Terms used in this chapter mean:

(1) “Accumulated amount,” the amount of financial responsibility an enrollee has incurred at the time a request for cost-sharing information is made, with respect to a deductible or out-of-pocket limit as calculated under rules promulgated by the director;

(2) “Billed charge,” the total charges for an item or service billed to a health insurer by a provider;

(3) “Billing code,” the code used by a health insurer or provider to identify a health care item or service for purposes of billing, adjudicating, and paying a claim for a covered item or service, including current procedural terminology (CPT) code, health care common procedure coding system (HCPCS) code, diagnosis-related group (DRG) code, national drug code (NDC), or other common payer identifier;

(4) “Bundled payment arrangement,” a payment model under which a provider is paid a single payment for all covered items and services provided to an enrollee for a specific treatment or procedure;

(5) “Cost-sharing liability,” the amount an enrollee is responsible for paying for a covered item or service under the terms of the health insurance coverage;

(6) “Cost-sharing information,” information related to any expenditure required by or on behalf of an enrollee with respect to health care benefits that are relevant to a determination of the enrollee’s cost-sharing liability for a particular covered item or service;

(7) “Covered item or service,” an item or service, including a prescription drug, the cost for which is payable, in whole or in part, under the terms of the health insurance coverage;

(8) “Derived amount,” the price that a health insurer assigns to an item or service for the purpose of internal accounting, reconciliation with providers, or submitting data;

(9) “Enrollee,” an individual receiving health insurance coverage from a health insurer;

(10) “Historical net price,” the retrospective average amount a health insurer paid for a prescription drug, inclusive of any reasonably allocated rebates, discounts, chargebacks, fees, and any additional price concessions received by the health insurer with respect to the prescription drug as calculated under rules promulgated by the director;

(11) “In-network provider,” any provider of any item or service with which a health insurer or a third party for the insurer has a contract setting forth the terms and conditions on which a relevant item or service is provided to an enrollee;

(12) “Item or service,” any encounters, procedures, medical tests, supplies, prescription drugs, durable medical equipment, and fees, including facility fees, provided or assessed in connection with the provision of health care;

(13) “Machine-readable file,” a digital representation of data or information in a file that can be imported or read by a computer system for further processing without human intervention, while ensuring no semantic meaning is lost;

(14) “Negotiated rate,” the amount a health insurer has contractually agreed to pay an in-network provider, including an in-network pharmacy or other prescription drug dispenser, for covered items and services, whether directly or indirectly, including through a third-party administrator or pharmacy benefit manager;

(15) “Out-of-network allowed amount,” the maximum amount a health insurer will pay for a covered item or service furnished by an out-of-network provider;

(16) “Out-of-network provider,” a provider of any item or service that does not have a contract under an enrollee’s health insurance coverage to provide items or services;

(17) “Out-of-pocket limit,” the maximum amount that an enrollee is required to pay during a coverage period for the enrollee’s share of the costs of covered items and services under the enrollee’s health insurance coverage, including for self-only and other than self-only coverage, as applicable;

(18) “Prerequisite,” concurrent review, prior authorization, and step-therapy or fail-first protocols related to a covered item or service that must be satisfied before a health insurer will cover the item or service. The term does not include a medical necessity determination generally or other forms of medical management techniques; and

(19) “Underlying fee schedule rate,” the rate for a covered item or service from a particular in-network provider, or a provider that a health insurer uses to determine an enrollee’s cost-sharing liability for the item or service, if that rate is different from the negotiated rate or derived amount.

Source: SL 2021, ch 213, § 1.