Indiana 2025 Regular Session

Indiana House Bill HB1252 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1
2	2	Introduced Version
3	3	HOUSE BILL No. 1252
4	4	_____
5	5	DIGEST OF INTRODUCED BILL
6	6	Citations Affected: IC 27-1.
7	7	Synopsis: Limitation on cost sharing. Requires an insurer, an
8	8	administrator, and a pharmacy benefit manager to apply the annual
9	9	limitation on cost sharing set forth in the federal Patient Protection and
10	10	Affordable Care Act under 42 U.S.C. 18022(c)(1). Provides that an
11	11	insurer, an administrator, and a pharmacy benefit manager may not
12	12	directly or indirectly set, alter, implement, or condition the terms of
13	13	health insurance coverage based in part or entirely on information
14	14	about the availability or amount of financial or product assistance
15	15	available for a prescription drug. Requires, before December 31 of each
16	16	year, each insurer and administrator to certify to the insurance
17	17	commissioner that the insurer or administrator has fully and completely
18	18	complied with the cost sharing requirements during the previous
19	19	calendar year.
20	20	Effective: January 1, 2026.
21	21	Smaltz, Lehman, McGuire
22	22	January 9, 2025, read first time and referred to Committee on Insurance.
23	23	2025 IN 1252—LS 7280/DI 141 Introduced
24	24	First Regular Session of the 124th General Assembly (2025)
25	25	PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana
26	26	Constitution) is being amended, the text of the existing provision will appear in this style type,
27	27	additions will appear in this style type, and deletions will appear in this style type.
28	28	Additions: Whenever a new statutory provision is being enacted (or a new constitutional
29	29	provision adopted), the text of the new provision will appear in this style type. Also, the
30	30	word NEW will appear in that style type in the introductory clause of each SECTION that adds
31	31	a new provision to the Indiana Code or the Indiana Constitution.
32	32	Conflict reconciliation: Text in a statute in this style type or this style type reconciles conflicts
33	33	between statutes enacted by the 2024 Regular Session of the General Assembly.
34	34	HOUSE BILL No. 1252
35	35	A BILL FOR AN ACT to amend the Indiana Code concerning
36	36	insurance.
37	37	Be it enacted by the General Assembly of the State of Indiana:
38	38	1 SECTION 1. IC 27-1-24.5-0.8 IS ADDED TO THE INDIANA
39	39	2 CODE AS A NEW SECTION TO READ AS FOLLOWS
40	40	3 [EFFECTIVE JANUARY 1, 2026]: Sec. 0.8. As used in this chapter,
41	41	4 "cost sharing" means any copayment, coinsurance, deductible, or
42	42	5 other similar charge that is:
43	43	6 (1) required of a covered individual for a health care service
44	44	7 covered by a health plan, including a prescription drug; and
45	45	8 (2) paid:
46	46	9 (A) by; or
47	47	10 (B) on behalf of;
48	48	11 the covered individual.
49	49	12 SECTION 2. IC 27-1-24.5-4.5 IS ADDED TO THE INDIANA
50	50	13 CODE AS A NEW SECTION TO READ AS FOLLOWS
51	51	14 [EFFECTIVE JANUARY 1, 2026]: Sec. 4.5. As used in this chapter,
52	52	15 "health care service" means a service or good furnished for the
53	53	16 purpose of preventing, alleviating, curing, or healing:
54	54	17 (1) human illness;
55	55	2025 IN 1252—LS 7280/DI 141 2
56	56	1 (2) physical disability; or
57	57	2 (3) injury.
58	58	3 SECTION 3. IC 27-1-24.5-5, AS AMENDED BY P.L.207-2021,
59	59	4 SECTION 52, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
60	60	5 JANUARY 1, 2026]: Sec. 5. As used in this chapter, "health plan"
61	61	6 means a plan through which coverage is provided for health care
62	62	7 services through insurance, prepayment, reimbursement, or
63	63	8 otherwise. The term includes the following:
64	64	9 (1) A state employee health plan (as defined in IC 5-10-8-6.7).
65	65	10 (2) A policy of accident and sickness insurance (as defined in
66	66	11 IC 27-8-5-1). However, the term does not include the coverages
67	67	12 described in IC 27-8-5-2.5(a).
68	68	13 (3) An individual contract (as defined in IC 27-13-1-21) or a
69	69	14 group contract (as defined in IC 27-13-1-16) that provides
70	70	15 coverage for basic health care services (as defined in
71	71	16 IC 27-13-1-4).
72	72	17 (4) Any other plan or program that provides payment,
73	73	18 reimbursement, or indemnification to a covered individual for the
74	74	19 cost of prescription drugs.
