CALIFORNIA LEGISLATURE 20232024 REGULAR SESSION Assembly Bill No. 2180Introduced by Assembly Member WeberFebruary 07, 2024 An act to add Section 1367.0062 to the Health and Safety Code, and to add Section 10192.292 to the Insurance Code, relating to health care coverage. LEGISLATIVE COUNSEL'S DIGESTAB 2180, as introduced, Weber. Health care coverage: cost sharing.Existing law generally prohibits a person who manufactures a prescription drug from offering in California any discount, repayment, product voucher, or other reduction in an individuals out-of-pocket expenses associated with the individuals health insurance, health care service plan, or other health coverage, including, but not limited to, a copayment, coinsurance, or deductible, for any prescription drug if a lower cost generic drug is covered under the individuals health insurance, health care service plan, or other health coverage on a lower cost-sharing tier that is designated as therapeutically equivalent to the prescription drug manufactured by that person or if the active ingredients of the drug are contained in products regulated by the federal Food and Drug Administration, are available without prescription at a lower cost, and are not otherwise contraindicated for the condition for which the prescription drug is approved.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance.This bill would require a health care service plan, health insurance policy, or pharmacy benefit manager that administers pharmacy benefits for a health care service plan or health insurer to apply any amounts paid by the enrollee, insured, or another source pursuant to a discount, repayment, product voucher, or other reduction to the enrollees or insureds out-of-pocket expenses toward the enrollees or insureds overall contribution to any out-of-pocket maximum, deductible, copayment, coinsurance, or applicable cost-sharing requirement under the enrollees or insureds health care service plan contract or health insurance policy. The bill would limit the application of the section to health care service plans and health insurance policies issued, amended, delivered, or renewed on or after January 1, 2025. Because a willful violation of these requirements by a health care service plan would be a crime, this bill would impose a state-mandated local program.The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.This bill would provide that no reimbursement is required by this act for a specified reason.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YES Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 1367.0062 is added to the Health and Safety Code, to read:1367.0062. (a) (1) To the extent permitted by federal law, and consistent with Sections 132000 and 132002, a health care service plan or a pharmacy benefit manager that administers pharmacy benefits for a health care service plan shall apply any amounts paid by either the enrollee or third-party patient assistance program to the enrollees cost-sharing requirement. This requirement shall be limited to only those enrollees who have a chronic disease or terminal illness.(2) This section shall only apply with respect to health care service plan contracts issued, amended, delivered, or renewed on or after January 1, 2025.(b) If under federal law, application of subdivision (a) would result in health savings account ineligibility under Section 223 of the Internal Revenue Code, this requirement shall apply for health savings account-qualified high deductible health plans with respect to the deductible of a policy after the enrollee has satisfied the minimum deductible under Section 223 of the Internal Revenue Code, except with respect to items or services that are preventive care pursuant to Section 223(c)(2)(C) of the Internal Revenue Code, in which case the requirements of this subdivision shall apply regardless of whether the minimum deductible under Section 223 of the Internal Revenue Code has been satisfied.(c) This section does not apply with respect to self-insured employer plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) (Public Law 83-406).(d) For purposes of this section, the following definitions apply:(1) Cost-sharing requirement means any copayment, coinsurance, deductible, or annual limitation on cost-sharing, including a limitation subject to Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, required by, or on behalf of, an enrollee in order to receive a specific health care service, including a prescription drug, covered by a health care service plan contract. When calculating an enrollees overall contribution to the annual limitation on cost sharing set forth in Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, a health care service plan shall include expenditures for any item or service covered by the health care service plan, and include within a category of essential health benefits as described in Section 18022(b)(1) of Title 42 of the United States Code, which expenditures shall be considered expenditures for essential health coverage benefits covered under the health care service plan contract.(2) Pharmacy Benefit Manager means a person or business that administers the prescription drug or device program of one or more health care service plans on behalf of a third party in accordance with a pharmacy benefit program. This term includes any agent or representative of a pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the administering of the drug program and any wholly or partially owned or controlled subsidiary of a pharmacy benefit manager.(3) Third-party patient assistance program shall include, but is not limited to, manufacturer or other charitable programs that provide financial assistance intended to augment existing prescription drug coverage. Third-party patient assistance program does not include discounts, drug vouchers, or general manufacturer coupons.(4) Chronic disease is defined as conditions that have a tendency to last one year or more and require ongoing medical attention or limit activities of daily living or both.(5) Terminal illness is defined as a medical condition that is life-limiting and expected to result in death.SEC. 2. Section 10192.292 is added to the Insurance Code, to read:10192.292. (a) (1) To the extent permitted by federal law, and consistent with Sections 132000 and 132002 of the Health and Safety Code, a health insurer or a pharmacy benefit manager that administers pharmacy benefits for a health insurer shall apply any amounts paid by either the insured, or third-party patient assistance program to the insureds cost-sharing requirement. This requirement shall be limited to only those insureds who have a chronic disease or terminal illness.(2) This section shall only apply with respect to health insurance policies issued, amended, delivered, or renewed on or after January 1, 2025.(b) If under federal law, application of subdivision (a) would result in health savings account ineligibility under Section 223 of the Internal Revenue Code, this requirement shall apply for Health Savings Account-qualified High Deductible Health Plans with respect to the deductible of a policy after the insured has satisfied the minimum deductible under Section 223 of the Internal Revenue Code, except with respect to items or services that are preventive care pursuant to Section 223(c)(2)(C) of the Internal Revenue Code, in which case the requirements of this subdivision shall apply regardless of whether the minimum deductible under Section 223 of the Internal Revenue Code has been satisfied.