procedures or services provided by individual Physicians or Physician
practices:
(i) The list of procedures and
services identified in Appendix A; or an alternative list filed with the
Commissioner, if the Commissioner determines that the alternative list will
accomplish the purposes of this Rule.
(ii) Such alternative list may include for
Physician services and procedures a list approved by the Commissioner of
"examination and management" codes, plus the code for routine obstetrical
care.
(iii) Such alternative list
may also include a list approved by the Commissioner after consideration of an
advisory committee of affected parties convened by the Department to assist in
the development of filing instructions for Consumer Information Plans filed on
or before January 1, 2011. The Commissioner may require Health Insurers to use
a uniform or substantially uniform list of Physician procedures and services in
the Health Insurer's Consumer Information Plan, if the Commissioner determines
that a reasonable state-wide or national consensus has been reached with
respect to the disclosure of Price information for Physician procedures and
services;
(C) The 200
prescription drugs most frequently prescribed to the Health Insurer's Members,
not including prescription drugs administered by a health care provider in the
office environment. Price information shall permit comparison of the list of
most frequently prescribed drugs with those Brand Name Drugs, Therapeutic
Equivalent Drugs, and Generic Drugs, which can be prescribed for a specific
illness or condition, or for a category of illnesses or conditions. In counting
the 200 most frequently prescribed drugs, a Brand Name Drug and its Generic
Drug equivalent shall be counted as one drug, and different dosages of the same
drug shall be counted as one drug. If a Health Insurer's Price for prescription
drugs does not vary from pharmacy to pharmacy, the Health Insurer may disclose
to Members that one Price applies for all pharmacies, and the Health Insurer
need not list Price for individual pharmacies;
(D) The 40 items of durable medical equipment
most frequently purchased or leased by the Health Insurer's Members;
and
(E) The 20 items of medical
supplies, such as diabetic supplies, excluding any items obtained through the
Health Insurer's pharmacy benefit manager's website most frequently purchased
by the Health Insurer's Members.
(4) Fourth Phase. A Consumer Information Plan
filed with the Commissioner on or before January 1, 2013, and every two years
thereafter, shall describe how the Health Insurer will provide consumers with
the following Price information:
(A) At least
the information identified or described in subdivisions (3)(A) through (E),
above;
(B) After consultation with
affected parties, and with the approval of the Commissioner, Price information
shall include an increase of the number of items disclosed of up to 400
prescription drugs, and up to 80 items of durable medical equipment, and up to
40 medical supply items; and
(C)
after consultation with affected parties, and with the approval of the
Commissioner by means of an order issued pursuant to
8 V.S.A. §
15, Price information concerning the
following categories of care and treatment, if such care and treatment is
covered by the Health Insurer: chiropractic, psychological and other mental
health care and treatment, naturopathic, dental, physical therapy, osteopathic,
nursing home, home health, and other care and treatment provided by Health Care
Providers. A person aggrieved by an order issued under this subdivision may
file an administrative appeal pursuant to BISHCA Regulation 82-1 (Revised), and
the order appealed from shall be stayed as to the appellant until the final
decision of the Commissioner is issued.
(D) Upon request of a Health Insurer, the
Commissioner may waive or modify one or more requirements of this subdivision
(4) if the Health Insurer demonstrates and the Commissioner finds that
application of the requirement is unreasonable, unnecessary, or contrary to the
purposes of this Rule.
(d) Phased-In Consumer Information Plan
Quality Information.
(1) Hospital Quality
Information.
(A) On and after October 1,
2008, each Health Insurer shall provide Members with a link on the Health
Insurer's website to, or information on how to access the Department of Health
and Human Services, or Centers for Medicare and Medicaid Services "Compare"
websites for hospitals, nursing homes, home health agencies, and other Health
Care Providers and Health Care Facilities for which similar information
resources are developed in the future.
