Bill Text: IA SF489 | 2019-2020 | 88th General Assembly | Introduced

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Bill Title: A bill for an act relating to continuity of care for covered persons with epilepsy, and nonmedical switching by health carriers, health benefit plans, and utilization review organizations, and including applicability provisions. (Formerly SF 292.)

Spectrum: Committee Bill

Status: (Introduced - Dead) 2020-01-16 - Subcommittee: Carlin, Jochum, and Sweeney. S.J. 108. [SF489 Detail]

Download: Iowa-2019-SF489-Introduced.html

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Senate File 489 - Introduced
SENATE FILE 489
BY COMMITTEE ON HUMAN
RESOURCES
(SUCCESSOR TO SF 292)
A BILL FOR
An Act relating to continuity of care for covered persons with
epilepsy, and nonmedical switching by health carriers,
health benefit plans, and utilization review organizations,
and including applicability provisions.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
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Section 1. NEW SECTION . 514F.8 Continuity of care ——
nonmedical switching.
1. Definitions. For the purpose of this section:
a. “Authorized representative” means the same as defined in
section 514J.102.
b. “Commissioner” means the commissioner of insurance.
c. “Cost sharing” means any coverage limit, copayment,
coinsurance, deductible, or other out-of-pocket expense
requirement.
d. “Coverage exemption” means a determination made by a
health carrier, health benefit plan, or utilization review
organization to cover a prescription drug that is otherwise
excluded from coverage.
e. “Coverage exemption determination” means a determination
made by a health carrier, health benefit plan, or utilization
review organization whether to cover a prescription drug that
is otherwise excluded from coverage.
f. “Covered person” means a policyholder, subscriber,
enrollee, or other individual participating in a health benefit
plan who has been diagnosed with epilepsy.
g. “Discontinued health benefit plan” means a covered
person’s existing health benefit plan that is discontinued by a
health carrier during open enrollment for the next plan year.
h. “Formulary” means a complete list of prescription drugs
eligible for coverage under a health benefit plan.
i. “Health benefit plan” means the same as defined in
section 514J.102.
j. “Health care professional” means the same as defined in
section 514J.102.
k. “Health care services” means services for the diagnosis,
prevention, treatment, cure, or relief of a health condition,
illness, injury, or disease.
l. “Health carrier” means the same as defined in section
514J.102.
m. “Nonmedical switching” means a health benefit plan’s
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restrictive changes to the health benefit plan’s formulary
after the current plan year has begun or during the open
enrollment period for the upcoming plan year, causing a covered
person who is medically stable on the covered person’s current
prescribed drug as determined by the prescribing health care
professional, to switch to a less costly alternate prescription
drug.
n. “Open enrollment” means the yearly time period an
individual can enroll in a health benefit plan.
o. “Utilization review” means the same as defined in 514F.7.
p. “Utilization review organization” means the same as
defined in 514F.7.
2. Nonmedical switching. With respect to a health carrier
that has entered into a health benefit plan with a covered
person that covers prescription drug benefits, all of the
following apply:
a. A health carrier, health benefit plan, or utilization
review organization shall not limit or exclude coverage of
a prescription drug for any covered person who is medically
stable on such drug as determined by the prescribing health
care professional, if all of the following apply:
(1) The prescription drug was previously approved by the
health carrier for coverage for the covered person.
(2) The covered person’s prescribing health care
professional has prescribed the drug for the medical condition
within the previous six months.
(3) The covered person continues to be an enrollee of the
health benefit plan.
b. Coverage of a covered person’s prescription drug, as
described in paragraph “a” , shall continue through the last day
of the covered person’s eligibility under the health benefit
plan, inclusive of any open enrollment period.
c. Prohibited limitations and exclusions referred to in
paragraph “a” include but are not limited to the following:
(1) Limiting or reducing the maximum coverage of
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prescription drug benefits.
(2) Increasing cost sharing for a covered prescription
drug.
(3) Moving a prescription drug to a more restrictive tier if
the health carrier uses a formulary with tiers.
(4) Removing a prescription drug from a formulary, unless
the United States food and drug administration has issued a
statement about the drug that calls into question the clinical
safety of the drug, or the manufacturer of the drug has
notified the United States food and drug administration of a
manufacturing discontinuance or potential discontinuance of the
drug as required by section 506C of the Federal Food, Drug, and
Cosmetic Act, as codified in 21 U.S.C. §356c.
3. Coverage exemption determination process.
a. To ensure continuity of care, a health carrier, health
plan, or utilization review organization shall provide a
covered person and prescribing health care professional with
