►
Description
House Insurance Subcommittee - March 30, 2021 - House Hearing Room 2
A
D
A
You,
the
chairman
of
the
texas
quorum.
Thank
you
very
much,
ladies
and
gentlemen.
We
do
have
a
calendar
before
us
that
we
will
work
our
way
through.
If
I
could
make
a
few
announcements
as
we
get
started
on
today's
calendar,
we
do
have
some
requests
from
some
bill
sponsors
that
we
will
be
honoring
and
we
may
have
a
few
things
that
occur
as
the
meeting
goes
on
today
as
well.
Item
number
eight
on
our
calendars
house,
bill
451
by
representative
hodges.
A
That
bill
has
been.
The
representative
has
requested
that
that
be
sent
to
our
last
calendar
and
I'll
make
an
announcement
about
that
in
a
moment
as
well
item
number
13
on
our
calendars
house.
Bill
number
two
request
by
representative
smith
has
been
to
roll
that
bill.
One
week
we
will.
We
will
honor
the
representative's
request
that
to
to
roll
one
week.
I
will
make
an
announcement
in
this
committee
and
I
will
make
an
announcement
on
the
floor.
In
consultation
with
the
chairman,
kumar
and
vice
chair
rudder.
A
We
have
decided
that
we
will
announce
our
last
calendar
for
insurance.
Sub
will
be
april
13th,
so
april.
13Th
will
be
our
last
calendar.
Hopefully
that
will
be
the
last
meeting
as
well.
I
think
we've
got
a
few
bills
that
have
not
been
put
on
notice
yet
and
we're
working
our
way
through.
Hopefully
we
can
get
most
everything
disposed
of
next
week,
but
our
last
calendar
will
be
april
13th
once
again.
A
A
E
A
We
have
a
motion
and
a
second
let's
go
ahead
and
put
the
amendment
on
the
bill.
All
those
in
favor
of
putting
house
bill.
5906.
Excuse
me
amendment
number
tracking
code
5906
on
the
bill.
Please
signify
by
saying
aye
aye
any
opposed.
Please
say
no,
the
eyes
have
it.
The
amendment
is
on
the
bill.
Please
feel
free
to
explain
your
legislation
as
amended.
E
A
A
C
A
All
right
amendment
before
us,
ladies
and
gentlemen,
we
have
a
motion
and
a
second
tracking
code
5618
to
go
on
house
bill,
1398.,
all
those
in
favor
of
placing
this
amendment
on
the
bill.
Please
signify
by
saying
aye
any
of
those
opposed.
Please
say:
no,
the
ice
have
it.
We
are
working
on
your
bill
as
amended,
chair
lady
hilton
you're.
Recognizing
thank.
C
You,
mr
chairman
and
committee,
the
amendment
changes
number
one.
It
prohibits
pbms
from
interfering
with
patients
right
to
choose
the
pharmacy
or
provider
number
two.
It
bases
the
calculation
for
the
coinsurance
or
deductible
on
prescription,
drug
or
device
on
the
allowed
amount
of
the
drug
or
device
number
three.
It
establishes
that
coinsurance
or
deductible
does
not
mean
or
include
copayments
number
four
states
that
pharmacies
cannot
be
paid
below
their
acquisition.
Cost
number
five
changes
the
effective
date
for
sections
one
through
four
effective
july
1st
2021
and
section
5
is
january
1st
2022
in
tennessee.
C
We
believe
patients
should
have
choice
in
their
health
care,
whether
it
be
choosing
your
doctor
choosing
your
pharmacy
or
choosing
the
right
treatment
plan
for
you.
Patients
should
be
empowered
to
make
the
right
decisions
for
their
needs
for
too
long
pharmacy
benefit
managers
have
imposed
restrictions
on
patients
access
to
care.
They
need
by
steering
them
away
from
the
providers
and
pharmacies
they
trust
toward
bureaucratic
corporations
who
seek
to
increase
their
profits.
C
This
is
kind
of
lengthy,
so
please
be
patient.
Section
1
addresses
340b
discrimination.
340B
entities
are
safety.
Net
providers
that
serve
the
state's
most
vulnerable
populations,
pbms
can
amend
a
340b
entities
contract
and
reimburse
at
a
lower
rate
than
negotiated,
essentially
withholding
money
from
indigent
care
facilities.
C
C
Spread
pricing
occurs
when
a
pbm
charges
a
health
plan
more
for
a
certain
drug
than
it
reimburses
the
pharmacy
dispensing
the
drug
artificially
inflating
the
cost.
This
practice
results
in
higher
cost
to
the
consumer,
while
allowing
pbms
to
divert
fees
for
profit.
It
is
most
common
with
cheaper
generic
drugs.
C
C
C
This
provision
states
that
a
pbm
has
a
responsibility
to
report.
Any
entitlement
benefit
to
both
the
plan
and
covered
person
that
either
are
entitled
to
this
section
of
the
bill
will
remove
the
opaqueness
within
the
pbm
system
by
freeing
up
data
to
provide
accurate
information
to
patients
at
the
point
of
care,
empowering
discussions
and
decisions
about
medicines
a
patient
can
afford
and
what
it
is
going
to
cost
house
bill.
1398
will
put
patients
back
into
the
center
of
health
care
where
they
belong
and
give
them
more
access,
choice
and
transparency.
A
Thank
you
chair,
lady
helton.
We
do
have
a
couple
of
folks
who
would
like
to
speak
on
this
legislation.
We
can
any
questions
of
the
the
chair,
lady
at
the
moment.
