Bill Text: IA HF2453 | 2017-2018 | 87th General Assembly | Introduced
Bill Title: A bill for an act relating to continuity of care and nonmedical switching by health carriers, health benefit plans, and utilization review organizations, and including applicability provisions. (Formerly HSB 516.)
Spectrum: Committee Bill
Status: (Introduced - Dead) 2018-03-15 - Referred to Human Resources. H.J. 594. [HF2453 Detail]
Download: Iowa-2017-HF2453-Introduced.html
House File 2453 - Introduced HOUSE FILE BY COMMITTEE ON HUMAN RESOURCES (SUCCESSOR TO HSB 516) A BILL FOR 1 An Act relating to continuity of care and nonmedical switching 2 by health carriers, health benefit plans, and utilization 3 review organizations, and including applicability 4 provisions. 5 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: TLSB 5061HV (6) 87 ko/rj PAG LIN 1 1 Section 1. NEW SECTION. 514F.8 Continuity of care ==== 1 2 nonmedical switching. 1 3 1. Definitions. For the purpose of this section: 1 4 a. "Authorized representative" means the same as defined in 1 5 section 514J.102. 1 6 b. "Commissioner" means the commissioner of insurance. 1 7 c. "Cost sharing" means any coverage limit, copayment, 1 8 coinsurance, deductible, or other out=of=pocket expense 1 9 requirement. 1 10 d. "Coverage exemption" means a determination made by a 1 11 health carrier, health benefit plan, or utilization review 1 12 organization to cover a prescription drug that is otherwise 1 13 excluded from coverage. 1 14 e. "Coverage exemption determination" means a determination 1 15 made by a health carrier, health benefit plan, or utilization 1 16 review organization whether to cover a prescription drug that 1 17 is otherwise excluded from coverage. 1 18 f. "Covered person" means the same as defined in section 1 19 514J.102. 1 20 g. "Discontinued health benefit plan" means a covered 1 21 person's existing health benefit plan that is discontinued by a 1 22 health carrier during open enrollment for the next plan year. 1 23 h. "Formulary" means a complete list of prescription drugs 1 24 eligible for coverage under a health benefit plan. 1 25 i. "Health benefit plan" means the same as defined in 1 26 section 514J.102. 1 27 j. "Health care professional" means the same as defined in 1 28 section 514J.102. 1 29 k. "Health care services" means the same as defined in 1 30 section 514J.102. 1 31 l. "Health carrier" means the same as defined in section 1 32 514J.102. 1 33 m. "Nonmedical switching" means a health benefit plan's 1 34 restrictive changes to the health benefit plan's formulary 1 35 after the current plan year has begun or during the open 2 1 enrollment period for the upcoming plan year, causing a covered 2 2 person who is medically stable on the covered person's current 2 3 prescribed drug as determined by the prescribing health care 2 4 professional, to switch to a less costly alternate prescription 2 5 drug. 2 6 n. "Open enrollment" means the yearly time period an 2 7 individual can enroll in a health benefit plan. 2 8 o. "Utilization review" means the same as defined in 514F.7. 2 9 p. "Utilization review organization" means the same as 2 10 defined in 514F.7. 2 11 2. Nonmedical switching. With respect to a health carrier 2 12 that has entered into a health benefit plan with a covered 2 13 person that covers prescription drug benefits, all of the 2 14 following apply: 2 15 a. A health carrier, health benefit plan, or utilization 2 16 review organization shall not limit or exclude coverage of 2 17 a prescription drug for any covered person who is medically 2 18 stable on such drug as determined by the prescribing health 2 19 care professional, if all of the following apply: 2 20 (1) The prescription drug was previously approved by the 2 21 health carrier for coverage for the covered person. 2 22 (2) The covered person's prescribing health care 2 23 professional has prescribed the drug for the medical condition 2 24 within the previous six months. 2 25 (3) The covered person continues to be an enrollee of the 2 26 health benefit plan. 2 27 b. Coverage of a covered person's prescription drug, as 2 28 described in paragraph "a", shall continue through the last day 2 29 of the covered person's eligibility under the health benefit 2 30 plan, inclusive of any open enrollment period. 