CONTRIBUTION CALCULATION When calculating an enrollee's contribution to an applicable cost sharing requirement, present law requires an insurer to include cost sharing amounts paid by the enrollee or on behalf of the enrollee by another person. This bill adds that, if under federal law the cost sharing amounts paid would result in health savings account ineligibility, then the cost sharing amounts must, instead, be applied to a health savings account-qualified high deductible health plan, once the enrollee has satisfied the minimum deductible for the high deductible plan. Under federal law, a plan will not fail to be treated as a high deductible health plan for failing to meet the deductible for items or services that are preventative care. Therefore, for items that are preventative care, when calculating an enrollee's contribution to an applicable cost sharing requirement for a health savings account-qualified high deductible health plan, an insurer must include cost sharing amounts paid by the enrollee or on behalf of the enrollee by another person and this requirement will apply regardless of whether the minimum deductible has been met. Present law clarifies that the above requirement does not apply to a prescription drug for which there is a generic alternative, unless the enrollee has obtained access to the brand name prescription drug through prior authorization, a step therapy protocol, or the insurer's exceptions and appeals process. This bill also requires the annual limitation on cost sharing to apply to all healthcare services covered under a health plan offered or issued by an insurer in this state. HEALTH PLAN COVERAGE TERMS This bill prohibits an insurer, pharmacy benefits manager, or third-party administrator from changing or conditioning the terms of health plan coverage based on availability of financial or other product assistance for a prescription drug. ENTITIES REGULATED In implementing the requirements of this bill, this bill requires the state to only regulate an insurer, pharmacy benefits manager, or third-party administrator to the extent permissible under applicable law.

Statutes affected:
Introduced: 56-7-3201, 56-7-3205