Okay,
I
think
we'll
do
we'll
go
into
recess
at
this
moment
without
objection.
Our
friends
at
tenncare
would
like
to
discuss
this
legislation
as
well.
We
have
a
couple
of
individuals
later
on.
Dr
stephen
schleicher
and
kim
deal
boyd
would
like
to
speak,
but
at
this
moment
we
since
we're
in
recess,
we
will
go
to
our
friends
from
tenncare
and
allow
testimony.
A
F
Mr
chairman
members,
so
tinker's
concern
with
this
bill
is
really
around
section.
Five.
The
bill
language
requires
tenncare
or
its
pba
to
report.
Real-Time
cost
benefit
and
coverage
data
in
a
format
made
by
the
requesting
party
of
data
to
the
enrollee,
enrollees
healthcare,
healthcare
provider
or
enrollees
authorized
representative.
There
are
no
restrictions
on
the
number
of
times.
F
Data
can
be
requested
upon
granting
authorization
and
there
are
no
restrictions
on
a
third
party's
use
of
data
beyond
the
authorized
representative
near
real-time
data
output
on
this
scale
is
currently
unavailable
and
out
of
scope
for
10
care
or
its
pba
system
offerings.
We
also
need
to
ensure
that
we
follow
hipaa
guidelines.
F
A
A
A
G
Thank
you,
mr
chairman
and
committee.
My
name
is
kim
boyd
and
I
am
a
resident
tennessean.
I
was
born
and
raised
here.
I
grew
up
in
mount
juliet
and
I
live
in
rutherford
county,
but
I'm
also
head
of
public
policy
in
industry.
Relations
for
an
entity
called
cover,
my
meds,
which
is
a
health
innovation
technology
company
that
was
founded
in
2008
but
prior
to
getting
into
public
policy.
I
was
also
in
operations.
G
G
It
is
inherent
upon
us
to
embrace
the
call
to
action
in
this
legislation
and
to
create
change
not
only
for
ourselves
and
our
families,
but
for
all
tennesseans,
a
prospective
comprehensive
view
of
our
patient-specific
eligibility
benefit
policies
and
terms
is
lacking
in
health
care.
Today,
for
far
too
long,
there
has
been
significant
opaqueness
in
health
care
that
harms
patients
and
actually
is
a
fiscal
stain
on
the
health
care
system
itself.
G
G
I'm
sure
that
you
and
or
a
member
of
your
family
have
experienced
these
unknowns.
Am
I
covered
for
the
treatment
or
the
medication
that
my
provider
is
ordering?
If
I'm
not
covered,
can
I
still
obtain
that
treatment
or
what
other
options
do
I
have?
Why
didn't?
I
know
that
a
prior
authorization
was
required
for
said
treatment.
G
G
A
H
Ms
boyd,
thank
you
for
your
testimony,
just
as
a
clarification.
So
what
I'm
hearing
you
say
is
the
the
the
data
that
you're
you're
wanting
to
be
made
available
through
chairman
helton's
bill
just
empowers
patients
to
know
more
information
about
their
own
medical
decisions,
their
own
medication
and
potentially
their
costs.
So
price
transparency
is
more
a
part
of
information,
as
opposed
to
necessarily
giving
them
the
power
to
steer
direction,
but
you're,
just
saying
that
this
is
information
that
now
would
be
available
to
the
patient
and
not
just
hidden
within
a
contract.
Is
that
correct?
I
G
I
Most
businesses
that
most
of
us
are
familiar
with
have
got
a
manufacturer,
wholesaler
distributor.
The
more
I
learn
about
this.
It
seems
to
me
that
these
pbms,
however
innocently
they
started
with
a
with
a
card
for
drug
care,
have
somehow
worked
their
way
into
that
distribution
cycle.
They
are
owners
of
pharmacies.
They
are
directors
of.
I
guess
what
kind
of
drugs
get
made
they
steer.
Folks
back
and
forth.
G
Well,
you're
correct,
so
the
pharmacy
benefit
management
industry.
You
know
really
started
out
in
the
80s
and
they
really
took
off.
You
know,
with
the
electronic
exchange
of
information
and
being
able
to
help
ensure
self
self-funded
employers
manage
what
was
a
growing
and
burgeoning
part
of
health
care,
which
was
the
pharmacy
benefit
management
side
and
they
had
expertise
in
helping
insurers
and
and
employers
figure
out.
G
As
we've
grown
in
the
industry,
the
trend
has
really
been
focused
more
on
the
high
cost
of
medications
that
are
coming
out
of
market,
but
you're
correct.
We
started
with
individual
entities
that
were
separate
and,
apart
from
the
totality
of
health
care
being
advisors
to
the
industry.
Now
you
have
to
your
points.
Are
entities
that
are
now
integrated
into
health
systems,
owned
and
operated
by
health
plans
owned
and
operated
by
different
entities
owned
specialty
pharmacies
where
they
did
not
used
to
own
specialty
pharmacies.
A
J
Hello,
so
chairman
and
members
of
the
committee,
thank
you
very
much
for
allowing
me
to
be
here
today
and
time
to
present
about
this
bill.
I
am
going
to
add.
One
thing
that
was
brought
up
last
year
in
2000
are
in
2019
across
the
u.s
125
billion.
Did
you
give
your
name?
I'm
sorry,
dr
stephen
schleicher
medical
oncologist
here
practicing
primarily
in
lebanon,
tennessee,
the
nashville
native
as
well.
J
Thank
you
chairman,
hawk,
just
want
to
add
briefly
last
year
or
in
2019,
125
billion
dollars
were
spent
on
rebates
in
the
united
states
for
every
dollar
on
rebates
that
doesn't
go
to
the
patient.
The
price
of
the
drug
goes
up
a
dollar
and
17
cents.
This
is
a
big
problem
today.
I
want
to
talk
about
three
patients
through
my
group
that
have
been
negatively
impacted
by
patient
lack
of
right
to
choice.
Tennessee
oncology
has
34
clinics
in
rural
areas
across
tennessee.
J
I
myself
an
oncologist
and
a
lot
of
my
patients
have
incurable
cancer,
that
causes
pain,
anxiety,
financial
toxicity
and
many
other
things,
and
while
that
patient's
trying
to
stay
strong
for
him
or
herself
and
their
family,
we
have
an
excellent
cancer
team
to
help
them.
This
includes
myself
my
nurse,
a
palliative
care
provider
nutritionist
and
a
pharmacist
as
drugs
go
from
iv
to
oral.
That
specialty
pharmacist
is
more
important
than
ever.
If
a
patient
has
high
copay,
we
find
assistance.
J
Tennessee
oncology
spent
48
million
dollars
out
of
our
pocket
to
provide
free
drug
on
the
oral
side
for
patients.
If
a
patient
has
distress,
I
know
about
it.
If
they
have
diarrhea,
the
pharmacist
can
link
me
a
message
if
the
patient
stressed
and
missed
a
dose,
I
know
about
it.
If
they
didn't
pick
up
the
drug,
I
know
about
it.
This
is
what's
supposed
to
happen.
35
of
the
time
pbms
and
insurers
have
forced
our
patients
to
use
other
pharmacies.
J
I
want
to
go
through
three
examples
of
this
and
how
that
is
different
than
what
I
just
described.
The
first
is
a
63
year
old
patient
of
myself.
He
has
three
kids
he's
60.
He
has
pancreatic
cancer
in
this
case.
We're
actually
going
for
cure
as
part
of
that
cure,
he's
got
to
get
to
surgery
and
to
do
that,
we
are
using
radiation
with
a
chemotherapy
pill
that
must
be
taken
on
the
day
of
radiation.
J
In
his
case,
the
drug
had
to
be
shipped
through
a
credo
which
is
not
us
through
the
pbm,
and
we
found
out
about
halfway
through
that.
He
was
running
out
of
his
pills.
The
next
day
we
contacted
his
specialty
pharmacy.
I
got
my
pharmacy
involved
as
well.
He
came
back
four
days
later
and
had
not
received
his
oral
chemotherapy
pill
yet
frantically
in
clinic.
We
tried
again
and
finally,
the
drug
had
to
be
shipped
through
our
own
pharmacy
at
a
price
actually
cheaper
than
what
his
insurance
had
demanded
through
their
specialty
pharmacy.
J
Another
case,
a
patient
who
has
metastatic
kidney
cancer,
again
not
curable
on
two
oral
drugs
together.
The
goal
of
this
treatment
is
to
improve
quality
of
care
and
reduce
symptoms
from
his
cancer.
For
a
year,
we
had
prescribed
those
drugs
through
our
pharmacy
using
copay
assistance,
his
insurance
switched,
and
thus
he
was
forced
to
pick
out
his
pick
up
his
drugs
from
a
different
specialty
pharmacy.
J
One
of
those
specialty
pharmacies
did
not
have
access
to
copay
cars,
so
cards,
so
his
price
went
up
and
he
didn't
take
his
medication.
The
other
drug,
the
specialty
pharmacy
did
not
even
carry
they
didn't
have
that
drug.
He
went
two
weeks
without
the
drug
before
we
finally
got
the
insurance
to
override
it,
so
we
could
supply
the
drugs
ourselves
and
also
taught
the
specialty
pharmacy
how
to
get
the
copia
assistance
for
his
other
drug.
A
third
final
case,
a
patient
with
metastatic
colon
cancer
on
an
oral
drug
which
is
third
line
treatment.
J
He
started
treatment
with
one
of
my
colleagues
and
had
the
first
cycle
came
back
six
weeks
later
for
assessment
on
the
third
cycle
and
we
found
out
he
had
not
received
his
drug
for
the
time
in
between
and
missed
a
full
cycle,
because
we
had
no
control
over
that
process
and
were
not
communicated
as
well.
This
is
not
how
it
should
be
for
these
patients
we're
not
asking
to
demand
a
patient
to
go
anywhere.
We
just
want
the
patient
to
choose
where
he
or
she
picks
up
their
important
anti-cancer
drugs.
Thank
you.
A
H
So
each
of
the
companies
that
I
just
name
again
they're
great
partners.
We
need
them
so
cigna,
aetna,
united
healthcare
and
humana
all
own
their
own
pharmacy
benefit
manager
and
their
own
specialty
pharmacy,
for
which
they
would
they
steer
their
own
patients
toward
and
they
determine
within
that
vertical
alignment.
They
determine
the
formularies,
the
things
that
are
not
covered
and
they
steer
patient
care.
J
H
H
How
do
you
navigate
those
channels
and
if
you
could
make
that
there's
there's
a
very
robust
discussion
about
things
like
medical
necessity
in
this
body
right
now,
along
with
some
other
things,
I'd
just
like
for
you
to
speak
as
a
clinician
about
how
you
navigate
different
health
care
plans.
Thank
you.