2 31 c. Prohibited limitations and exclusions referred to in 2 32 paragraph "a" include but are not limited to the following: 2 33 (1) Limiting or reducing the maximum coverage of 2 34 prescription drug benefits. 2 35 (2) Increasing cost sharing for a covered prescription 3 1 drug. 3 2 (3) Moving a prescription drug to a more restrictive tier if 3 3 the health carrier uses a formulary with tiers. 3 4 (4) Removing a prescription drug from a formulary, unless 3 5 the United States food and drug administration has issued a 3 6 statement about the drug that calls into question the clinical 3 7 safety of the drug, or the manufacturer of the drug has 3 8 notified the United States food and drug administration of a 3 9 manufacturing discontinuance or potential discontinuance of the 3 10 drug as required by section 506C of the Federal Food, Drug, and 3 11 Cosmetic Act, as codified in 21 U.S.C. {356c. 3 12 3. Coverage exemption determination process. 3 13 a. To ensure continuity of care, a health carrier, health 3 14 plan, or utilization review organization shall provide a 3 15 covered person and prescribing health care professional with 3 16 access to a clear and convenient process to request a coverage 3 17 exemption determination. A health carrier, health plan, or 3 18 utilization review organization may use its existing medical 3 19 exceptions process to satisfy this requirement. The process 3 20 used shall be easily accessible on the internet site of the 3 21 health carrier, health benefit plan, or utilization review 3 22 organization. 3 23 b. A health carrier, health benefit plan, or utilization 3 24 review organization shall respond to a coverage exemption 3 25 determination request within seventy=two hours of receipt. In 3 26 cases where exigent circumstances exist, a health carrier, 3 27 health benefit plan, or utilization review organization shall 3 28 respond within twenty=four hours of receipt. If a response by 3 29 a health carrier, health benefit plan, or utilization review 3 30 organization is not received within the applicable time period, 3 31 the coverage exemption shall be deemed granted. 3 32 (1) A coverage exemption shall be expeditiously granted for 3 33 a discontinued health benefit plan if a covered person enrolls 3 34 in a comparable plan offered by the same health carrier, and 3 35 all of the following conditions apply: 4 1 (a) The covered person is medically stable on a prescription 4 2 drug as determined by the prescribing health care professional. 4 3 (b) The prescribing health care professional continues 4 4 to prescribe the drug for the covered person for the medical 4 5 condition. 4 6 (c) In comparison to the discontinued health benefit plan, 4 7 the new health benefit plan does any of the following: 4 8 (i) Limits or reduces the maximum coverage of prescription 4 9 drug benefits. 4 10 (ii) Increases cost sharing for the prescription drug. 4 11 (iii) Moves the prescription drug to a more restrictive tier 4 12 if the health carrier uses a formulary with tiers. 4 13 (iv) Excludes the prescription drug from the formulary. 4 14 c. Upon granting of a coverage exemption for a drug 4 15 prescribed by a covered person's prescribing health care 4 16 professional, a health carrier, health benefit plan, or 4 17 utilization review organization shall authorize coverage no 4 18 more restrictive than that offered in a discontinued health 4 19 benefit plan, or than that offered prior to implementation of 4 20 restrictive changes to the health benefit plan's formulary 4 21 after the current plan year began. 4 22 d. If a determination is made to deny a request for a 4 23 coverage exemption, the health carrier, health benefit plan, 4 24 or utilization review organization shall provide the covered 4 25 person or the covered person's authorized representative and 4 26 the authorized person's prescribing health care professional 4 27 with the reason for denial and information regarding the 4 28 procedure to appeal the denial. Any determination to deny a 4 29 coverage exemption may be appealed by a covered person or the 4 30 covered person's authorized representative. 