Exchange Transparency Act Exposed

The Exchange Transparency Act was adopted by ALEC's Health and Human Services Task Force at the 2014 Annual Meeting, approved by the Board of Directors October 11, 2014. (Accessed January 30, 2017)

ALEC Bill Text

Summary

Requires health plans offered through a state-based health exchange to provide specific information in order for consumers to draw meaningful comparisons between plans.

Model Policy

Section 1 This Act shall be known as the “Exchange Transparency Act.”

Section 2 Form of Information Available to the Public and Disclosures Required of Health Insurers.

The following information about each health plan offered for sale to consumers shall be available to consumers on {insert state-based exchange website} in a clear and understandable form for use in comparing plans, plan coverage, and plan premiums:

(1) The ability to determine whether specific types of specialists are in network and to determine whether a named physician, hospital or other health care provider is in network;

(2) Any exclusions from coverage and any restrictions on use or quantity of covered items and services in each category of benefits;

(3) A description of how medications will specifically be included in or excluded from the deductible, including a description of out-of-pocket costs that may not apply to the deductible for a medication;

(4) The specific dollar amount of any copay or percentage coinsurance for each item or service;

(5) The ability to determine whether a specific drug is available on formulary, the applicable cost-sharing requirement, whether a specific drug is covered when furnished by a physician or clinic, and any clinical prerequisites or authorization requirements for coverage of a drug;

(6) The process for a patient to obtain reversal of a health plan decision where an item or service prescribed or ordered by the treating physician has been denied; and

(7) An explanation of the amount of coverage for out of network providers or non- covered services, and any rights of appeal that exist when out of network providers or non-covered services are medically necessary.

Section 3 Enforcement.

The {insert state insurance commissioner} may impose fines on any entity failing to meet the requirements of this act.

Section 4 Severability Clause.

Section 5 Repealer Clause.

Section 6 Effective Date.