J
No
thank
you,
chairman
smith.
It's
challenging.
Most
importantly
often
I
have
to
get
on
the
phone
with
someone
from
the
insurer
who
sometimes
can't
pronounce
the
name
of
the
drug.
Explain
why
it's
needed
and
the
bigger
issue
is
delay.
Often
a
drug
that
I
know
is
standard
of
care
that
is
in
ccn,
which
is
our
national
guidelines
recommended.
J
A
A
C
A
K
K
A
A
Ladies
and
gentlemen,
let's
go
ahead
and
place
the
amendment
on
the
bill,
and
then
we
will
have
description
by
chairman
williams
after
that
all
those
in
favor
of
placing
amendment
number
one
tracking
code
5743
on
the
bill.
Please
signify
by
saying
aye
any
of
those
opposed.
Please
say
no,
the
eyes
haven't.
We
are
on
your
bill
as
amended
for
description.
Thank.
K
K
As
you
know,
didn't
do
very
much
last
session,
but
this
bill
this
committee
passed
last
year,
but
what
it
would
do
would
allow
for
automatic
enrollment
of
people
in
long-term
short-term
disabilities,
currently
the
operating
procedure
for
some
companies
to
do
that,
and
then
those
citizens
would
have
the
opportunity
to
opt
out
of
that
coverage
within
30
days.
If
they
want
to.
This
does
have
a
small
fiscal
note,
but
it
has
to
do
with
the
tax
credits.
K
This
law
would
encourage
our
employers
to
enroll
people
early
on
in
order
to
utilize
these
tax
credits.
In
so
doing
it
would
protect
these
citizens,
as,
as
many
of
you
may
know,
you
may
have
long-term
or
short-term
disability
coverage,
it's
very
inexpensive,
and
so
it's
one
of
those
things
where
we
can.
We
can
give
businesses
an
opportunity
to
support
their
citizens
through
this
tax
credit
and
auto
enrollment.
I'm
happy
to
answer
any
questions.
Members
may
have.
L
K
L
H
I
just
want
to
say
thank
you.
One
of
the
things
I
think
we
overlook
is
the
fact
that,
for
those
that
do
not
have
disability
insurance,
I
would
assume
it's
fair
to
say,
chairman,
that
these
people
end
up
on
tenncare
if
they
don't
have
that.
So
this
is
a
a
mechanism
that
will
protect
our
tax
dollars.
So
thank
you.
M
M
I,
during
part
of
the
duties
I
had,
I
manage
benefit
programs,
and
I
worked
for
organizations
that
had
the
auto
enroll
and
some
that
did
not,
and
I
saw
a
lot
of
the
difference,
especially
when
you
had
employees
coming
back
later,
who
were
disabled
and
in
the
standard
what
we
could
offer
them
with
long-term
disability
and
and
without
it
too.
So
this
is
a
good
bill
and
it'll
be
of
the
benefit
of
of
of
working
people
all
over
the
state.
Thank
you.
A
K
A
A
A
K
Thank
you
chairman
and
members
house
bill
988
originated
last
year
in
the
discussion
and
then
followed
again
this
year
house,
bill
988,
as
amended
by
this
drafting
code,
addresses
the
lack
of
oversight
of
air
ambulance
companies
and
their
membership
plans
in
tennessee
by
redefining
the
sale
of
memberships
as
insurance
as
they
currently
aren't.
These
memberships
are
sold
to
protect
against
future
medical
expenses,
just
like
other
insurance
insurance
types
of
insurance
would,
instead
of
going
of
working
to
go
in
network
with
insurance
companies.
K
Some
air
ambulance
companies
offer
membership
fees
to
cover
out-of-pocket
expenses,
expenses
or
deductibles.
In
the
same
way,
insurance
protects
medical
insure,
medical
expense,
expenses
and
gap
insurance
coverage
deductibles
this
bill
does
not
remove
the
ability
for
any
of
these
folks
to
operate
their
businesses
or
those
or
to
offer
memberships.
It
simply
allows
tennessee
department
of
commerce
and
insurance
to
ensure
that
consumer
protections
are
in
place
to
make
sure
the
citizens
of
tennessee
are
protected.
K
N
Thank
you,
mr
chairman,
chairman
williams,
we've
we've
rode
on
many
horses
together
on
this,
and
this
is
one
I'm
not
going
to
be
able
to
ride
with
you
on
we
have,
for.
I
have
firsthand
experience
with
airyvac
when
I
was
living
in
missouri
of
somebody
that
had
a
tractor
accident
and
they
responded
in
a
very
quickly
quick
way.
I've
had
it
when
I've
lived
on
the
farm
to
provide
that
level
of
coverage
for
myself
and
my
family
that
there
ever
was
an
incident.
N
N
I
know
there's
going
to
be
an
argument
for
this.
I
get
it,
but
I'm
just
struggling
with
trying
to
regulate
something
that
seems
to
be
working
rather
well,
and
I
don't
want
to
put
them
under
the
bureaucracy
of
of
insurance
and
have
to
meet
all
that
and
then
start
to
drive
the
cost
up
to
our
rural
communities
of
people
that
really
can't
afford
much
more,
but
just
the
safety
of
a
flight.
So
that's
all
I
want
to
say,
mr
chairman,
you
have
to
get
responsibility.
That's
fine!.
K
As
I
stated
previously
that
this
does
not
prohibit
anyone
from
being
able
to
currently
do
that,
there
is
no
imposition
whatsoever
on
the
air
ambulance.