4 31 e. A health carrier, health benefit plan, or utilization 4 32 review organization shall uphold or reverse a determination to 4 33 deny a coverage exemption within seventy=two hours of receipt 4 34 of an appeal of denial. In cases where exigent circumstances 4 35 exist, a health carrier, health benefit plan, or utilization 5 1 review organization shall uphold or reverse a determination to 5 2 deny a coverage exemption within twenty=four hours of receipt. 5 3 If the determination to deny a coverage exemption is not upheld 5 4 or reversed on appeal within the applicable time period, the 5 5 denial shall be deemed reversed and the coverage exemption 5 6 shall be deemed approved. 5 7 f. If a determination to deny a coverage exemption is 5 8 upheld on appeal, the health carrier, health benefit plan, 5 9 or utilization review organization shall provide the covered 5 10 person or covered person's authorized representative and the 5 11 covered person's prescribing health care professional with 5 12 the reason for upholding the denial on appeal and information 5 13 regarding the procedure to request external review of the 5 14 denial pursuant to chapter 514J. Any denial of a request for a 5 15 coverage exemption that is upheld on appeal shall be considered 5 16 a final adverse determination for purposes of chapter 514J and 5 17 is eligible for a request for external review by a covered 5 18 person or the covered person's authorized representative 5 19 pursuant to chapter 514J. 5 20 4. Limitations. This section shall not be construed to do 5 21 any of the following: 5 22 a. Prevent a health care professional from prescribing 5 23 another drug covered by the health carrier that the health care 5 24 professional deems medically necessary for the covered person. 5 25 b. Prevent a health carrier from doing any of the following: 5 26 (1) Adding a prescription drug to its formulary. 5 27 (2) Removing a prescription drug from its formulary if the 5 28 drug manufacturer has removed the drug for sale in the United 5 29 States. 5 30 (3) Requiring a pharmacist to effect a substitution of a 5 31 generic or interchangeable biological drug product pursuant to 5 32 section 155A.32. 5 33 5. Enforcement. The commissioner may take any enforcement 5 34 action under the commissioner's authority to enforce compliance 5 35 with this section. 6 1 6. Applicability. This section is applicable to a health 6 2 benefit plan that is delivered, issued for delivery, continued, 6 3 or renewed in this state on or after January 1, 2019. 6 4 EXPLANATION 6 5 The inclusion of this explanation does not constitute agreement with 6 6 the explanation's substance by the members of the general assembly. 6 7 This bill relates to the continuity of care for a covered 6 8 person and nonmedical switching by health carriers, health 6 9 benefit plans, and utilization review organizations. 6 10 The bill defines "nonmedical switching" as a health benefit 6 11 plan's restrictive changes to the health benefit plan's 6 12 formulary after the current plan year has begun or during the 6 13 open enrollment period for the upcoming plan year, causing a 6 14 covered person who is medically stable on the covered person's 6 15 current prescribed drug as determined by the prescribing 6 16 health care professional, to switch to a less costly alternate 6 17 prescription drug. 6 18 The bill provides that during a covered person's eligibility 6 19 under a health benefit plan, inclusive of any open enrollment 6 20 period, a health plan carrier, health benefit plan, or 6 21 utilization review organization shall not limit or exclude 6 22 coverage of a prescription drug for the covered person if the 6 23 covered person is medically stable on the drug as determined 6 24 by the prescribing health care professional, the drug was 6 25 previously approved by the health carrier for coverage for the 6 26 person, and the person's prescribing health care professional 6 27 has prescribed the drug for the covered person's medical 6 28 condition within the previous six months. The bill includes, 6 29 as prohibited limitations or exclusions, reducing the maximum 6 30 coverage of prescription drug benefits, increasing cost sharing 6 31 for a covered drug, moving a drug to a more restrictive tier, 6 32 and removing a drug from a formulary. A prescription drug 6 33 may, however, be removed from a formulary if the United States 6 34 food and