44-1407. Shared savings incentive payment program; incentive payments; calculation.

(1) An insurance carrier shall develop and implement a shared savings incentive payment program that provides incentive payments for enrollees in a health plan who elect to receive shoppable health care services that are covered by the plan from providers that charge less than the average price paid by that insurance carrier for that shoppable health care service.

(2) Incentive payments may be calculated as a percentage of the difference in price, as a flat dollar amount, or by some other reasonable methodology approved by the director. The insurance carrier must provide the incentive payment as a cash payment to the enrollee.

(3) The shared savings incentive payment program must provide enrollees with at least fifty percent of the insurance carrier’s saved costs for each shoppable health care service or category of shoppable health care service resulting from shopping by enrollees. An insurance carrier is not required to provide an incentive payment or credit to an enrollee when the insurance carrier’s saved cost is fifty dollars or less.

(4) An insurance carrier shall base the average price on the average amount paid to an in-network provider for the procedure or service under the enrollee’s health plan within a reasonable timeframe not to exceed one year. An insurance carrier may determine an alternate methodology for calculating the average price if approved by the director.

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