(c) This section does not apply with respect to self-insured employer plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) (Public Law 83-406).(d) For purposes of this section, the following definitions apply:(1) Cost-sharing requirement means any copayment, coinsurance, deductible, or annual limitation on cost-sharing, including a limitation subject to Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, required by, or on behalf of, an enrollee in order to receive a specific health care service, including a prescription drug, covered by a health insurance policy. When calculating an insureds overall contribution to the annual limitation on cost sharing set forth in Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, a health insurer shall include expenditures for any item or service covered by the health insurer, and include within a category of essential health benefits as described in Section 18022(b)(1) of Title 42 of the United States Code, which expenditures shall be considered expenditures for essential health coverage benefits covered under the health insurance policy.(2) Pharmacy Benefit Manager means a person or business that administers the prescription drug or device program of one or more health insurance policies on behalf of a third party in accordance with a pharmacy benefit program. This term includes any agent or representative of a pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the administering of the drug program and any wholly or partially owned or controlled subsidiary of a pharmacy benefit manager.(3) Third-party patient assistance program shall include, but is not limited to, manufacturer or other charitable programs that provide financial assistance intended to augment existing prescription drug coverage. Third party patient assistance program does not include discounts, drug vouchers or general manufacturer coupons.(4) Chronic disease is defined as conditions that have a tendency to last one year or more and require ongoing medical attention or limit activities of daily living or both.(5) Terminal illness is defined as a medical condition that is life-limiting and expected to result in death.SEC. 3. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.
CALIFORNIA LEGISLATURE 20232024 REGULAR SESSION Assembly Bill No. 2180Introduced by Assembly Member WeberFebruary 07, 2024 An act to add Section 1367.0062 to the Health and Safety Code, and to add Section 10192.292 to the Insurance Code, relating to health care coverage. LEGISLATIVE COUNSEL'S DIGESTAB 2180, as introduced, Weber. Health care coverage: cost sharing.Existing law generally prohibits a person who manufactures a prescription drug from offering in California any discount, repayment, product voucher, or other reduction in an individuals out-of-pocket expenses associated with the individuals health insurance, health care service plan, or other health coverage, including, but not limited to, a copayment, coinsurance, or deductible, for any prescription drug if a lower cost generic drug is covered under the individuals health insurance, health care service plan, or other health coverage on a lower cost-sharing tier that is designated as therapeutically equivalent to the prescription drug manufactured by that person or if the active ingredients of the drug are contained in products regulated by the federal Food and Drug Administration, are available without prescription at a lower cost, and are not otherwise contraindicated for the condition for which the prescription drug is approved.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance.This bill would require a health care service plan, health insurance policy, or pharmacy benefit manager that administers pharmacy benefits for a health care service plan or health insurer to apply any amounts paid by the enrollee, insured, or another source pursuant to a discount, repayment, product voucher, or other reduction to the enrollees or insureds out-of-pocket expenses toward the enrollees or insureds overall contribution to any out-of-pocket maximum, deductible, copayment, coinsurance, or applicable cost-sharing requirement under the enrollees or insureds health care service plan contract or health insurance policy. The bill would limit the application of the section to health care service plans and health insurance policies issued, amended, delivered, or renewed on or after January 1, 2025. Because a willful violation of these requirements by a health care service plan would be a crime, this bill would impose a state-mandated local program.The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.This bill would provide that no reimbursement is required by this act for a specified reason.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YES
CALIFORNIA LEGISLATURE 20232024 REGULAR SESSION
Assembly Bill
No. 2180
Introduced by Assembly Member WeberFebruary 07, 2024
Introduced by Assembly Member Weber
February 07, 2024
An act to add Section 1367.0062 to the Health and Safety Code, and to add Section 10192.292 to the Insurance Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
## LEGISLATIVE COUNSEL'S DIGEST
AB 2180, as introduced, Weber. Health care coverage: cost sharing.
Existing law generally prohibits a person who manufactures a prescription drug from offering in California any discount, repayment, product voucher, or other reduction in an individuals out-of-pocket expenses associated with the individuals health insurance, health care service plan, or other health coverage, including, but not limited to, a copayment, coinsurance, or deductible, for any prescription drug if a lower cost generic drug is covered under the individuals health insurance, health care service plan, or other health coverage on a lower cost-sharing tier that is designated as therapeutically equivalent to the prescription drug manufactured by that person or if the active ingredients of the drug are contained in products regulated by the federal Food and Drug Administration, are available without prescription at a lower cost, and are not otherwise contraindicated for the condition for which the prescription drug is approved.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance.This bill would require a health care service plan, health insurance policy, or pharmacy benefit manager that administers pharmacy benefits for a health care service plan or health insurer to apply any amounts paid by the enrollee, insured, or another source pursuant to a discount, repayment, product voucher, or other reduction to the enrollees or insureds out-of-pocket expenses toward the enrollees or insureds overall contribution to any out-of-pocket maximum, deductible, copayment, coinsurance, or applicable cost-sharing requirement under the enrollees or insureds health care service plan contract or health insurance policy. The bill would limit the application of the section to health care service plans and health insurance policies issued, amended, delivered, or renewed on or after January 1, 2025. Because a willful violation of these requirements by a health care service plan would be a crime, this bill would impose a state-mandated local program.The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.This bill would provide that no reimbursement is required by this act for a specified reason.
Existing law generally prohibits a person who manufactures a prescription drug from offering in California any discount, repayment, product voucher, or other reduction in an individuals out-of-pocket expenses associated with the individuals health insurance, health care service plan, or other health coverage, including, but not limited to, a copayment, coinsurance, or deductible, for any prescription drug if a lower cost generic drug is covered under the individuals health insurance, health care service plan, or other health coverage on a lower cost-sharing tier that is designated as therapeutically equivalent to the prescription drug manufactured by that person or if the active ingredients of the drug are contained in products regulated by the federal Food and Drug Administration, are available without prescription at a lower cost, and are not otherwise contraindicated for the condition for which the prescription drug is approved.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance.
This bill would require a health care service plan, health insurance policy, or pharmacy benefit manager that administers pharmacy benefits for a health care service plan or health insurer to apply any amounts paid by the enrollee, insured, or another source pursuant to a discount, repayment, product voucher, or other reduction to the enrollees or insureds out-of-pocket expenses toward the enrollees or insureds overall contribution to any out-of-pocket maximum, deductible, copayment, coinsurance, or applicable cost-sharing requirement under the enrollees or insureds health care service plan contract or health insurance policy. The bill would limit the application of the section to health care service plans and health insurance policies issued, amended, delivered, or renewed on or after January 1, 2025. Because a willful violation of these requirements by a health care service plan would be a crime, this bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
## Digest Key
## Bill Text
The people of the State of California do enact as follows:SECTION 1. Section 1367.0062 is added to the Health and Safety Code, to read:1367.0062. (a) (1) To the extent permitted by federal law, and consistent with Sections 132000 and 132002, a health care service plan or a pharmacy benefit manager that administers pharmacy benefits for a health care service plan shall apply any amounts paid by either the enrollee or third-party patient assistance program to the enrollees cost-sharing requirement. This requirement shall be limited to only those enrollees who have a chronic disease or terminal illness.(2) This section shall only apply with respect to health care service plan contracts issued, amended, delivered, or renewed on or after January 1, 2025.(b) If under federal law, application of subdivision (a) would result in health savings account ineligibility under Section 223 of the Internal Revenue Code, this requirement shall apply for health savings account-qualified high deductible health plans with respect to the deductible of a policy after the enrollee has satisfied the minimum deductible under Section 223 of the Internal Revenue Code, except with respect to items or services that are preventive care pursuant to Section 223(c)(2)(C) of the Internal Revenue Code, in which case the requirements of this subdivision shall apply regardless of whether the minimum deductible under Section 223 of the Internal Revenue Code has been satisfied.(c) This section does not apply with respect to self-insured employer plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) (Public Law 83-406).(d) For purposes of this section, the following definitions apply:(1) Cost-sharing requirement means any copayment, coinsurance, deductible, or annual limitation on cost-sharing, including a limitation subject to Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, required by, or on behalf of, an enrollee in order to receive a specific health care service, including a prescription drug, covered by a health care service plan contract. When calculating an enrollees overall contribution to the annual limitation on cost sharing set forth in Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, a health care service plan shall include expenditures for any item or service covered by the health care service plan, and include within a category of essential health benefits as described in Section 18022(b)(1) of Title 42 of the United States Code, which expenditures shall be considered expenditures for essential health coverage benefits covered under the health care service plan contract.(2) Pharmacy Benefit Manager means a person or business that administers the prescription drug or device program of one or more health care service plans on behalf of a third party in accordance with a pharmacy benefit program. This term includes any agent or representative of a pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the administering of the drug program and any wholly or partially owned or controlled subsidiary of a pharmacy benefit manager.(3) Third-party patient assistance program shall include, but is not limited to, manufacturer or other charitable programs that provide financial assistance intended to augment existing prescription drug coverage. Third-party patient assistance program does not include discounts, drug vouchers, or general manufacturer coupons.(4) Chronic disease is defined as conditions that have a tendency to last one year or more and require ongoing medical attention or limit activities of daily living or both.(5) Terminal illness is defined as a medical condition that is life-limiting and expected to result in death.SEC. 2. Section 10192.292 is added to the Insurance Code, to read:10192.292. (a) (1) To the extent permitted by federal law, and consistent with Sections 132000 and 132002 of the Health and Safety Code, a health insurer or a pharmacy benefit manager that administers pharmacy benefits for a health insurer shall apply any amounts paid by either the insured, or third-party patient assistance program to the insureds cost-sharing requirement. This requirement shall be limited to only those insureds who have a chronic disease or terminal illness.(2) This section shall only apply with respect to health insurance policies issued, amended, delivered, or renewed on or after January 1, 2025.(b) If under federal law, application of subdivision (a) would result in health savings account ineligibility under Section 223 of the Internal Revenue Code, this requirement shall apply for Health Savings Account-qualified High Deductible Health Plans with respect to the deductible of a policy after the insured has satisfied the minimum deductible under Section 223 of the Internal Revenue Code, except with respect to items or services that are preventive care pursuant to Section 223(c)(2)(C) of the Internal Revenue Code, in which case the requirements of this subdivision shall apply regardless of whether the minimum deductible under Section 223 of the Internal Revenue Code has been satisfied.(c) This section does not apply with respect to self-insured employer plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) (Public Law 83-406).(d) For purposes of this section, the following definitions apply:(1) Cost-sharing requirement means any copayment, coinsurance, deductible, or annual limitation on cost-sharing, including a limitation subject to Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, required by, or on behalf of, an enrollee in order to receive a specific health care service, including a prescription drug, covered by a health insurance policy. When calculating an insureds overall contribution to the annual limitation on cost sharing set forth in Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, a health insurer shall include expenditures for any item or service covered by the health insurer, and include within a category of essential health benefits as described in Section 18022(b)(1) of Title 42 of the United States Code, which expenditures shall be considered expenditures for essential health coverage benefits covered under the health insurance policy.(2) Pharmacy Benefit Manager means a person or business that administers the prescription drug or device program of one or more health insurance policies on behalf of a third party in accordance with a pharmacy benefit program. This term includes any agent or representative of a pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the administering of the drug program and any wholly or partially owned or controlled subsidiary of a pharmacy benefit manager.(3) Third-party patient assistance program shall include, but is not limited to, manufacturer or other charitable programs that provide financial assistance intended to augment existing prescription drug coverage. Third party patient assistance program does not include discounts, drug vouchers or general manufacturer coupons.(4) Chronic disease is defined as conditions that have a tendency to last one year or more and require ongoing medical attention or limit activities of daily living or both.(5) Terminal illness is defined as a medical condition that is life-limiting and expected to result in death.SEC. 3. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.
The people of the State of California do enact as follows:
## The people of the State of California do enact as follows:
SECTION 1. Section 1367.0062 is added to the Health and Safety Code, to read:1367.0062. (a) (1) To the extent permitted by federal law, and consistent with Sections 132000 and 132002, a health care service plan or a pharmacy benefit manager that administers pharmacy benefits for a health care service plan shall apply any amounts paid by either the enrollee or third-party patient assistance program to the enrollees cost-sharing requirement. This requirement shall be limited to only those enrollees who have a chronic disease or terminal illness.(2) This section shall only apply with respect to health care service plan contracts issued, amended, delivered, or renewed on or after January 1, 2025.(b) If under federal law, application of subdivision (a) would result in health savings account ineligibility under Section 223 of the Internal Revenue Code, this requirement shall apply for health savings account-qualified high deductible health plans with respect to the deductible of a policy after the enrollee has satisfied the minimum deductible under Section 223 of the Internal Revenue Code, except with respect to items or services that are preventive care pursuant to Section 223(c)(2)(C) of the Internal Revenue Code, in which case the requirements of this subdivision shall apply regardless of whether the minimum deductible under Section 223 of the Internal Revenue Code has been satisfied.(c) This section does not apply with respect to self-insured employer plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) (Public Law 83-406).(d) For purposes of this section, the following definitions apply:(1) Cost-sharing requirement means any copayment, coinsurance, deductible, or annual limitation on cost-sharing, including a limitation subject to Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, required by, or on behalf of, an enrollee in order to receive a specific health care service, including a prescription drug, covered by a health care service plan contract. When calculating an enrollees overall contribution to the annual limitation on cost sharing set forth in Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, a health care service plan shall include expenditures for any item or service covered by the health care service plan, and include within a category of essential health benefits as described in Section 18022(b)(1) of Title 42 of the United States Code, which expenditures shall be considered expenditures for essential health coverage benefits covered under the health care service plan contract.(2) Pharmacy Benefit Manager means a person or business that administers the prescription drug or device program of one or more health care service plans on behalf of a third party in accordance with a pharmacy benefit program. This term includes any agent or representative of a pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the administering of the drug program and any wholly or partially owned or controlled subsidiary of a pharmacy benefit manager.(3) Third-party patient assistance program shall include, but is not limited to, manufacturer or other charitable programs that provide financial assistance intended to augment existing prescription drug coverage. Third-party patient assistance program does not include discounts, drug vouchers, or general manufacturer coupons.(4) Chronic disease is defined as conditions that have a tendency to last one year or more and require ongoing medical attention or limit activities of daily living or both.(5) Terminal illness is defined as a medical condition that is life-limiting and expected to result in death.
SECTION 1. Section 1367.0062 is added to the Health and Safety Code, to read:
### SECTION 1.
1367.0062. (a) (1) To the extent permitted by federal law, and consistent with Sections 132000 and 132002, a health care service plan or a pharmacy benefit manager that administers pharmacy benefits for a health care service plan shall apply any amounts paid by either the enrollee or third-party patient assistance program to the enrollees cost-sharing requirement. This requirement shall be limited to only those enrollees who have a chronic disease or terminal illness.(2) This section shall only apply with respect to health care service plan contracts issued, amended, delivered, or renewed on or after January 1, 2025.(b) If under federal law, application of subdivision (a) would result in health savings account ineligibility under Section 223 of the Internal Revenue Code, this requirement shall apply for health savings account-qualified high deductible health plans with respect to the deductible of a policy after the enrollee has satisfied the minimum deductible under Section 223 of the Internal Revenue Code, except with respect to items or services that are preventive care pursuant to Section 223(c)(2)(C) of the Internal Revenue Code, in which case the requirements of this subdivision shall apply regardless of whether the minimum deductible under Section 223 of the Internal Revenue Code has been satisfied.(c) This section does not apply with respect to self-insured employer plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) (Public Law 83-406).(d) For purposes of this section, the following definitions apply:(1) Cost-sharing requirement means any copayment, coinsurance, deductible, or annual limitation on cost-sharing, including a limitation subject to Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, required by, or on behalf of, an enrollee in order to receive a specific health care service, including a prescription drug, covered by a health care service plan contract. When calculating an enrollees overall contribution to the annual limitation on cost sharing set forth in Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, a health care service plan shall include expenditures for any item or service covered by the health care service plan, and include within a category of essential health benefits as described in Section 18022(b)(1) of Title 42 of the United States Code, which expenditures shall be considered expenditures for essential health coverage benefits covered under the health care service plan contract.(2) Pharmacy Benefit Manager means a person or business that administers the prescription drug or device program of one or more health care service plans on behalf of a third party in accordance with a pharmacy benefit program. This term includes any agent or representative of a pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the administering of the drug program and any wholly or partially owned or controlled subsidiary of a pharmacy benefit manager.(3) Third-party patient assistance program shall include, but is not limited to, manufacturer or other charitable programs that provide financial assistance intended to augment existing prescription drug coverage. Third-party patient assistance program does not include discounts, drug vouchers, or general manufacturer coupons.(4) Chronic disease is defined as conditions that have a tendency to last one year or more and require ongoing medical attention or limit activities of daily living or both.(5) Terminal illness is defined as a medical condition that is life-limiting and expected to result in death.
1367.0062. (a) (1) To the extent permitted by federal law, and consistent with Sections 132000 and 132002, a health care service plan or a pharmacy benefit manager that administers pharmacy benefits for a health care service plan shall apply any amounts paid by either the enrollee or third-party patient assistance program to the enrollees cost-sharing requirement. This requirement shall be limited to only those enrollees who have a chronic disease or terminal illness.(2) This section shall only apply with respect to health care service plan contracts issued, amended, delivered, or renewed on or after January 1, 2025.(b) If under federal law, application of subdivision (a) would result in health savings account ineligibility under Section 223 of the Internal Revenue Code, this requirement shall apply for health savings account-qualified high deductible health plans with respect to the deductible of a policy after the enrollee has satisfied the minimum deductible under Section 223 of the Internal Revenue Code, except with respect to items or services that are preventive care pursuant to Section 223(c)(2)(C) of the Internal Revenue Code, in which case the requirements of this subdivision shall apply regardless of whether the minimum deductible under Section 223 of the Internal Revenue Code has been satisfied.(c) This section does not apply with respect to self-insured employer plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) (Public Law 83-406).(d) For purposes of this section, the following definitions apply:(1) Cost-sharing requirement means any copayment, coinsurance, deductible, or annual limitation on cost-sharing, including a limitation subject to Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, required by, or on behalf of, an enrollee in order to receive a specific health care service, including a prescription drug, covered by a health care service plan contract. When calculating an enrollees overall contribution to the annual limitation on cost sharing set forth in Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, a health care service plan shall include expenditures for any item or service covered by the health care service plan, and include within a category of essential health benefits as described in Section 18022(b)(1) of Title 42 of the United States Code, which expenditures shall be considered expenditures for essential health coverage benefits covered under the health care service plan contract.(2) Pharmacy Benefit Manager means a person or business that administers the prescription drug or device program of one or more health care service plans on behalf of a third party in accordance with a pharmacy benefit program. This term includes any agent or representative of a pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the administering of the drug program and any wholly or partially owned or controlled subsidiary of a pharmacy benefit manager.(3) Third-party patient assistance program shall include, but is not limited to, manufacturer or other charitable programs that provide financial assistance intended to augment existing prescription drug coverage. Third-party patient assistance program does not include discounts, drug vouchers, or general manufacturer coupons.(4) Chronic disease is defined as conditions that have a tendency to last one year or more and require ongoing medical attention or limit activities of daily living or both.(5) Terminal illness is defined as a medical condition that is life-limiting and expected to result in death.
1367.0062. (a) (1) To the extent permitted by federal law, and consistent with Sections 132000 and 132002, a health care service plan or a pharmacy benefit manager that administers pharmacy benefits for a health care service plan shall apply any amounts paid by either the enrollee or third-party patient assistance program to the enrollees cost-sharing requirement. This requirement shall be limited to only those enrollees who have a chronic disease or terminal illness.(2) This section shall only apply with respect to health care service plan contracts issued, amended, delivered, or renewed on or after January 1, 2025.(b) If under federal law, application of subdivision (a) would result in health savings account ineligibility under Section 223 of the Internal Revenue Code, this requirement shall apply for health savings account-qualified high deductible health plans with respect to the deductible of a policy after the enrollee has satisfied the minimum deductible under Section 223 of the Internal Revenue Code, except with respect to items or services that are preventive care pursuant to Section 223(c)(2)(C) of the Internal Revenue Code, in which case the requirements of this subdivision shall apply regardless of whether the minimum deductible under Section 223 of the Internal Revenue Code has been satisfied.(c) This section does not apply with respect to self-insured employer plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) (Public Law 83-406).(d) For purposes of this section, the following definitions apply:(1) Cost-sharing requirement means any copayment, coinsurance, deductible, or annual limitation on cost-sharing, including a limitation subject to Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, required by, or on behalf of, an enrollee in order to receive a specific health care service, including a prescription drug, covered by a health care service plan contract. When calculating an enrollees overall contribution to the annual limitation on cost sharing set forth in Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, a health care service plan shall include expenditures for any item or service covered by the health care service plan, and include within a category of essential health benefits as described in Section 18022(b)(1) of Title 42 of the United States Code, which expenditures shall be considered expenditures for essential health coverage benefits covered under the health care service plan contract.(2) Pharmacy Benefit Manager means a person or business that administers the prescription drug or device program of one or more health care service plans on behalf of a third party in accordance with a pharmacy benefit program. This term includes any agent or representative of a pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the administering of the drug program and any wholly or partially owned or controlled subsidiary of a pharmacy benefit manager.(3) Third-party patient assistance program shall include, but is not limited to, manufacturer or other charitable programs that provide financial assistance intended to augment existing prescription drug coverage. Third-party patient assistance program does not include discounts, drug vouchers, or general manufacturer coupons.(4) Chronic disease is defined as conditions that have a tendency to last one year or more and require ongoing medical attention or limit activities of daily living or both.(5) Terminal illness is defined as a medical condition that is life-limiting and expected to result in death.
1367.0062. (a) (1) To the extent permitted by federal law, and consistent with Sections 132000 and 132002, a health care service plan or a pharmacy benefit manager that administers pharmacy benefits for a health care service plan shall apply any amounts paid by either the enrollee or third-party patient assistance program to the enrollees cost-sharing requirement. This requirement shall be limited to only those enrollees who have a chronic disease or terminal illness.
(2) This section shall only apply with respect to health care service plan contracts issued, amended, delivered, or renewed on or after January 1, 2025.
(b) If under federal law, application of subdivision (a) would result in health savings account ineligibility under Section 223 of the Internal Revenue Code, this requirement shall apply for health savings account-qualified high deductible health plans with respect to the deductible of a policy after the enrollee has satisfied the minimum deductible under Section 223 of the Internal Revenue Code, except with respect to items or services that are preventive care pursuant to Section 223(c)(2)(C) of the Internal Revenue Code, in which case the requirements of this subdivision shall apply regardless of whether the minimum deductible under Section 223 of the Internal Revenue Code has been satisfied.
(c) This section does not apply with respect to self-insured employer plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) (Public Law 83-406).
(d) For purposes of this section, the following definitions apply:
(1) Cost-sharing requirement means any copayment, coinsurance, deductible, or annual limitation on cost-sharing, including a limitation subject to Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, required by, or on behalf of, an enrollee in order to receive a specific health care service, including a prescription drug, covered by a health care service plan contract. When calculating an enrollees overall contribution to the annual limitation on cost sharing set forth in Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, a health care service plan shall include expenditures for any item or service covered by the health care service plan, and include within a category of essential health benefits as described in Section 18022(b)(1) of Title 42 of the United States Code, which expenditures shall be considered expenditures for essential health coverage benefits covered under the health care service plan contract.
(2) Pharmacy Benefit Manager means a person or business that administers the prescription drug or device program of one or more health care service plans on behalf of a third party in accordance with a pharmacy benefit program. This term includes any agent or representative of a pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the administering of the drug program and any wholly or partially owned or controlled subsidiary of a pharmacy benefit manager.
(3) Third-party patient assistance program shall include, but is not limited to, manufacturer or other charitable programs that provide financial assistance intended to augment existing prescription drug coverage. Third-party patient assistance program does not include discounts, drug vouchers, or general manufacturer coupons.
(4) Chronic disease is defined as conditions that have a tendency to last one year or more and require ongoing medical attention or limit activities of daily living or both.
(5) Terminal illness is defined as a medical condition that is life-limiting and expected to result in death.
SEC. 2. Section 10192.292 is added to the Insurance Code, to read:10192.292. (a) (1) To the extent permitted by federal law, and consistent with Sections 132000 and 132002 of the Health and Safety Code, a health insurer or a pharmacy benefit manager that administers pharmacy benefits for a health insurer shall apply any amounts paid by either the insured, or third-party patient assistance program to the insureds cost-sharing requirement. This requirement shall be limited to only those insureds who have a chronic disease or terminal illness.(2) This section shall only apply with respect to health insurance policies issued, amended, delivered, or renewed on or after January 1, 2025.(b) If under federal law, application of subdivision (a) would result in health savings account ineligibility under Section 223 of the Internal Revenue Code, this requirement shall apply for Health Savings Account-qualified High Deductible Health Plans with respect to the deductible of a policy after the insured has satisfied the minimum deductible under Section 223 of the Internal Revenue Code, except with respect to items or services that are preventive care pursuant to Section 223(c)(2)(C) of the Internal Revenue Code, in which case the requirements of this subdivision shall apply regardless of whether the minimum deductible under Section 223 of the Internal Revenue Code has been satisfied.(c) This section does not apply with respect to self-insured employer plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) (Public Law 83-406).(d) For purposes of this section, the following definitions apply:(1) Cost-sharing requirement means any copayment, coinsurance, deductible, or annual limitation on cost-sharing, including a limitation subject to Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, required by, or on behalf of, an enrollee in order to receive a specific health care service, including a prescription drug, covered by a health insurance policy. When calculating an insureds overall contribution to the annual limitation on cost sharing set forth in Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, a health insurer shall include expenditures for any item or service covered by the health insurer, and include within a category of essential health benefits as described in Section 18022(b)(1) of Title 42 of the United States Code, which expenditures shall be considered expenditures for essential health coverage benefits covered under the health insurance policy.(2) Pharmacy Benefit Manager means a person or business that administers the prescription drug or device program of one or more health insurance policies on behalf of a third party in accordance with a pharmacy benefit program. This term includes any agent or representative of a pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the administering of the drug program and any wholly or partially owned or controlled subsidiary of a pharmacy benefit manager.(3) Third-party patient assistance program shall include, but is not limited to, manufacturer or other charitable programs that provide financial assistance intended to augment existing prescription drug coverage. Third party patient assistance program does not include discounts, drug vouchers or general manufacturer coupons.(4) Chronic disease is defined as conditions that have a tendency to last one year or more and require ongoing medical attention or limit activities of daily living or both.(5) Terminal illness is defined as a medical condition that is life-limiting and expected to result in death.
SEC. 2. Section 10192.292 is added to the Insurance Code, to read:
### SEC. 2.
10192.292. (a) (1) To the extent permitted by federal law, and consistent with Sections 132000 and 132002 of the Health and Safety Code, a health insurer or a pharmacy benefit manager that administers pharmacy benefits for a health insurer shall apply any amounts paid by either the insured, or third-party patient assistance program to the insureds cost-sharing requirement. This requirement shall be limited to only those insureds who have a chronic disease or terminal illness.(2) This section shall only apply with respect to health insurance policies issued, amended, delivered, or renewed on or after January 1, 2025.(b) If under federal law, application of subdivision (a) would result in health savings account ineligibility under Section 223 of the Internal Revenue Code, this requirement shall apply for Health Savings Account-qualified High Deductible Health Plans with respect to the deductible of a policy after the insured has satisfied the minimum deductible under Section 223 of the Internal Revenue Code, except with respect to items or services that are preventive care pursuant to Section 223(c)(2)(C) of the Internal Revenue Code, in which case the requirements of this subdivision shall apply regardless of whether the minimum deductible under Section 223 of the Internal Revenue Code has been satisfied.(c) This section does not apply with respect to self-insured employer plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) (Public Law 83-406).(d) For purposes of this section, the following definitions apply:(1) Cost-sharing requirement means any copayment, coinsurance, deductible, or annual limitation on cost-sharing, including a limitation subject to Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, required by, or on behalf of, an enrollee in order to receive a specific health care service, including a prescription drug, covered by a health insurance policy. When calculating an insureds overall contribution to the annual limitation on cost sharing set forth in Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, a health insurer shall include expenditures for any item or service covered by the health insurer, and include within a category of essential health benefits as described in Section 18022(b)(1) of Title 42 of the United States Code, which expenditures shall be considered expenditures for essential health coverage benefits covered under the health insurance policy.(2) Pharmacy Benefit Manager means a person or business that administers the prescription drug or device program of one or more health insurance policies on behalf of a third party in accordance with a pharmacy benefit program. This term includes any agent or representative of a pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the administering of the drug program and any wholly or partially owned or controlled subsidiary of a pharmacy benefit manager.(3) Third-party patient assistance program shall include, but is not limited to, manufacturer or other charitable programs that provide financial assistance intended to augment existing prescription drug coverage. Third party patient assistance program does not include discounts, drug vouchers or general manufacturer coupons.(4) Chronic disease is defined as conditions that have a tendency to last one year or more and require ongoing medical attention or limit activities of daily living or both.(5) Terminal illness is defined as a medical condition that is life-limiting and expected to result in death.
10192.292. (a) (1) To the extent permitted by federal law, and consistent with Sections 132000 and 132002 of the Health and Safety Code, a health insurer or a pharmacy benefit manager that administers pharmacy benefits for a health insurer shall apply any amounts paid by either the insured, or third-party patient assistance program to the insureds cost-sharing requirement. This requirement shall be limited to only those insureds who have a chronic disease or terminal illness.(2) This section shall only apply with respect to health insurance policies issued, amended, delivered, or renewed on or after January 1, 2025.(b) If under federal law, application of subdivision (a) would result in health savings account ineligibility under Section 223 of the Internal Revenue Code, this requirement shall apply for Health Savings Account-qualified High Deductible Health Plans with respect to the deductible of a policy after the insured has satisfied the minimum deductible under Section 223 of the Internal Revenue Code, except with respect to items or services that are preventive care pursuant to Section 223(c)(2)(C) of the Internal Revenue Code, in which case the requirements of this subdivision shall apply regardless of whether the minimum deductible under Section 223 of the Internal Revenue Code has been satisfied.(c) This section does not apply with respect to self-insured employer plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) (Public Law 83-406).(d) For purposes of this section, the following definitions apply:(1) Cost-sharing requirement means any copayment, coinsurance, deductible, or annual limitation on cost-sharing, including a limitation subject to Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, required by, or on behalf of, an enrollee in order to receive a specific health care service, including a prescription drug, covered by a health insurance policy. When calculating an insureds overall contribution to the annual limitation on cost sharing set forth in Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, a health insurer shall include expenditures for any item or service covered by the health insurer, and include within a category of essential health benefits as described in Section 18022(b)(1) of Title 42 of the United States Code, which expenditures shall be considered expenditures for essential health coverage benefits covered under the health insurance policy.(2) Pharmacy Benefit Manager means a person or business that administers the prescription drug or device program of one or more health insurance policies on behalf of a third party in accordance with a pharmacy benefit program. This term includes any agent or representative of a pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the administering of the drug program and any wholly or partially owned or controlled subsidiary of a pharmacy benefit manager.(3) Third-party patient assistance program shall include, but is not limited to, manufacturer or other charitable programs that provide financial assistance intended to augment existing prescription drug coverage. Third party patient assistance program does not include discounts, drug vouchers or general manufacturer coupons.(4) Chronic disease is defined as conditions that have a tendency to last one year or more and require ongoing medical attention or limit activities of daily living or both.(5) Terminal illness is defined as a medical condition that is life-limiting and expected to result in death.
10192.292. (a) (1) To the extent permitted by federal law, and consistent with Sections 132000 and 132002 of the Health and Safety Code, a health insurer or a pharmacy benefit manager that administers pharmacy benefits for a health insurer shall apply any amounts paid by either the insured, or third-party patient assistance program to the insureds cost-sharing requirement. This requirement shall be limited to only those insureds who have a chronic disease or terminal illness.(2) This section shall only apply with respect to health insurance policies issued, amended, delivered, or renewed on or after January 1, 2025.(b) If under federal law, application of subdivision (a) would result in health savings account ineligibility under Section 223 of the Internal Revenue Code, this requirement shall apply for Health Savings Account-qualified High Deductible Health Plans with respect to the deductible of a policy after the insured has satisfied the minimum deductible under Section 223 of the Internal Revenue Code, except with respect to items or services that are preventive care pursuant to Section 223(c)(2)(C) of the Internal Revenue Code, in which case the requirements of this subdivision shall apply regardless of whether the minimum deductible under Section 223 of the Internal Revenue Code has been satisfied.(c) This section does not apply with respect to self-insured employer plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) (Public Law 83-406).(d) For purposes of this section, the following definitions apply:(1) Cost-sharing requirement means any copayment, coinsurance, deductible, or annual limitation on cost-sharing, including a limitation subject to Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, required by, or on behalf of, an enrollee in order to receive a specific health care service, including a prescription drug, covered by a health insurance policy. When calculating an insureds overall contribution to the annual limitation on cost sharing set forth in Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, a health insurer shall include expenditures for any item or service covered by the health insurer, and include within a category of essential health benefits as described in Section 18022(b)(1) of Title 42 of the United States Code, which expenditures shall be considered expenditures for essential health coverage benefits covered under the health insurance policy.(2) Pharmacy Benefit Manager means a person or business that administers the prescription drug or device program of one or more health insurance policies on behalf of a third party in accordance with a pharmacy benefit program. This term includes any agent or representative of a pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the administering of the drug program and any wholly or partially owned or controlled subsidiary of a pharmacy benefit manager.(3) Third-party patient assistance program shall include, but is not limited to, manufacturer or other charitable programs that provide financial assistance intended to augment existing prescription drug coverage. Third party patient assistance program does not include discounts, drug vouchers or general manufacturer coupons.(4) Chronic disease is defined as conditions that have a tendency to last one year or more and require ongoing medical attention or limit activities of daily living or both.(5) Terminal illness is defined as a medical condition that is life-limiting and expected to result in death.
10192.292. (a) (1) To the extent permitted by federal law, and consistent with Sections 132000 and 132002 of the Health and Safety Code, a health insurer or a pharmacy benefit manager that administers pharmacy benefits for a health insurer shall apply any amounts paid by either the insured, or third-party patient assistance program to the insureds cost-sharing requirement. This requirement shall be limited to only those insureds who have a chronic disease or terminal illness.
(2) This section shall only apply with respect to health insurance policies issued, amended, delivered, or renewed on or after January 1, 2025.
(b) If under federal law, application of subdivision (a) would result in health savings account ineligibility under Section 223 of the Internal Revenue Code, this requirement shall apply for Health Savings Account-qualified High Deductible Health Plans with respect to the deductible of a policy after the insured has satisfied the minimum deductible under Section 223 of the Internal Revenue Code, except with respect to items or services that are preventive care pursuant to Section 223(c)(2)(C) of the Internal Revenue Code, in which case the requirements of this subdivision shall apply regardless of whether the minimum deductible under Section 223 of the Internal Revenue Code has been satisfied.
(c) This section does not apply with respect to self-insured employer plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) (Public Law 83-406).
(d) For purposes of this section, the following definitions apply:
(1) Cost-sharing requirement means any copayment, coinsurance, deductible, or annual limitation on cost-sharing, including a limitation subject to Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, required by, or on behalf of, an enrollee in order to receive a specific health care service, including a prescription drug, covered by a health insurance policy. When calculating an insureds overall contribution to the annual limitation on cost sharing set forth in Sections 18022(c) and 300gg-6(b) of Title 42 of the United States Code, a health insurer shall include expenditures for any item or service covered by the health insurer, and include within a category of essential health benefits as described in Section 18022(b)(1) of Title 42 of the United States Code, which expenditures shall be considered expenditures for essential health coverage benefits covered under the health insurance policy.
(2) Pharmacy Benefit Manager means a person or business that administers the prescription drug or device program of one or more health insurance policies on behalf of a third party in accordance with a pharmacy benefit program. This term includes any agent or representative of a pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the administering of the drug program and any wholly or partially owned or controlled subsidiary of a pharmacy benefit manager.
(3) Third-party patient assistance program shall include, but is not limited to, manufacturer or other charitable programs that provide financial assistance intended to augment existing prescription drug coverage. Third party patient assistance program does not include discounts, drug vouchers or general manufacturer coupons.
(4) Chronic disease is defined as conditions that have a tendency to last one year or more and require ongoing medical attention or limit activities of daily living or both.
(5) Terminal illness is defined as a medical condition that is life-limiting and expected to result in death.
SEC. 3. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.
SEC. 3. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.
SEC. 3. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.
### SEC. 3.