Folks,
you
know
in
in
this
instance,
it
allows
for
consumer
protection
and
if,
if
what
you
say
is
correct-
and
I
have
no
reason
to
disagree-
what
you're
saying
or
what
they
might
even
say
as
to
whether
there's
any
complaints,
if
there
are
none,
then
there
should
be
no
concern
if,
as
it
relates
to
a
consumer
protection
model,
I
agree
with
you.
K
We
never
really
want
to
add
additional
bureaucracy,
but
this
we
have
bureaucracy
in
place,
sometimes
in
order
to
protect
citizens
in
this.
In
this
instance,
I
have
the
opportunity
to
buy,
through
my
insurance
company
a
discounted
rate
for
these
air
ambulance
companies,
and
I
think
they
provide
a
much
needed
service
to
not
just
the
rural
tennessee
but
other
areas
across
tennessee
as
well,
and
so
I
get
your
points,
but
there.
This
would
not
give
any
imposition
to
them
whatsoever,
except
for
reporting
to
the
to
commerce
and
insurance,
and
that's
all
thank
you.
I
I
I
hear
the
consumer
protection
side
of
things,
but
if
the
consumers
aren't
clamoring
for
it,
I'm
not
sure
what
we're
what
we're
looking
to
do
beyond
that.
Also,
it
seems
everything
that
gets
we're
talking
about
health
care
right,
we're
moving
this
into
kind
of
a
health
care
kind
of
insurance
policy.
I
K
K
Thankfully
not
many
of
them
are
needing
them
and
it's
that's
the
nature
of
an
insurance
policy.
In
most
cases,
people
don't
can
be
transported
using
a
an
ambulance
and
not
an
air
ambulance
and
a
lot
of
that
based
upon
that
availability,
even
if
you
were
in
a
rural
area
and
so
the
costs
for
medicaid
medicare
are
already
covered
for
air
ambulance,
and
so
all
this
would
do
would
protect
those
citizens
who
may
have
bought
a
membership
somewhere,
and
then
someone
else
ended
up
picking
them
up.
H
H
Because
I'm
unfamiliar
with
how
these
work
is
there
a
possibility
that
a
patient
could
be
given
a
balanced
bill
in
a
case
of
they
pay
their
65
85
105
monthly
membership,
but
they
have
to
engage.
Are
they?
Is
there
any
sort
of
protection
in
place?
Should
they
have
to
use
that
that
all
of
a
sudden
there's
a
bill
that
exceeds
that
monthly
charge?
And
it's
going
to
be
in
the
tens
of
thousands
of
dollars
and
the
reason
I
asked
that
question
is:
that
is
one
of
the
main
issues
behind
the
air
ambulance.
Surprise.
K
K
K
Maybe
if
something
were
to
happen
to
me,
I'd
be
covered,
but
I
really
didn't
know
what
what
I
was
covering,
and
so,
when
you
really
don't
know
until
you
get
a
bill
and
then
you
don't
know
what
the
coverage
is
entails
or
whether
the
person
you
bought
a
premium
from
actually
provided
that
service
so
or
in
this
case
it's
not
a
premium.
It's
a
membership,
but
I'm
happy
to
answer
any
other
questions.
I
know
chairman
there.
Some
others
would
like
to
testify.
I'm
happy
to
stand
away.
I.
E
Thank
you,
mr
chairman.
It
represents
I'm
just
trying
to
figure
out,
and
I
I'm
kind
of
on
the
fence
on
this,
because
I
see
this
as
almost
an
ancillary
insurance
product,
so
I
almost
get
the
idea
where
you're
going,
but
also
too
many
times
down
here
we
seem
to
get
involved
in
picking
winners
and
losers
in
an
industry,
and
I'm
trying
to
figure
out
is
that
what
we're
getting
into
in
in
in
this
situation,
because
there
seems
to
be
two
competitors,
one
seems
to
be
a
better
marketer
than
the
other.
E
K
K
I
can't
thank
you,
representative
mitchell.
I
can't
speak
to
the
big
guy
and
the
little
guy
or
the
excellent
marketer
or
whatever,
but
our
role
as
citizens
legislators
is
to
protect
the
citizens
really
in
this
instance,
in
looking
at
the
way
this
process
works.
I
feel
like
that.
This
would
be
a
good
thing.
It's
not
like
anyone's
saying
you
can't
be
in
business
because
you
don't
have
a
good
marketer.
K
All
we're
saying
is:
is
that
because
they're
providing
a
club,
a
marketing
membership-
and
there
are
citizens
who
are
buying
this
in
in
the
in
the
numbers
of
hundreds
of
thousands
of
tennesseans?
If
it,
I
believe,
it's
in
the
states
and
the
citizens
best
interest
to
have
commerce
and
insurance
at
least
oversee
it.
E
Yeah
and-
and
I
I
kind
of
agree
with
you
in
protecting
the
public,
but
unfortunately
I
see
every
day
there
are
so
many
areas,
you
know
whether
it
be
in
the
lending
industry
or
you
know,
insurance
products
out
there.
That's
that,
I
think
in
my
personal
opinion,
consumers
are
wasting
their
money
and
we
ought
to
do
something
about
it
or
or
gambling
in
this
state.
E
B
This
is
another
one
that
I
I
I
guess
is
the
I'm
just.
I
can't
be
with
you
on
this
one,
and
I
have
told
you
that
I
had
quite
a
bit
of
interest
in
this
bill
and
did
some
and
did
some
research
and
what
I
found
out,
and
I
don't
guess
I
have
a
question,
it's
more
of
a
statement,
but
what
I
found
out
that
in
my
county
there
were
my
district.