access to a clear and convenient process to request a coverage
exemption determination. A health carrier, health plan, or
utilization review organization may use its existing medical
exceptions process to satisfy this requirement. The process
used shall be easily accessible on the internet site of the
health carrier, health benefit plan, or utilization review
organization.
b. A health carrier, health benefit plan, or utilization
review organization shall respond to a coverage exemption
determination request within seventy-two hours of receipt. In
cases where exigent circumstances exist, a health carrier,
health benefit plan, or utilization review organization shall
respond within twenty-four hours of receipt. If a response by
a health carrier, health benefit plan, or utilization review
organization is not received within the applicable time period,
the coverage exemption shall be deemed granted.
c. A coverage exemption shall be expeditiously granted for a
discontinued health benefit plan if a covered person enrolls in
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a comparable plan offered by the same health carrier, and all
of the following conditions apply:
(1) The covered person is medically stable on a prescription
drug as determined by the prescribing health care professional.
(2) The prescribing health care professional continues
to prescribe the drug for the covered person for the medical
condition.
(3) In comparison to the discontinued health benefit plan,
the new health benefit plan does any of the following:
(a) Limits or reduces the maximum coverage of prescription
drug benefits.
(b) Increases cost sharing for the prescription drug.
(c) Moves the prescription drug to a more restrictive tier
if the health carrier uses a formulary with tiers.
(d) Excludes the prescription drug from the formulary.
d. Upon granting of a coverage exemption for a drug
prescribed by a covered person’s prescribing health care
professional, a health carrier, health benefit plan, or
utilization review organization shall authorize coverage no
more restrictive than that offered in a discontinued health
benefit plan, or than that offered prior to implementation of
restrictive changes to the health benefit plan’s formulary
after the current plan year began.
e. If a determination is made to deny a request for a
coverage exemption, the health carrier, health benefit plan,
or utilization review organization shall provide the covered
person or the covered person’s authorized representative and
the authorized person’s prescribing health care professional
with the reason for denial and information regarding the
procedure to appeal the denial. Any determination to deny a
coverage exemption may be appealed by a covered person or the
covered person’s authorized representative.
f. A health carrier, health benefit plan, or utilization
review organization shall uphold or reverse a determination to
deny a coverage exemption within seventy-two hours of receipt
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of an appeal of denial. In cases where exigent circumstances
exist, a health carrier, health benefit plan, or utilization
review organization shall uphold or reverse a determination to
deny a coverage exemption within twenty-four hours of receipt.
If the determination to deny a coverage exemption is not upheld
or reversed on appeal within the applicable time period, the
denial shall be deemed reversed and the coverage exemption
shall be deemed approved.
g. If a determination to deny a coverage exemption is
upheld on appeal, the health carrier, health benefit plan,
or utilization review organization shall provide the covered
person or covered person’s authorized representative and the
covered person’s prescribing health care professional with
the reason for upholding the denial on appeal and information
regarding the procedure to request external review of the
denial pursuant to chapter 514J. Any denial of a request for a
coverage exemption that is upheld on appeal shall be considered
a final adverse determination for purposes of chapter 514J and
is eligible for a request for external review by a covered
person or the covered person’s authorized representative
pursuant to chapter 514J.
4. Limitations. This section shall not be construed to do
any of the following:
a. Prevent a health care professional from prescribing
another drug covered by the health carrier that the health care
professional deems medically necessary for the covered person.
b. Prevent a health carrier from doing any of the following:
(1) Adding a prescription drug to its formulary.
(2) Removing a prescription drug from its formulary if the
drug manufacturer has removed the drug for sale in the United
States.
(3) Requiring a pharmacist to effect a substitution of a
generic or interchangeable biological drug product pursuant to
section 155A.32.
5. Enforcement. The commissioner may take any enforcement
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action under the commissioner’s authority to enforce compliance
with this section.
6. Applicability. This section is applicable to a health
benefit plan that is delivered, issued for delivery, continued,
or renewed in this state on or after January 1, 2020.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
This bill relates to the continuity of care for covered
persons with epilepsy, and nonmedical switching by health
carriers, health benefit plans, and utilization review
organizations.
The bill defines “nonmedical switching” as a health benefit
plan’s restrictive changes to the health benefit plan’s
formulary after the current plan year has begun or during the
open enrollment period for the upcoming plan year, causing a
covered person who is medically stable on the covered person’s
current prescribed drug as determined by the prescribing
health care professional, to switch to a less costly alternate
prescription drug.
The bill provides that during a covered person’s eligibility
under a health benefit plan, inclusive of any open enrollment
period, a health plan carrier, health benefit plan, or
utilization review organization shall not limit or exclude
coverage of a prescription drug for the covered person if the
covered person is medically stable on the drug as determined
by the prescribing health care professional, the drug was
previously approved by the health carrier for coverage for the
person, and the person’s prescribing health care professional
has prescribed the drug for the covered person’s medical
condition within the previous six months. The bill includes,
as prohibited limitations or exclusions, reducing the maximum
coverage of prescription drug benefits, increasing cost sharing
for a covered drug, moving a drug to a more restrictive tier,
and removing a drug from a formulary. A prescription drug
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may, however, be removed from a formulary if the United States
food and drug administration issues a statement regarding the
clinical safety of the drug, or the manufacturer of the drug
notifies the United States food and drug administration of a
manufacturing discontinuance or potential discontinuance of the
drug as required by section 506c of the Federal Food, Drug, and
Cosmetic Act.
The bill requires a covered person and prescribing health
care professional to have access to a process to request a
coverage exemption determination. The bill defines “coverage
exemption determination” as a determination made by a
health carrier, health benefit plan, or utilization review
organization whether to cover a prescription drug that is
otherwise excluded from coverage.
A coverage exemption determination request must be approved
or denied by the health carrier, health benefit plan, or
utilization review organization within 72 hours, or within 24
hours if exigent circumstances exist. If a determination is
not received within the applicable time period the coverage
exemption is deemed granted.
The bill requires a coverage exemption to be expeditiously
granted for a health benefit plan discontinued for the next
plan year if a covered person enrolls in a comparable plan
offered by the same health carrier, and in comparison to the
discontinued health benefit plan, the new health benefit plan
limits or reduces the maximum coverage for a prescription drug,
increases cost sharing for the prescription drug, moves the
prescription drug to a more restrictive tier, or excludes the
prescription drug from the formulary.
If a coverage exemption is granted, the bill requires the
authorization of coverage that is no more restrictive than that
offered in a discontinued health benefit plan, or than that
offered prior to implementation of restrictive changes to the
health benefit plan’s formulary after the current plan year
began.
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If a determination is made to deny a request for a
coverage exemption, the reason for denial and the procedure
to appeal the denial must be provided to the requestor. Any
determination to deny a coverage exemption may be appealed to
the health carrier, health benefit plan, or utilization review
organization.
A determination to uphold or reverse denial of a coverage
exemption must be made within 72 hours of receipt of an appeal,
or within 24 hours if exigent circumstances exist. If a
determination is not made within the applicable time period,
the denial is deemed reversed and the coverage exemption is
deemed approved.
If a determination to deny a coverage exemption is upheld on
appeal, the reason for upholding the denial and the procedure
to request external review of the denial pursuant to Code
chapter 514J must be provided to the individual who filed the
appeal. Any denial of a request for a coverage exemption that
is upheld on appeal is considered a final adverse determination
for purposes of Code chapter 514J and is eligible for a request
for external review by a covered person or the covered person’s
authorized representative pursuant to Code chapter 514J.
The bill shall not be construed to prevent a health care
professional from prescribing another drug covered by the
health carrier that the health care professional deems
medically necessary for the covered person.
The bill shall not be construed to prevent a health carrier
from adding a drug to its formulary or removing a drug from its
formulary if the drug manufacturer removes the drug for sale in
the United States.
The bill shall not be construed to require a pharmacist
to effect a substitution of a generic or interchangeable
biological drug product pursuant to Code section 155A.32.
The bill allows the commissioner to take any necessary
enforcement action under the commissioner’s authority to
enforce compliance with the bill.
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The bill is applicable to health benefit plans that are
delivered, issued for delivery, continued, or renewed in this
state on or after January 1, 2020.
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