(B) In a Consumer Information Plan filed with
the Commissioner on or before January 1, 2009, a Health Insurer shall use, or
provide a link to the hospital quality information maintained pursuant to Act
53 to satisfy the Hospital quality information requirements of this Rule. In
addition, the Health Insurer may use other Hospital quality measures approved
by the Commissioner as valid and reliable, after consultation with affected
parties.
(2) Physician
Quality Information.
(A) In the Consumer
Information Plan filed with the Commissioner on or before January 1, 2009, the
Health Insurer shall describe how the Health Insurer will provide quality
information at least with respect to Primary Care Physicians. In connection
with such Plan, the Health Insurer shall use either:
(i) NCQA physician recognition certification
to satisfy the Health Care Provider quality information requirements of this
Rule. The Health Insurer shall not be obligated to secure, facilitate or
promote NCQA physician recognition certification for Physicians, but shall
report on whether the Physician has been certified by NCQA. The Health Insurer
shall not be required to report that a Physician has not been certified by
NCQA; or
(ii) quality measures
approved by the Commissioner, after consultation with affected parties, as
valid and reliable, or designated as "nationally recognized" by the
Commissioner, after consultation with affected parties. The Commissioner may
prescribe terms and conditions in connection with any such approval or
designation relating to the reliable and comprehensive use of such measures.
The Commissioner may require Health Insurers to use uniform or substantially
uniform quality measures if the Commissioner determines that a reasonable,
national consensus has been reached with respect to uniform quality measures.
The Commissioner shall designate as "nationally recognized" those quality
information and reporting measures endorsed by the Centers for Medicare and
Medicaid Services, the National Quality Forum, or the Ambulatory Quality
Alliance. The Commissioner, after consultation with affected parties, may
designate other nationally recognized quality information and reporting
measures.
(B) In the
Consumer Information Plan filed with the Commissioner on or before January 1,
2011, the Health Insurer shall describe how the Health Insurer will provide
quality information with respect to Primary Care Physicians and with respect to
other Physicians. In connection with such Plan, the Health Insurer shall use
both:
(i) NCQA physician recognition
certification to satisfy the Health Care Provider quality information
requirements of this Rule with respect to Primary Care Physicians and with
respect to other Physicians. The Health Insurer shall not be obligated to
secure, facilitate or promote NCQA physician recognition certification for
Physicians, but shall report on whether the Physician has, or has not been
certified by NCQA; and
(ii) quality
measures approved by the Commissioner, after consultation with affected
parties, as valid and reliable, or designated as "nationally recognized" by the
Commissioner, after consultation with affected parties. The Commissioner may
prescribe terms and conditions in connection with any such approval or
designation relating to the reliable and comprehensive use of such measures.
The Commissioner may require Health Insurers to use uniform or substantially
uniform quality measures if the Commissioner determines that a reasonable,
national consensus has been reached with respect to uniform quality measures.
The Commissioner shall designate as "nationally recognized" quality information
and reporting measures those measures endorsed by the Centers for Medicare and
Medicaid Services, the National Quality Forum, or the Ambulatory Quality
Alliance. The Commissioner, after consultation with affected parties, may
designate other nationally recognized quality information and reporting
measures.
(3)
The Health Insurer may elect to not provide quality information for particular
procedures and services performed by an individual Physician, or by a Hospital
if the number of procedures or services performed by such individual Physician
or Hospital is too small to be statistically significant; and in such
circumstances, the Commissioner may approve a Health Insurer's proposed use of
alternative means of obtaining statistically significant quality
measures.