There
was
over
4
300
people
that
have
bought
these
memberships.
B
I
also
found
out
that
a
lot
of
times
in
these
rural
areas
people
buy.
I
had
one
gentleman
told
me
he
bought
a
five-year
membership,
knowing
that
he
would
probably
never
use
it,
but
what
it
did
was
help
get
an
air
ambulance
via
the
memberships
into
his
district,
so
that
was
so
important
in
a
rural
area.
The
other
thing
that
I
would
like
to
add
was
that
I
did
ask
the
department
of
health:
had
there
ever
been
a
any
complaints
about
air
ambulances,
and
I
will
tell
you
that
the
answer
was
no.
B
H
I
did,
and
I
was
going
to
ask
if
I
could
just
speak
to
the
sponsor
and
ask
if
I
could
work
with
you,
possibly
on
an
amendment
or
may
put
this
in
a
position
where
we,
I
don't
think
anyone
argues
on
this
panel.
We
need
some
consumer
protections,
but
I
think
you
hear
that
we
also
don't
want
to
interfere
with.
We
don't
want
to
pick
winners
and
losers
as
it
were
so.
K
H
K
D
A
A
L
O
L
O
O
The
patient
and
the
physician
has
a
relationship
on
addressing
the
most
aggressive
and
the
most
effective
treatment.
The
way
it
stands
now
you
have
to
go
through
a
series
of
drugs
and
treatments
before
you
get
to
the
most
effective.
This
would
bypass
that
therefore,
given
cost
avoidance,
which
would
eliminate
the
physical
note-
and
this
is-
this-
has
already
taken
place
in
26
other
states,
and
I
haven't
figured
out
how
they're
doing
it
yet,
but
I'll
have
it
give
up.
So
I
seek
direction
from
this
committee
on
on
how
we
need
to
move
on
this.
L
L
Take
it
off
notice
or
roll
the
bill
until
you
can
work
with
the
stakeholders
and
see
if
you
can
have
a
good
lunch
or
dinner
with
them,
and
you
guys
can
convince
each
other,
it's
a
matter
of
working
with
them,
and
what
I
found
is
that
personally,
it's
good
to
con
touch
base
with
the
person
who
opposes
you
first,
because
you
learn
from
them
and
working
together.
We
come
up
with
better
legislation
that
serves
our
citizens
better
members.
Do
we
have
any
other
direction
or
advice
for
chairman
hall.
O
O
L
L
P
P
It's
simply
a
bill
that
clarifies
a
section
of
code
and
it
says
that
basically,
an
insurance
company
is
allowed
if
they
want
to
to
offer
a
plan
where,
if
you
as
a
patient,
go
to
the
doctor,
negotiate
a
cash
rate
you
can
get
reimbursed
for
that
from
your
insurance
company
again,
there
just
seemed
to
be
a
little
bit
of
confusion
in
the
market,
whether
or
not
that
was
allowed.
This
just
clarifies
it
and
hopefully
that
clarification
will
result
in
some
innovation.
H
Thank
you
for
for
bringing
this
bill.
I'm
just
curious.
Is
this
something
that
you're
seeing
or
has
seen
in
another
state
where
there
are
plans,
or
because
I
know
here
in
the
state
of
tennessee,
we
have
passed
the
associated
health
plans,
we've
done
the
direct
medical
contracting,
where
you
don't
have
to
have
insurance,
and
you
engage
directly
with
your
provider
on
a
menu
of
services
and
and
I'm
all
about
innovation
that
knocks
down
barriers.
Where
have
you
seen
this
ship.
P
P
H
L
Thank
you
you're
right
in
the
sense
that
it
used
to
be
that
when
you
went
to
see
the
doctor,
you
signed
a
piece
of
paper,
assigning
the
benefits
or
not
assigning
the
benefits.
If
you
assigned
the
benefits
payment
went
to
the
physician.
If
you
did
not
sign
the
payment
came
to
you
sure,
but
anyway
I
think
you're
simplifying
the
matter
and
giving
people
a
choice.
Any
other
questions.
You
know
we
have
a
motion
for
question
all
those
in
favor
of
house
bill.
L
L
B
B
B
L
D
L
H
Thank
you,
mr
chairman
and
committee,
as
part
of
the
federal
surprise.
No
surprise
act
that
settles
the
erisa
plan
issue
of
surprise
billing.
In
that
language
there
was
enabling
monies
that
were
made
available
to
all
states
for
an
all
payers
claims
database
and
all
payers
claims
database.
It
will
be
a
a
a
clearing
house
of
information
that
the
health
services
development
agency,
oversees
it
will
be
very
much
protected.
The
data
will
be
protected.
H
The
purpose
of
this
is
to
aggregate
the
cost
of
services
in
a
blinded
fashion,
so
that
patients
will
be
able
to
that
that
information
is
provided
to
the
state
they
can
benchmark
and
compare
costs
and
and
provide
information,
also
part
of
the
arbitration
settlement
period.
In
the
surprise,
billing
act
federally,
and
even
if
we
have
a
state
level
remedy,
this
will
be
a
tool
that's
used.
The
logan
grant
here
has
been
working
on
this
particular
amendment
for
about
two
years.
D
L
H
L
I
H
I
L
L
L
H
Thank
you,
mr
chairman.
It
would
include
a
whole
list
of
information
that
is
laid
out
by
the
federal
bill.
