HOUSE BILL NO. 1681 103RD GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVE SEITZ.
5031H.01I JOSEPH ENGLER, Chief Clerk
AN ACT To amend chapter 376, RSMo, by adding thereto one new section relating to cost-sharing under health benefit plans.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Chapter 376, RSMo, is amended by adding thereto one new section, to be 2 known as section 376.448, to read as follows: 376.448. 1. As used in this section, the following terms mean: 2 (1) "Cost-sharing", any co-payment, coinsurance, deductible, amount paid by 3 an enrollee for health care services in excess of a coverage limitation, or similar charge 4 required by or on behalf of an enrollee in order to receive a specific health care service 5 covered by a health benefit plan, whether covered under medical benefits or pharmacy 6 benefits. The term "cost-sharing" shall include cost-sharing as defined in 42 U.S.C. 7 Section 18022(c); 8 (2) "Enrollee", the same meaning given to the term in section 376.1350; 9 (3) "Generic drug", the same meaning given to the term in 42 CFR 423.4; 10 (4) "Health benefit plan", the same meaning given to the term in section 11 376.1350; 12 (5) "Health care service", the same meaning given to the term in section 13 376.1350; 14 (6) "Health carrier", the same meaning given to the term in section 376.1350; 15 (7) "Pharmacy benefits manager", the same meaning given to the term in section 16 376.388.
EXPLANATION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is intended to be omitted from the law. Matter in bold-face type in the above bill is proposed language. HB 1681 2
17 2. When calculating an enrollee's overall contribution to any out-of-pocket 18 maximum or any cost-sharing requirement under a health benefit plan, a health carrier 19 or pharmacy benefits manager shall include any amounts paid by the enrollee or paid 20 on behalf of the enrollee for any medication where a generic drug substitute for such 21 medication is not available. 22 3. A health carrier or pharmacy benefits manager shall not vary an enrollee's 23 out-of-pocket maximum or any cost-sharing requirement based on, or otherwise design 24 benefits in a manner that takes into account, the availability of any cost-sharing 25 assistance program for any medication where a generic drug substitute for such 26 medication is not available. 27 4. If, under federal law, application of the requirement under subsection 2 of this 28 section would result in health savings account ineligibility under Section 223 of the 29 Internal Revenue Code of 1986, as amended, the requirement under subsection 2 of this 30 section shall apply to health savings account-qualified high deductible health plans with 31 respect to any cost-sharing of such a plan after the enrollee has satisfied the minimum 32 deductible under Section 223, except with respect to items or services that are 33 preventive care under Section 223(c)(2)(C) of the Internal Revenue Code of 1986, as 34 amended, in which case the requirement of subsection 2 of this section shall apply 35 regardless of whether the minimum deductible under Section 223 has been satisfied. 36 5. Nothing in this section shall prohibit a health carrier or health benefit plan 37 from utilizing step therapy in accordance with section 376.2034. 38 6. The provisions of this section shall not apply to health benefit plans that are 39 covered under the Labor Management Relations Act of 1947, 29 U.S.C. Section 141 et 40 seq., as amended. 41 7. The provisions of this section shall apply to health benefit plans entered into, 42 amended, extended, or renewed on or after August 28, 2026. ✔
Statutes affected: