House Bill 90

AN ACT TO PROHIBIT HEALTH CARE SERVICE PLAN CONTRACTS AND HEALTH INSURANCE POLICIES ISSUED, AMENDED OR RENEWED AFTER JANUARY 1, 2016, FROM CREATING SPECIALTY TIERS AND CHARGING CERTAIN COPAYMENTS; TO ALLOW CERTAIN MODIFICATIONS TO A DRUG COVERAGE TIER; AND FOR RELATED PURPOSES.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:

SECTION 1. The Legislature finds and declares all of the following:

(a) The cost-sharing, deductible and coinsurance obligations are for certain drugs used to treat complex, chronic conditions and require special administration, handling and care management. Many of these specialty drugs are used to treat conditions such as: cancer; autoimmune conditions like Crohn's disease, lupus, multiple sclerosis, myasthenia gravis, myositis, scieroderma, rheumatoid arthritis; hemophilia and other bleeding disorders; hepatitis; primary and secondary immune deficiencies; neuropathy; and transplant patients.

(b) The State of Mississippi, along with other states, has experienced the creation of a new cost-sharing mechanism known as prescription drug specialty tiers.

(c) Specialty tiers include prescription drugs where some plans and insurers are requiring patients to pay a percentage cost of the drug instead of a copay. Such drugs are typically new, infusible or injectable biologics or plasma-derived therapies produced in lesser quantities than other drugs and not available as less costly brand name or generic prescription drugs.

(d) Paying hundreds or even thousands of dollars each month for prescription drugs would be a strain for any person, but for people with chronic illnesses and life-threatening conditions, this unfortunate social policy has the potential to destroy a family's financial solvency or end the ability to take a necessary medication.

(e) Many patients who cannot afford their copays have been forced to go on disability, resulting in additional costs to the state's budget.

(f) Specialty tiers are contrary to the original purpose of insurance, which was the spreading of costs. Specialty tiers create a structure where those who are sickest pay more, and those who are healthy pay less. Additionally, this type of cost sharing arrangement will not keep health care costs down because there are no generic alternatives available for the biologic treatments that make up the vast majority of drugs placed on specialty tiers. Therefore, the creation of specialty tiers is a discriminatory practice.

SECTION 2. (1) A health care service plan contract issued, amended or renewed on or after January 1, 2016, that covers prescription medicine shall not create specialty tiers that require payment of a percentage cost of prescription drugs.

(2) A health care service plan contract issued, amended or renewed on or after January 1, 2016, shall not charge a copayment for medication in excess of five hundred percent (500%) of the lowest copayment required by the plan for medications in the plan's formulary.

(3) Nothing in this section shall be construed to require a health care service plan contract to provide coverage for any additional medication not otherwise required by law.

(4) If a health care service plan contract issued, amended or renewed on or after January 1, 2016, provides a limit for out-of-pocket expenses for benefits other than prescription drugs, the plan shall include one (1) of the following provisions in the plan that would result in the lowest out-of-pocket prescription drug cost to the insured:

(a) Out-of-pocket expenses for prescription drugs shall be included under the plan's total limit for out-of-pocket expenses for all benefits provided under the plan; or

(b) Out-of-pocket expenses for prescription drugs per contract year shall not exceed One Thousand Dollars ($1,000.00) per insured or Two Thousand Dollars ($2,000.00) per insured family, adjusted for inflation.

(5) For purposes of this section, "copayment" means a flat dollar amount an enrollee pays, out-of-pocket, at the time of receiving a health care service or when paying for a prescription, after any applicable deductible. The term shall not be construed to include any other forms of cost sharing.

(6) A health benefit plan issuer may modify a drug coverage tier provided under a health care service plan contract issued, amended or renewed on or after January 1, 2016, if the modification is not later than the sixtieth day before the date the modification is effective and the issuer provides written notice of the modification to the Commissioner of Insurance, each affected group health benefit plan sponsor, each affected enrollee in an affected group health benefit plan and each affected individual health benefit plan holder.

SECTION 3. (1) A health insurance policy issued, amended or renewed on or after January 1, 2016, that covers prescription medicine shall not create specialty tiers that require payment of a percentage cost of prescription drugs.

(2) A health insurance policy issued, amended or renewed on or after January 1, 2016, shall not charge a copayment for medication in excess of five hundred percent (500%) of the lowest copayment required by the policy for medications in the policy's formulary.

(3) Nothing in this section shall be construed to require a health insurance policy issued, amended or renewed on or after January 1, 2016, to provide coverage for any additional medication not otherwise required by law.

(4) If a health insurance policy issued, amended or renewed on or after January 1, 2016, provides a limit for out-of-pocket expenses for benefits other than prescription drugs, the insurer shall include one (1) of the following provisions in the policy that would result in the lowest out-of-pocket prescription drug cost to the insured:

(a) Out-of-pocket expenses for prescription drugs shall be included under the policy's total limit for out-of-pocket expenses for all benefits provided under the policy; or

SECTION 4. This act shall take effect and be in force from and after July 1, 2015.