This
is
a
again.
This
is
an
enabling
piece
of
legislation,
we're
not
making
the
determination
here
in
the
state
of
tennessee.
There
will
be
a
national
platform
that
is
constructed
and
every
state
will
have
a
a
minimum
or
a
floor
of
information
that
will
be
collected.
H
The
the
monies
that
are
available
from
the
federal
government
total
to
be
2.5
million.
The
hsda
has
already
begun
engaging
with
various
vendors
that
they
would
receive
a
million
dollars
for
the
first
year,
a
million
dollars
for
the
second
year
500
000
for
the
third
year
and
again,
every
state
will
be
forming
their
own
all
payers
claims
database,
and
that
will
be
part
of
the
information
that
is
disclosed
to
the
state.
H
L
I
should
have
figured
that
out.
If
the
federal
government
is
asking
to
be
creative,
it
will
include
everything
so
back
to
the
direction
of
this
bill.
It
appears
that
considering
the
13-page
amendment,
considering
the
fact
that
we
cannot
hear
from
the
agency
that's
going
to
run
it,
we
will
roll
it
to
the
heel
of
the
calendar
without
objection.
D
D
Q
Q
Thank
you,
mr
chairman,
and
really
appreciate
members
of
committee
for
allowing
me
to
speak
this
way.
I
my
name
is
randy
pate,
I'm
the
founder
of
randolph
paid
advisors,
it's
a
strategic
marketing
and
consulting
firm,
but
for
purposes
of
this
discussion
today,
I'm
the
former
director
of
cesaio,
it's
the
center
for
consumer
information
and
insurance
oversight.
It
was
within,
is
within
centers
for
medicare
medicaid
services,
and
I
served
in
that
capacity
for
four
years
and
we
had
oversight
over
the
individual
health
insurance
exchanges.
Q
So,
in
my
role
as
I
stated
before,
at
cesaio
within
cms,
we
ran
healthcare.gov
and
we
also
worked
with
the
the
state-based
exchanges.
There
are
29
states
that
are
currently
still
on
the
healthcare.gov
federal
platform,
but,
based
on
this
experience,
I
can
tell
you
really
firsthand
of
the
importance
of
states
in
regulating
their
own
health
insurance
markets.
States
rather
than
the
federal
government
are
in
the
best
position
to
address
issues
unique
to
their
markets
and
to
their
citizens.
Q
I
want
to
make
clear
from
the
outset-
and
I
would
like
my
testimony
to
reflect
that
this
discussion
is
not
at
all
about
medicaid
expansion
and
really
has
nothing
to
do
with
that.
It's
really
talking
about
private
health
insurance
and
the
individual
insurance
market
under
federal
law,
a
private
health
insurance.
I'm
sorry,
a
public
health
insurance
exchange
serves
as
a
gateway
to
access
federal
premium.
Q
Tax
credits
exchanges
also
play
an
important
role
in
how
consumers
shop
forward
enroll
in
coverage
provide
not
only
the
front-end
shopping
experience
through
the
exchange
website
and
application
process,
but
also
deciding
which
plans
will
be
certified
as
qualified
health
plans
under
federal
law.
If
the
state
doesn't
chooses
not
to
establish
and
operate
its
own
exchange,
the
federal
government
must
step
in
and
run
the
exchange
on.
Behalf
of
the
state.
Tennessee's
exchange
has
been
run
by
the
federal
government.
Q
Like
many
other
states,
tennessee's
market
was
in
a
crisis,
while
premiums
in
the
individual
market
nearly
doubled
nationwide
from
the
year
the
affordable
care
act's
main
rules
went
into
effect
in
2013
up
until
2017,
when
we
came
in
tennessee's
situation
was
even
worse.
Premiums
in
the
state's
individual
markets,
spiked
by
about
150
percent
from
2015
to
2019
and
enrollment
plummeted.
As
a
result,
unsubsidized
enrollment,
meaning
enrollment
among
people
who
did
not
qualify
for
the
aca's
premium.
Tax
credits
decreased
by
more
than
half
in
just
one
year
from
2016
to
2017..
Q
Looking
at
the
two-year
period
from
2016
to
2018,
tennessee's
unsubsidized
enrollment
nearly
went
away
entirely
dropping
by
an
eye-popping
76
percent
in
two
years,
and
as
many
of
you
on
the
committee
probably
remember
vividly,
we
were
also
seeing
health
insurance
companies
flee
the
market.
At
that
point,
including
here
in
tennessee,
we
scrambled
to
work
with
former
commissioner
mcpeak
and
others
in
the
state
to
make
sure
that
there
was
even
one
health
insurance
company.
That's
just
one
choice
for
consumers
available
in
every
tennessee
county.
Q
First
and
foremost,
we
put
in
place
policies
that
empowered
states
we
gave
states
ability
to
have
significant
input
and
direction
over
key
regulations,
such
as
rate
review,
medical
loss
ratio
and
risk
adjustment.
Finally,
we
greatly
expanded
what
states
could
accomplish,
through
the
section
1332
state
innovation
waivers
and
we
approved
15
reinsurance
waivers
around
the
country
that
in
many
cases,
reduced
premiums
by
double
digits
and
brought
relief
to
these
unsubsidized
enrollees
around
the
country
and
as
a
result
of
these
policies
in
giving
states
more
flexibility
and
really
promoting
competition
and
choice.
Q
Average
premiums
for
the
benchmark
plans
in
healthcare.gov
actually
went
down
for
the
first
time
in
2019
and
they've
decreased
for
three
straight
years.