drug administration issues a statement regarding the 6 35 clinical safety of the drug, or the manufacturer of the drug 7 1 notifies the United States food and drug administration of a 7 2 manufacturing discontinuance or potential discontinuance of the 7 3 drug as required by section 506c of the Federal Food, Drug, and 7 4 Cosmetic Act. 7 5 The bill requires a covered person and prescribing health 7 6 care professional to have access to a process to request a 7 7 coverage exemption determination. The bill defines "coverage 7 8 exemption determination" as a determination made by a 7 9 health carrier, health benefit plan, or utilization review 7 10 organization whether to cover a prescription drug that is 7 11 otherwise excluded from coverage. 7 12 A coverage exemption determination request must be approved 7 13 or denied by the health carrier, health benefit plan, or 7 14 utilization review organization within 72 hours, or within 24 7 15 hours if exigent circumstances exist. If a determination is 7 16 not received within the applicable time period the coverage 7 17 exemption is deemed granted. 7 18 The bill requires a coverage exemption to be expeditiously 7 19 granted for a health benefit plan discontinued for the next 7 20 plan year if a covered person enrolls in a comparable plan 7 21 offered by the same health carrier, and in comparison to the 7 22 discontinued health benefit plan, the new health benefit plan 7 23 limits or reduces the maximum coverage for a prescription drug, 7 24 increases cost sharing for the prescription drug, moves the 7 25 prescription drug to a more restrictive tier, or excludes the 7 26 prescription drug from the formulary. 7 27 If a coverage exemption is granted, the bill requires the 7 28 authorization of coverage that is no more restrictive than that 7 29 offered in a discontinued health benefit plan, or than that 7 30 offered prior to implementation of restrictive changes to the 7 31 health benefit plan's formulary after the current plan year 7 32 began. 7 33 If a determination is made to deny a request for a 7 34 coverage exemption, the reason for denial and the procedure 7 35 to appeal the denial must be provided to the requestor. Any 8 1 determination to deny a coverage exemption may be appealed to 8 2 the health carrier, health benefit plan, or utilization review 8 3 organization. 8 4 A determination to uphold or reverse denial of a coverage 8 5 exemption must be made within 72 hours of receipt of an appeal, 8 6 or within 24 hours if exigent circumstances exist. If a 8 7 determination is not made within the applicable time period, 8 8 the denial is deemed reversed and the coverage exemption is 8 9 deemed approved. 8 10 If a determination to deny a coverage exemption is upheld on 8 11 appeal, the reason for upholding the denial and the procedure 8 12 to request external review of the denial pursuant to Code 8 13 chapter 514J must be provided to the individual who filed the 8 14 appeal. Any denial of a request for a coverage exemption that 8 15 is upheld on appeal is considered a final adverse determination 8 16 for purposes of Code chapter 514J and is eligible for a request 8 17 for external review by a covered person or the covered person's 8 18 authorized representative pursuant to Code chapter 514J. 8 19 The bill shall not be construed to prevent a health care 8 20 professional from prescribing another drug covered by the 8 21 health carrier that the health care professional deems 8 22 medically necessary for the covered person. 8 23 The bill shall not be construed to prevent a health carrier 8 24 from adding a drug to its formulary or removing a drug from its 8 25 formulary if the drug manufacturer removes the drug for sale in 8 26 the United States. 8 27 The bill shall not be construed to require a pharmacist 8 28 to effect a substitution of a generic or interchangeable 8 29 biological drug product pursuant to Code section 155A.32. 8 30 The bill allows the commissioner to take any necessary 8 31 enforcement action under the commissioner's authority to 8 32 enforce compliance with the bill. 8 33 The bill is applicable to health benefit plans that are 8 34 delivered, issued for delivery, continued, or renewed in this 8 35 state on or after January 1, 2019. LSB 5061HV (6) 87 ko/rj
