ON MARCH 7, 2024, THE HOUSE ADOPTED AMENDMENT #1 AND PASSED HOUSE BILL 916, AS AMENDED.
AMENDMENT #1 rewrites this bill to add the following provisions relative to clinician-administered drugs, which are outpatient prescription drugs, other than vaccines, (i) that either cannot reasonably be self-administered by the patient or an individual assisting the patient or for which the prescriber has ordered administration by a healthcare provider and (ii) that is administered by a healthcare provider in a clinical setting:
(1) This amendment generally prohibits a health insurance entity from conditioning, denying, restricting, refusing to authorize or approve, failing to cover, or reducing payment to a participating healthcare provider for a clinician-administered drug solely because (i) the clinician-administered drug is either purchased or administered by a participating healthcare provider or (ii) the participating healthcare provider obtained the clinician-administered drug from a pharmacy that is not a contracted provider in the health insurance entity's network;
(2) This amendment requires a health insurance entity to comply with the above provision only if (i) the terms of the health insurance contract that do not conflict with the above provisions, including the covered person's health insurance coverage benefits and medical necessity criteria, can also be met; and (ii) the clinician-administered drug meets the requirements set forth in federal law;
(3) This amendment requires a health insurance entity to pay a participating healthcare provider at the rate for the clinician-administered drug set forth in the health insurance entity's agreement with the participating healthcare provider, or, if no rate is included in the agreement, at a rate not less than the health insurance entity's median rate of reimbursement currently payable to all providers in the health insurance entity's provider network for the clinician-administered drug;
(4) This amendment prohibits a health insurance entity from requiring a covered person to pay an additional fee or other increased cost-sharing amount for a clinician-administered drug administered by a participating healthcare provider solely because the drug is (i) purchased and administered by the participating healthcare provider or (ii) obtained by the participating healthcare provider from a pharmacy that is not a contracted provider in the health insurance entity's network;
(5) This amendment prohibits a health insurance entity from authorizing or permitting another person or entity acting on its behalf to administer claims or benefits under a health insurance contract in violation of this amendment;
(6) This amendment does not prohibit a health insurance entity from establishing differing copayments or other cost-sharing amounts within the health insurance contract for a covered person who receives a clinician-administered drug administered by a healthcare provider who is not contracted with the health insurance entity;
(7) This amendment does not prohibit a health insurance entity from refusing to authorize or approve, or denying coverage of, a clinician-administered drug based upon a failure to satisfy the required terms of coverage in the health insurance contract, including medical necessity criteria;
(8) This amendment requires a health insurance entity that has established a specialty pharmacy network to establish a process under which requests for authorization by a healthcare provider to administer clinician-administered drugs are handled in accordance with this amendment. If the healthcare provider treating the covered person submits an urgent care request, then the health insurance entity must provide review and determination;
(9) Except as provided in this amendment, a health insurance entity's specialty pharmacy network in existence as of January 1, 2025, is not subject to the requirements of this amendment, as long as the following is true:
(A) The health insurance entity does not control, directly or through an affiliate, a specialty pharmacy that is participating in the health insurance entity's specialty pharmacy network;
(B) The health insurance entity contracts with specialty pharmacies in this state at rates no less than the median of reimbursement rates applicable to other specialty pharmacies in the network and with the same terms and conditions applicable to other specialty pharmacies in the network. A specialty pharmacy seeking inclusion in the network must meet the reasonable credentialing standards established by the health insurance entity; and
(C) When a healthcare provider participating in the health insurance entity's provider network obtains a clinician-administered drug for a covered person from a source other than the health insurance entity's specialty pharmacy network, the health insurance entity reimburses the participating healthcare provider in an amount no less than the amount that would apply if the clinician-administered drug had been obtained from a pharmacy in the specialty pharmacy network;
(10) This amendment is not applicable to TennCare, the CoverKids program, or health benefit plans for public officers and employees; and
(11) This amendment applies to contracts for health insurance entered into, amended, or renewed on or after January 1, 2025.
ON APRIL 15, 2024, THE SENATE SUBSTITUTED HOUSE BILL 916 FOR SENATE BILL 502 AND ADOPTED AMENDMENT #2. HOUSE BILL 916, AS AMENDED, FAILED TO RECEIVE A CONSTITUTIONAL MAJORITY AND WAS REFERRED TO THE CALENDAR COMMITTEE.
AMENDMENT #2 clarifies that the bill does not apply to grandfathered health plan coverage under the federal Patient Protection and Affordable Care Act.
Statutes affected: Introduced: 4-3-1013(f), 4-3-1013
Amended with HA0533 -- 03/07/2024: 4-3-1013(f), 4-3-1013
Amended with HA0533, SA0869 -- 04/15/2024: 4-3-1013(f), 4-3-1013