Competition
on
the
exchanges
has
also
increased
as
a
percentage
of
counties
with
only
one
insurer,
often,
coverage
dropped
from
52
percent
in
2018,
down
to
only
nine
percent
in
2021.
Q
in
tennessee,
benchmark
premiums
have
dropped
by
six
percent
in
2020
and
again
by
10
in
2021
as
new
new
competitions
entered
the
market,
but
I
believe,
as
the
political
winds
have
shifted
in
washington,
there
is
a
real
danger
that
we're
going
to
see
a
return
to
the
concentration
of
regulatory
power
in
the
hands
of
federal
regulators
and
taking
away
critical
decision-making
authority
from
states
in
this
environment.
I
believe
that
establishing
a
state-based
exchange
is
one
important
way
that
tennessee
can
preserve
its
ability
to
oversee
its
own
market
and
plan
for
the
future.
Q
Q
Q
Q
It's
important
to
note
today
that
enrollees
on
the
federal
platform,
including
tennessee,
pay
user
fees
to
the
federal
government
in
the
form
of
higher
health
insurance
premiums
in
2019
tennessee
enrollees
sent
nearly
50
million
dollars
in
hidden
taxes
to
washington
to
cover
the
cost
of
the
federal
exchange.
The
burden
of
paying
the
user
fee
falls
primarily
on
taxpayers
and
unsubsidized
enrollees,
who
don't
even
directly
benefit
from
this
exchange.
By
establishing
its
own
exchange.
Q
Tennessee
would
have
the
opportunity
to
reduce
this
burden
on
its
enrollees
and
can
charge
a
lower
fee
or
can
seek
an
alternative
means
to
fund
exchange
operations
and,
finally,
a
well-designed
state-based
exchange
can
serve
as
the
foundation
for
future
market-based
reforms
because
of
the
additional
flexibility
and
regulatory
design.
Flexibility
given
states
exchanges
can
also
be
an
effective
platform
for
implementing
market-oriented
health
reforms.
In
november,
2019
cms
issued
four
waiver
concepts
that
were
designed
to
take
full
advantage
of
the
aca
section.
L
Thank
you
if
you
want
to
give
a
summary
sentence
or
two
basically
it's
about
establishing
as
tennessee
our
own
insurance
exchange
for
healthcare,
and
that
would
give
us
some
control
over
our
local
markets
and
avoid
increasing
intervention
from
the
federal
government.
Am
I
summarizing
it?
That's
exactly
right
all
right!
Well,
thank
you
for
coming,
gentlemen.
Do
we
have
any
questions
for
mr
tate,
german
lafferty,
you're
recognized.
I
Q
There's
just
one
person
in
the
company
right
now
and
that's
me,
but
you
know
I
will
say
you
know
I
do
have
a
lot
of
experience
in
in
helping
states
set
their
exchanges
up.
We
work
very
closely
with
pennsylvania,
new
jersey
and
nevada.
The
states
I
just
mentioned,
but
you
know
it's
just
me
for
now
and.
Q
Well,
so
it's
really
two
different
states.
The
states
has
done
the
state
that
has
done
it.
The
longest
is
nevada
and
they
they
migrated
off.
The
federal
exchange
about
three
years
ago
and
they've,
been
operating
at
a
lower
user
fee
than
the
federal
government
has
the
most
innovative
state.
Is
georgia
they're
the
one
that
we
actually
use?
Q
A
1332
state
innovation
waiver
for
them
to
basically
waive
healthcare.gov,
so
healthcare.gov
in
two
years
will
no
longer
operate
in
the
state
and
instead
you
will
have
private
health,
insurers
and
web
brokers
serve
as
really
the
shopping
experience
for
consumers,
so
they
would
be
the
most
innovative.
Thank
you.
H
Q
Thank
you
for
the
question,
so
initially,
what
I'm
talking
about
is
just
establishing
a
state-based
exchange.
You
know.
Minimum
essential
coverage
is
a
requirement
that
applies
across
the
individual
market
and
the
group
market.
Today
it
would
not.
You
would
not
be
waiving
that
requirement,
however,
in
the
future,
if
the
state
wanted
to
use
a
1332
waiver
to
make
more
affordable
products
available
in
the
market,
building,
a
state-based
exchange
could
help
to
enable
that,
in
the
future.
L
P
L
A
L
We
have
a
motion
on
the
amendment.
Do
we
have
a
second
all
those
without
objection?
We
are
voting
on
attaching
amendment
4425
to
house
bill
360.,
all
those
in
favor,
please
say
aye
all
right
oppose
the
amendment
goes
on
the
bill
chairman
hawk
you're,
recognized
on
the
amended
house
bill
360..
Thank.
A
This
bill
will
direct
tennessee
department
of
commerce
and
insurance
to
use
existing
resources
to
access
federal
reports
from
insurance
plans
to
make
this
data
available
to
us
in
a
report
that
they
will
provide
to
the
general
assembly.
With
that
explanation
of
the
amendment,
I
would
request
your
support
of
the
legislation.
Mr
chairman
of
members,.
L
Members,
do
we
have
any
questions
for
chairman
hawk,
seeing
none
are
we
ready
to
vote
without
objection?
We
are
voting
on
house
bill
360.,
all
those
in
for
favor,
please
say
aye
opposed
the
bill
goes
on
to
full
committee.
Thank
you,
chairman
hawk,
thank
you
chairman
and
members
and
members
without
objection
we
stand
adjourned.