(4) A Consumer
Information Plan filed with the Commissioner on or before January 1, 2013, and
every two years thereafter, shall describe how the Health Insurer will provide
consumers with the following quality information:
(A) at least the information identified or
described in subdivisions (d)(1) and (2), above;
(B) after consultation with affected parties,
and with the approval of the Commissioner by means of an order issued pursuant
to
8 V.S.A. §
15, quality information concerning the
following categories of care and treatment, if disclosure of Price information
with respect to such categories of care and treatment is required under Section
4(c)(4)(C)
of this Rule, and if such care and treatment is covered by the Health Insurer:
chiropractic, psychological and other mental health care and treatment,
naturopathic, dental, physical therapy, osteopathic, nursing home, home health,
and other care and treatment provided by Health Care Providers. A person
aggrieved by an order issued under this subdivision may file an administrative
appeal pursuant to BISHCA Regulation 82-1 (Revised), and the order appealed
from shall be stayed as to the appellant until the final decision of the
Commissioner is issued; and
(C) the
reporting of Price and quality information together in a manner that identifies
or describes the relative value of procedures, services, prescription drugs,
and major medical equipment and medical supplies.
(D) Upon request of a Health Insurer, the
Commissioner may waive or modify one or more requirements of this subdivision
(4) if the Health Insurer demonstrates and the Commissioner finds that
application of the requirement is unreasonable, unnecessary, or contrary to the
purposes of this Rule.
(e) General Content Requirements. A Consumer
Information Plan shall state the manner in which the Health Insurer will comply
with the following requirements during the period of time for which the
Consumer Information Plan is applicable:
(1)
The Health Insurer shall permit Members to view, by means of the Health
Insurer's website, the Price for a particular Hospital, Physician, pharmacy, or
other entity of the procedures, services, prescription drugs, and major medical
equipment and supplies identified in the Health Insurer's Consumer Information
Plan, or the median Price if there is a range of Prices. The Health Insurer
shall permit Members to compare Prices and median Prices among specific
Hospitals, Physicians, pharmacies and other entities.
(2) Price information shall be updated at
least annually, and when Hospital, Physician, pharmaceutical, or other seller
contracts are issued or reissued.
(3) If the Price for a particular procedure,
service, prescription drug, item of medical equipment, or medical supply varies
depending upon the different reimbursement rates of different Health Insurer
products, the Health Insurer shall disclose the different Prices associated
with the different products of the Health Insurer.
(4) During the First Phase of reporting, the
Health Insurer has the option to use a link on the Health Insurer's website to
the website of the applicable government agency to access the information
required by subdivision (c)(1) of this Section, or to provide access to such
information on the Health Insurer's own website.
(5) The Health Insurer may use a link on the
Health Insurer's website to the website of the Health Insurer's pharmacy
benefit manager for reporting of prescription drug information required by
subdivisions (c)(2)(C), (c)(3)(C), and (c)(4) of this Section, or medical
supplies purchased through the pharmacy benefit manager.
(6) The Health Insurer shall provide Members
with guidance on how to estimate their out-of-pocket costs (including
co-payments, coinsurance, and deductibles) for the procedures, services,
prescription drugs, and major medical equipment and supplies identified in the
Health Insurer's Consumer Information Plan. Upon request the Health Insurer
shall provide Members assistance with estimating out-of-pocket costs. A Health
Insurer shall not be required to provide on-line calculators to estimate
out-of-pocket costs, provided that any alternative method offers adequate
guidance to Members for estimating out-of-pocket costs.
(7) The Health Insurer shall permit Members,
by means of the Health Insurer's website, to view and compare quality of care
among specific Hospitals and Health Care Providers, in accordance with
subsection (d) of this Section, for the procedures and services identified in
the Health Insurer's Consumer Information Plan.
(8) The Health Insurer shall establish for
Members alternative mechanisms other than a website for obtaining the Price and
quality information required by this Rule, such as through a toll-free
telephone number available during normal business hours, or by providing
printed price and quality information.
(9) The Health Insurer shall disclose to
Members the source or sources of Price and quality information, information
relating to reliability and reporting period for the Price and quality
information provided in accordance with the Consumer Information Plan. The
Health Insurer may communicate to Members suitable provisions disclaiming
responsibility for the reliability and accuracy of the Price and quality
information provided under the Consumer Information Plan.
