Sec. 307. Alternative payment model for certain shoppable procedures
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A group health plan and a health insurance issuer offering group or individual health insurance coverage (as such terms are defined in section 2791 of the Public Health Service Act ( 42 U.S.C. 300gg–91 )) may elect, with respect to a plan year, to provide a set payment amount to an enrollee under such plan or coverage for certain shoppable procedures (as defined in subsection (b)) in accordance with the provisions of this section in lieu of otherwise providing coverage for such a procedure under such plan or coverage, but only if the enrollee so agrees to such set payment amount.
For purposes of this section, the term shoppable procedure means a procedure specified by the Secretary of Health and Human Services (in this section referred to as the Secretary ) with respect to which individuals may be expected to compare prices for such procedure of health care providers and facilities, including primary and preventive services, prenatal care and childbirth, common surgeries that can be scheduled, and other similar services. A set payment described in subsection
(a)under a group health plan or group or individual health insurance coverage offered by a health insurance issuer shall— be disclosed prior to beginning of each plan year such payment is in effect and shall not vary during such plan year; be the same amount with respect to the same shoppable procedure furnished in a geographic area (as defined by the Secretary); not be less than the median negotiated rate for all group health plans and health insurance coverage offered in such area for such procedure; be made available to an enrollee under such plan or such coverage regardless of the provider or facility furnishing the shoppable procedure; represent the entirety of the payment obligation of such plan or such issuer with respect to such procedure; and may be retained by such enrollee to the extent that the amount of such payment exceeds the amount charged by such provider or facility for such procedure. Each health care provider and facility that may furnish a shoppable procedure during a year shall post in a public area a notice containing the prices that will be charged by such provider of facility with respect to each such procedure to individuals making payment for such services pursuant to a set payment amount described in subsection (a). The Secretary may waive such provisions of section 1302(b) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18022(b) ) with respect to a group health plan, health insurance issuer offering group or individual health insurance coverage, and a plan year as the Secretary determines necessary to allow for the provision of set payment amounts described in subsection (a).
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- 42 USC 300gg–91
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