Bill Text: IA SF292 | 2019-2020 | 88th 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. (See SF 489.)

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced) 2019-03-06 - Reported out of committee as SF 489. S.J. 488. [SF292 Detail]

Download: Iowa-2019-SF292-Introduced.html
Senate File 292 - Introduced SENATE FILE 292 BY GREENE (COMPANION TO HF 204 BY MOORE) A BILL FOR An Act relating to continuity of care and nonmedical switching 1 by health carriers, health benefit plans, and utilization 2 review organizations, and including applicability 3 provisions. 4 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 5 TLSB 2154XS (1) 88 ko/rn
S.F. 292 Section 1. NEW SECTION . 514F.8 Continuity of care —— 1 nonmedical switching. 2 1. Definitions. For the purpose of this section: 3 a. “Authorized representative” means the same as defined in 4 section 514J.102. 5 b. “Commissioner” means the commissioner of insurance. 6 c. “Cost sharing” means any coverage limit, copayment, 7 coinsurance, deductible, or other out-of-pocket expense 8 requirement. 9 d. “Coverage exemption” means a determination made by a 10 health carrier, health benefit plan, or utilization review 11 organization to cover a prescription drug that is otherwise 12 excluded from coverage. 13 e. “Coverage exemption determination” means a determination 14 made by a health carrier, health benefit plan, or utilization 15 review organization whether to cover a prescription drug that 16 is otherwise excluded from coverage. 17 f. “Covered person” means the same as defined in section 18 514J.102. 19 g. “Discontinued health benefit plan” means a covered 20 person’s existing health benefit plan that is discontinued by a 21 health carrier during open enrollment for the next plan year. 22 h. “Formulary” means a complete list of prescription drugs 23 eligible for coverage under a health benefit plan. 24 i. “Health benefit plan” means the same as defined in 25 section 514J.102. 26 j. “Health care professional” means the same as defined in 27 section 514J.102. 28 k. “Health care services” means the same as defined in 29 section 514J.102. 30 l. “Health carrier” means the same as defined in section 31 514J.102. 32 m. “Nonmedical switching” means a health benefit plan’s 33 restrictive changes to the health benefit plan’s formulary 34 after the current plan year has begun or during the open 35 -1- LSB 2154XS (1) 88 ko/rn 1/ 8
S.F. 292 enrollment period for the upcoming plan year, causing a covered 1 person who is medically stable on the covered person’s current 2 prescribed drug as determined by the prescribing health care 3 professional, to switch to a less costly alternate prescription 4 drug. 5 n. “Open enrollment” means the yearly time period an 6 individual can enroll in a health benefit plan. 7 o. “Utilization review” means the same as defined in 514F.7. 8 p. “Utilization review organization” means the same as 9 defined in 514F.7. 10 2. Nonmedical switching. With respect to a health carrier 11 that has entered into a health benefit plan with a covered 12 person that covers prescription drug benefits, all of the 13 following apply: 14 a. A health carrier, health benefit plan, or utilization 15 review organization shall not limit or exclude coverage of 16 a prescription drug for any covered person who is medically 17 stable on such drug as determined by the prescribing health 18 care professional, if all of the following apply: 19 (1) The prescription drug was previously approved by the 20 health carrier for coverage for the covered person. 21 (2) The covered person’s prescribing health care 22 professional has prescribed the drug for the medical condition 23 within the previous six months. 24 (3) The covered person continues to be an enrollee of the 25 health benefit plan. 26 b. Coverage of a covered person’s prescription drug, as 27 described in paragraph “a” , shall continue through the last day 28 of the covered person’s eligibility under the health benefit 29 plan, inclusive of any open enrollment period. 30 c. Prohibited limitations and exclusions referred to in 31 paragraph “a” include but are not limited to the following: 32 (1) Limiting or reducing the maximum coverage of 33 prescription drug benefits. 34 (2) Increasing cost sharing for a covered prescription 35 -2- LSB 2154XS (1) 88 ko/rn 2/ 8
S.F. 292 drug. 1 (3) Moving a prescription drug to a more restrictive tier if 2 the health carrier uses a formulary with tiers. 3 (4) Removing a prescription drug from a formulary, unless 4 the United States food and drug administration has issued a 5 statement about the drug that calls into question the clinical 6 safety of the drug, or the manufacturer of the drug has 7 notified the United States food and drug administration of a 8 manufacturing discontinuance or potential discontinuance of the 9 drug as required by section 506C of the Federal Food, Drug, and 10 Cosmetic Act, as codified in 21 U.S.C. §356c. 11 3. Coverage exemption determination process. 12 a. To ensure continuity of care, a health carrier, health 13 plan, or utilization review organization shall provide a 14 covered person and prescribing health care professional with 15 access to a clear and convenient process to request a coverage 16 exemption determination. A health carrier, health plan, or 17 utilization review organization may use its existing medical 18 exceptions process to satisfy this requirement. The process 19 used shall be easily accessible on the internet site of the 20 health carrier, health benefit plan, or utilization review 21 organization. 22 b. A health carrier, health benefit plan, or utilization 23 review organization shall respond to a coverage exemption 24 determination request within seventy-two hours of receipt. In 25 cases where exigent circumstances exist, a health carrier, 26 health benefit plan, or utilization review organization shall 27 respond within twenty-four hours of receipt. If a response by 28 a health carrier, health benefit plan, or utilization review 29 organization is not received within the applicable time period, 30 the coverage exemption shall be deemed granted. 31 c. A coverage exemption shall be expeditiously granted for a 32 discontinued health benefit plan if a covered person enrolls in 33 a comparable plan offered by the same health carrier, and all 34 of the following conditions apply: 35 -3- LSB 2154XS (1) 88 ko/rn 3/ 8
S.F. 292 (1) The covered person is medically stable on a prescription 1 drug as determined by the prescribing health care professional. 2 (2) The prescribing health care professional continues 3 to prescribe the drug for the covered person for the medical 4 condition. 5 (3) In comparison to the discontinued health benefit plan, 6 the new health benefit plan does any of the following: 7 (a) Limits or reduces the maximum coverage of prescription 8 drug benefits. 9 (b) Increases cost sharing for the prescription drug. 10 (c) Moves the prescription drug to a more restrictive tier 11 if the health carrier uses a formulary with tiers. 12 (d) Excludes the prescription drug from the formulary. 13 d. Upon granting of a coverage exemption for a drug 14 prescribed by a covered person’s prescribing health care 15 professional, a health carrier, health benefit plan, or 16 utilization review organization shall authorize coverage no 17 more restrictive than that offered in a discontinued health 18 benefit plan, or than that offered prior to implementation of 19 restrictive changes to the health benefit plan’s formulary 20 after the current plan year began. 21 e. If a determination is made to deny a request for a 22 coverage exemption, the health carrier, health benefit plan, 23 or utilization review organization shall provide the covered 24 person or the covered person’s authorized representative and 25 the authorized person’s prescribing health care professional 26 with the reason for denial and information regarding the 27 procedure to appeal the denial. Any determination to deny a 28 coverage exemption may be appealed by a covered person or the 29 covered person’s authorized representative. 30 f. A health carrier, health benefit plan, or utilization 31 review organization shall uphold or reverse a determination to 32 deny a coverage exemption within seventy-two hours of receipt 33 of an appeal of denial. In cases where exigent circumstances 34 exist, a health carrier, health benefit plan, or utilization 35 -4- LSB 2154XS (1) 88 ko/rn 4/ 8
S.F. 292 review organization shall uphold or reverse a determination to 1 deny a coverage exemption within twenty-four hours of receipt. 2 If the determination to deny a coverage exemption is not upheld 3 or reversed on appeal within the applicable time period, the 4 denial shall be deemed reversed and the coverage exemption 5 shall be deemed approved. 6 g. If a determination to deny a coverage exemption is 7 upheld on appeal, the health carrier, health benefit plan, 8 or utilization review organization shall provide the covered 9 person or covered person’s authorized representative and the 10 covered person’s prescribing health care professional with 11 the reason for upholding the denial on appeal and information 12 regarding the procedure to request external review of the 13 denial pursuant to chapter 514J. Any denial of a request for a 14 coverage exemption that is upheld on appeal shall be considered 15 a final adverse determination for purposes of chapter 514J and 16 is eligible for a request for external review by a covered 17 person or the covered person’s authorized representative 18 pursuant to chapter 514J. 19 4. Limitations. This section shall not be construed to do 20 any of the following: 21 a. Prevent a health care professional from prescribing 22 another drug covered by the health carrier that the health care 23 professional deems medically necessary for the covered person. 24 b. Prevent a health carrier from doing any of the following: 25 (1) Adding a prescription drug to its formulary. 26 (2) Removing a prescription drug from its formulary if the 27 drug manufacturer has removed the drug for sale in the United 28 States. 29 (3) Requiring a pharmacist to effect a substitution of a 30 generic or interchangeable biological drug product pursuant to 31 section 155A.32. 32 5. Enforcement. The commissioner may take any enforcement 33 action under the commissioner’s authority to enforce compliance 34 with this section. 35 -5- LSB 2154XS (1) 88 ko/rn 5/ 8
S.F. 292 6. Applicability. This section is applicable to a health 1 benefit plan that is delivered, issued for delivery, continued, 2 or renewed in this state on or after January 1, 2020. 3 EXPLANATION 4 The inclusion of this explanation does not constitute agreement with 5 the explanation’s substance by the members of the general assembly. 6 This bill relates to the continuity of care for a covered 7 person and nonmedical switching by health carriers, health 8 benefit plans, and utilization review organizations. 9 The bill defines “nonmedical switching” as a health benefit 10 plan’s restrictive changes to the health benefit plan’s 11 formulary after the current plan year has begun or during the 12 open enrollment period for the upcoming plan year, causing a 13 covered person who is medically stable on the covered person’s 14 current prescribed drug as determined by the prescribing 15 health care professional, to switch to a less costly alternate 16 prescription drug. 17 The bill provides that during a covered person’s eligibility 18 under a health benefit plan, inclusive of any open enrollment 19 period, a health plan carrier, health benefit plan, or 20 utilization review organization shall not limit or exclude 21 coverage of a prescription drug for the covered person if the 22 covered person is medically stable on the drug as determined 23 by the prescribing health care professional, the drug was 24 previously approved by the health carrier for coverage for the 25 person, and the person’s prescribing health care professional 26 has prescribed the drug for the covered person’s medical 27 condition within the previous six months. The bill includes, 28 as prohibited limitations or exclusions, reducing the maximum 29 coverage of prescription drug benefits, increasing cost sharing 30 for a covered drug, moving a drug to a more restrictive tier, 31 and removing a drug from a formulary. A prescription drug 32 may, however, be removed from a formulary if the United States 33 food and drug administration issues a statement regarding the 34 clinical safety of the drug, or the manufacturer of the drug 35 -6- LSB 2154XS (1) 88 ko/rn 6/ 8
S.F. 292 notifies the United States food and drug administration of a 1 manufacturing discontinuance or potential discontinuance of the 2 drug as required by section 506c of the Federal Food, Drug, and 3 Cosmetic Act. 4 The bill requires a covered person and prescribing health 5 care professional to have access to a process to request a 6 coverage exemption determination. The bill defines “coverage 7 exemption determination” as a determination made by a 8 health carrier, health benefit plan, or utilization review 9 organization whether to cover a prescription drug that is 10 otherwise excluded from coverage. 11 A coverage exemption determination request must be approved 12 or denied by the health carrier, health benefit plan, or 13 utilization review organization within 72 hours, or within 24 14 hours if exigent circumstances exist. If a determination is 15 not received within the applicable time period the coverage 16 exemption is deemed granted. 17 The bill requires a coverage exemption to be expeditiously 18 granted for a health benefit plan discontinued for the next 19 plan year if a covered person enrolls in a comparable plan 20 offered by the same health carrier, and in comparison to the 21 discontinued health benefit plan, the new health benefit plan 22 limits or reduces the maximum coverage for a prescription drug, 23 increases cost sharing for the prescription drug, moves the 24 prescription drug to a more restrictive tier, or excludes the 25 prescription drug from the formulary. 26 If a coverage exemption is granted, the bill requires the 27 authorization of coverage that is no more restrictive than that 28 offered in a discontinued health benefit plan, or than that 29 offered prior to implementation of restrictive changes to the 30 health benefit plan’s formulary after the current plan year 31 began. 32 If a determination is made to deny a request for a 33 coverage exemption, the reason for denial and the procedure 34 to appeal the denial must be provided to the requestor. Any 35 -7- LSB 2154XS (1) 88 ko/rn 7/ 8
S.F. 292 determination to deny a coverage exemption may be appealed to 1 the health carrier, health benefit plan, or utilization review 2 organization. 3 A determination to uphold or reverse denial of a coverage 4 exemption must be made within 72 hours of receipt of an appeal, 5 or within 24 hours if exigent circumstances exist. If a 6 determination is not made within the applicable time period, 7 the denial is deemed reversed and the coverage exemption is 8 deemed approved. 9 If a determination to deny a coverage exemption is upheld on 10 appeal, the reason for upholding the denial and the procedure 11 to request external review of the denial pursuant to Code 12 chapter 514J must be provided to the individual who filed the 13 appeal. Any denial of a request for a coverage exemption that 14 is upheld on appeal is considered a final adverse determination 15 for purposes of Code chapter 514J and is eligible for a request 16 for external review by a covered person or the covered person’s 17 authorized representative pursuant to Code chapter 514J. 18 The bill shall not be construed to prevent a health care 19 professional from prescribing another drug covered by the 20 health carrier that the health care professional deems 21 medically necessary for the covered person. 22 The bill shall not be construed to prevent a health carrier 23 from adding a drug to its formulary or removing a drug from its 24 formulary if the drug manufacturer removes the drug for sale in 25 the United States. 26 The bill shall not be construed to require a pharmacist 27 to effect a substitution of a generic or interchangeable 28 biological drug product pursuant to Code section 155A.32. 29 The bill allows the commissioner to take any necessary 30 enforcement action under the commissioner’s authority to 31 enforce compliance with the bill. 32 The bill is applicable to health benefit plans that are 33 delivered, issued for delivery, continued, or renewed in this 34 state on or after January 1, 2020. 35 -8- LSB 2154XS (1) 88 ko/rn 8/ 8
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