(10) A Health Insurer may request that the
Commissioner permit the substitution of one or more of the procedures,
prescription drugs, or durable medical equipment and supplies for which Price
information would be otherwise provided if the Health Insurer demonstrates and
the Commissioner finds that the availability of price information would have
anticompetitive consequences detrimental to consumers.
(11) Upon request by a Health Insurer, the
Commissioner may waive one or more requirements of this Rule if the Health
Insurer demonstrates and the Commissioner finds that application of the
requirement is unreasonable, unnecessary, or contrary to the purposes of this
Rule.
(12) The Health Insurer shall
establish a procedure for Health Care Providers to review the Price and quality
information related to the Health Care Provider, and to comment on its
accuracy. The Health Insurer shall promptly correct inaccuracies where
warranted. The Health Insurer shall maintain records of such comments, the
Health Insurer's response to such comments, and corrections for five years, in
accordance with Department Regulation 99-1 (Record Retention).
Section 5 Security
Measures
A Health Insurer may establish and maintain security
procedures for limiting access to the Health Insurer's Price and other
information to Members only, through the on-line submission of a user name and
password, or through some other Member verification and security procedure
described in the Consumer Information Plan and approved by the
Commissioner.
Section 6
Consumer Charge and Quality Information for Uninsured Consumers
(a) Each Hospital and Health Care Provider
Practice shall establish, maintain, and administer an Uninsured Consumer
Information Plan that is approved by the Commissioner, and that complies with
the requirements of this Rule. The Uninsured Consumer Information Plan shall be
deemed approved unless the Commissioner, within 30 calendar days of filing,
approves, disapproves, or approves the Uninsured Consumer Information Plan
subject to such conditions as the Commissioner may prescribe as necessary to
carry out the purposes of
18 V.S.A. §
9410(a)(2). The Commissioner
may extend the time period to review and act upon the Plan for one additional
30 day period if necessary. The Uninsured Consumer Information Plan shall take
effect and be implemented six months after approval, unless the Hospital or
Health Care Provider Practice demonstrates and the Commissioner finds that a
later effective date is needed to avoid undue financial or administrative
burden. The Uninsured Consumer Information Plan shall be filed with the
Commissioner on or before January 1, 2009. The Hospital quality and charge
information shall be updated annually, and when relevant charge and other
changes are made.
(b) A Hospital
Uninsured Consumer Information Plan shall provide, or describe a mechanism for
consumers to access the following information, and to seek additional
information and assistance in understanding Hospital quality and Charge
information:
(1) Hospital quality
information. A Hospital shall use the hospital quality information maintained
pursuant to Act 53 to satisfy the hospital quality information requirements of
this Rule. In addition, a Hospital may use Hospital quality information
approved by the Commissioner under Section
4(d)(1)(B);
(2) Hospital Charge information, accompanied
by:
(i) free care and discount
policies;
(ii) eligibility
criteria, the application process, and toll-free numbers for public health
insurance programs such as Medicaid, VHAP, and Catamount Health Premium
Assistance; and
(iii) information
on how to access the Prescription Drug Price Finder of the Vermont Attorney
General's Office; and
(3)
A mechanism for a consumer to learn the estimated Charge for a specific
in-patient, out-patient or diagnostic procedure or service offered by the
Hospital.
(c) A Health
Care Provider Practice Uninsured Consumer Information Plan shall provide or
describe a mechanism for consumers to access the following information:
(1) Health Care Provider quality information.
A Health Care Provider Practice shall use NCQA physician recognition
certification for reporting on Health Care Provider quality. The Health Care
Provider shall not be obligated by this Rule to secure NCQA physician
recognition certification. In addition, a Health Care Provider Practice
Uninsured Consumer Information Plan may use Health Care Provider quality
information approved by the Commissioner under Section
4(d)(2)(B).
The Commissioner may require the use of additional quality information and
reporting standards and protocols approved under Section
4(d)(2)(B)(ii)
as a condition of approval of an Uninsured Consumer Information Plan.
(2) Health Care Provider Practice Charge
information, accompanied by free care and discount policies; and
(3) A mechanism for any uninsured patient of
a Health Care Provider Practice to learn the estimated Charge for a specific
health care procedure or service offered by the Health Care Provider
Practice.
(d) Upon the
request of any uninsured patient of a Health Care Provider, a Health Care
Provider shall inform the patient of the estimated Charge for a specific health
care procedure or service offered by the Health Care Provider, and shall inform
the consumer of the provider's free care and discount policies, if
any.
Section 7 Effective
Date
This Rule shall take effect on October 1, 2008.
Appendix A. CPT Codes.
CPT Code
|
Service Unit
|
CPT Code Descriptions
|
Plain English Descriptions
|
Anesthesia
|
00790
|
|
Anes Intraperitoneal Inc Shunts; Nos
|
Anesthesia for upper abdominal procedures
|
00840
|
|
Anes Intraperitoneal Low Abd; Nos
|
Anesthesia for lower abdominal procedures
|
01967
|
|
Neuraxial Labor Analgesia/Anesthesia For Planned
V
|
Epidural obstetric anesthesia
|
Surgery
|
11100
|
1,030
|
BX SKIN/SUBQ TISS (SEP PRO); 1 LES
|
Skin biopsy
|
17000
|
1,985
|
DESTRCT-ANY METHD-BEN LES; W/ANE; 1
|
Destruction of a single skin lesion
|
17003
|
2,452
|
DESTRCT-ANY METHD-BEN LES; 2-14, EA
|
Destruction of multiple skin lesions
|
20610
|
755
|
ARTHROCENTESIS/ASPIR/INJ; MAJOR JT
|
Aspiration or injection of a major joint
|
36415
|
33,713
|
ROUTINE VENIPUNCT/FINGER/HEEL STICK
|
Obtaining a sample of blood
|
45378
|
858
|
COLONOSCOPY FLEX; DX (SEP PRO)
|
Colonoscopy
|
45385
|
541
|
COLONOSCOPY FLEX; W/REMOV LES-SNARE
|
Colonoscopy with removal of lesion
|
Radiology
|
71010
|
5,150
|
RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW,
FRONTAL
|
Chest X-ray (single view)
|
71020
|
10,715
|
X-Ray Chest, Two Views, Frontal and Late
|
Chest X-ray (two views)
|
76083
|
|
Cmpt Aided Detect Phys Rev for Intepr; Scr
Mammo
|
Computer aided reading of a screening
mammogram
|
76092
|
|
Screening Mammography, Bilateral
|
Screening Mammography
|
Laboratory/Pathology
|
80061
|
2,128
|
LIPID PANEL
|
Cholesterol and lipid testing
|
81000
|
3,554
|
UA DIPSTIK/TABLET; NON-AUTO W/MICRO
|
Microscopic and chemical urine testing
|
81002
|
20,968
|
Urinalysis DIP STIK/TABLT; WO MICRO NON-AUTO
|
Chemical urine testing only
|
81025
|
6,754
|
URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON
METHODS
|
Pregnancy test (urine)
|
82270
|
2,823
|
BLD OCCULT; FECES 1-3 SIMULT DETERM
|
Stool blood test
|
83036
|
652
|
HGB; GLYCATED
|
Hemoglobin A1C blood test
|
85018
|
7,656
|
BLD CT; HGB
|
Hemoglobin test
|
85025
|
1,347
|
Bld Cnt;hemo/Pit,Auto,Cmplt Dif.Wbc
|
Complete blood count (CBC)
|
85610
|
756
|
PROTHROMBIN TIME
|
Blood clotting test (prothrombin time)
|
87880
|
13,625
|
AGT-IMMUNASSAY DIR OBS; STREP GRP A
|
Strep test, group A
|
88305
|
12,421
|
LEVEL IV-SURG PATH GROSS/MICRO EXAM
|
Level IV surgical pathology examination
|
Medicine - Immunizations
|
90465
|
4,399
|
IMMUNIZATION ADMINISTRATION UNDER 8 YEARS OF AGE
(INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMU
|
Childhood immunization administration
|
90471
|
39,995
|
IMMUNIZATION ADMINSTRATION
|
Immunization administration
|
90472
|
24,662
|
Immunization administration two or more single
or
|
Administration of multiple immunizations
|
90658
|
11,121
|
INFLUENZA VIRUS VACCINE
|
Influenza virus vaccine
|
90718
|
|
Tetanus and diptheria toxoids for intramuscular
or
|
Tetanus and diptheria vaccines
|
90772
|
6,760
|
THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC
INJECTION
|
Any injection
|
Medicine - Mental Health Visits
|
90805
|
6,787
|
PSYCHOTHER OP 20-30 MIN; W/MED E&M
|
Psychotherapy 20-30 minutes with medical
evaluation
|
90806
|
19,194
|
PSYCHOTHER OV/OP-BEHV MOD 45-50 MN;
|
Psychotherapy 45-50 minutes
|
90807
|
12,085
|
PSYCHOTHER OP 45-50 MIN; W/MED E&M
|
Psychotherapy 45-50 minutes with medical
evaluation
|
90853
|
21,982
|
GROUP MEDICAL PSYCHOTHERAPY (OTHER THAN OF A
MULTIPLE-FAMILY GROUP) - ONE UNIT = 15 MINUTES
|
Group Psychotherapy 15 minutes
|
90862
|
9,187
|
PHARM MGMT W/SCRIPT USE & REVIEW
|
Management of psychiatric medications
|
Medicine - Eye & Ear Exams
|
92004
|
1,319
|
Opthalmalogical exam; new patient,
intermediate
|
Eye examination, new patient, intermediate amount of
time
|
92012
|
2,690
|
OPHTH SERV: MED EXAM; INTERM ESTAB
|
Ophthalmological services intermediate established
patient
|
92014
|
4,835
|
OPHTH SERV: MED EXAM; COMP ESTAB PT
|
Ophthalmological services comprehensive exam
established patient
|
92015
|
6,838
|
DETERM REFRACTIVE STATE
|
Eye refraction determination
|
92567
|
4,246
|
TYMPANOMETRY
|
Middle ear test (tympanometry)
|
Medicine - Non-Invasive Vascular
Studies
|
93000
|
3,621
|
ECG-ROUTINE 12 LEAD; W/INTRPT & RPT
|
Electrocardiogram (EKG)
|
93010
|
10,046
|
Ecg;interpretation & Report Only
|
Electrocardiogram reading and report only
|
94760
|
690
|
NONINVAS OXIMETRY-O2 SAT; 1 DETERM
|
Test of blood oxygen saturation
|
95004
|
8,967
|
Percut Tests W/Extrac Immed React #
|
Allergy testing
|
Physical Medicine - PT/Chiro
Procedures
|
95165
|
3,169
|
Professional Services Supervision Provisions
Antig
|
Supervision of allergen preparation
|
97001
|
2,299
|
Physical Therapy Evaluation
|
Physical Therapy Evaluation
|
97010
|
6,403
|
App. Of Modality, hot or cold packs
|
Application of hot or cold packs
|
97012
|
1,302
|
Phys. Med, traction, mechanical
|
Mechanical traction
|
97014
|
2,945
|
Phys. Med - Electrical Stimulation
(unattended)
|
Electrical stimulation
|
97032
|
7,313
|
Appl. Of modality, electrical stimulation
(manual)
|
Electrical stimulation requiring constant provider
attendance
|
97033
|
1,530
|
Phys.Med., iontophoresis
|
Iontophoresis requiring constant attendance
|