75	75	20 SECTION 4. IC 27-1-24.5-6.5 IS ADDED TO THE INDIANA
76	76	21 CODE AS A NEW SECTION TO READ AS FOLLOWS
77	77	22 [EFFECTIVE JANUARY 1, 2026]: Sec. 6.5. As used in this chapter,
78	78	23 "insurer" means an insurer subject to state law and rules
79	79	24 regulating insurance or subject to the jurisdiction of the
80	80	25 department that contracts, or offers to contract, to:
81	81	26 (1) provide;
82	82	27 (2) deliver;
83	83	28 (3) arrange for;
84	84	29 (4) pay for; or
85	85	30 (5) reimburse;
86	86	31 any of the costs of health care services to a covered individual
87	87	32 under a health plan.
88	88	33 SECTION 5. IC 27-1-24.5-11.5 IS ADDED TO THE INDIANA
89	89	34 CODE AS A NEW SECTION TO READ AS FOLLOWS
90	90	35 [EFFECTIVE JANUARY 1, 2026]: Sec. 11.5. As used in this chapter,
91	91	36 "pharmacy benefit management services" means:
92	92	37 (1) negotiating the price of prescription drugs, including
93	93	38 negotiating and contracting for direct or indirect rebates,
94	94	39 discounts, or other price concessions;
95	95	40 (2) managing any aspect of a prescription drug benefit,
96	96	41 including:
97	97	42 (A) the processing and payment of claims for prescription
98	98	2025 IN 1252—LS 7280/DI 141 3
99	99	1 drugs;
100	100	2 (B) arranging alternative access to or funding for
101	101	3 prescription drugs;
102	102	4 (C) the performance of drug utilization review;
103	103	5 (D) the processing of drug prior authorization requests;
104	104	6 (E) the adjudication of appeals or grievances related to the
105	105	7 prescription drug benefit;
106	106	8 (F) contracting with network pharmacies;
107	107	9 (G) controlling the cost of covered prescription drugs;
108	108	10 (H) managing or providing data relating to the
109	109	11 prescription drug benefit;
110	110	12 (I) the provision of services related to the prescription drug
111	111	13 benefit; or
112	112	14 (J) creating or updating prescription drug formularies;
113	113	15 (3) performance of any administrative, managerial, clinical,
114	114	16 pricing, financial, reimbursement, data administration or
115	115	17 reporting, or billing service; and
116	116	18 (4) any other services specified in a rule adopted by the
117	117	19 department.
118	118	20 SECTION 6. IC 27-1-24.5-12, AS AMENDED BY P.L.32-2021,
119	119	21 SECTION 77, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
120	120	22 JANUARY 1, 2026]: Sec. 12. (a) As used in this chapter, "pharmacy
121	121	23 benefit manager" means: an entity that, on behalf of a health plan, state
122	122	24 agency, insurer, managed care organization, or other third party payor:
123	123	25 (1) a person who, under a written agreement with an insurer,
124	124	26 health plan, state agency, managed care organization, or other
125	125	27 third party payor, directly or indirectly provides one (1) or
126	126	28 more pharmacy benefit management services on behalf of the
127	127	29 insurer, health plan, state agency, managed care organization,
128	128	30 or other third party payor; and
129	129	31 (2) an agent, a contractor, an intermediary, an affiliate, a
130	130	32 subsidiary, or a related entity of a person described in
131	131	33 subdivision (1) who facilitates, provides, directs, or oversees
132	132	34 the provision of the pharmacy benefit management services.
133	133	35 (1) contracts directly or indirectly with pharmacies to provide
134	134	36 prescription drugs to individuals;
135	135	37 (2) administers a prescription drug benefit;
136	136	38 (3) processes or pays pharmacy claims;
137	137	39 (4) creates or updates prescription drug formularies;
138	138	40 (5) makes or assists in making prior authorization determinations
139	139	41 on prescription drugs;
140	140	42 (6) administers rebates on prescription drugs; or
141	141	2025 IN 1252—LS 7280/DI 141 4
142	142	1 (7) establishes a pharmacy network.
143	143	2 (b) The term does not include the following:
144	144	3 (1) A person licensed under IC 16.
145	145	4 (2) A health provider who is:
146	146	5 (A) described in IC 25-0.5-1; and
147	147	6 (B) licensed or registered under IC 25.
148	148	7 (3) A consultant who only provides advice concerning the
149	149	8 selection or performance of a pharmacy benefit manager.
150	150	9 SECTION 7. IC 27-1-24.5-20, AS AMENDED BY P.L.158-2024,
151	151	10 SECTION 8, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
152	152	11 JANUARY 1, 2026]: Sec. 20. (a) The commissioner shall do the
153	153	12 following:
154	154	13 (1) Prescribe an application for use in applying for a license to
155	155	14 operate as a pharmacy benefit manager.
156	156	15 (2) Adopt rules under IC 4-22-2 to establish the following:
157	157	16 (A) Pharmacy benefit manager licensing requirements.
158	158	17 (B) Licensing fees.
159	159	18 (C) A license application.
160	160	19 (D) Financial standards for pharmacy benefit managers.
161	161	20 (E) Reporting requirements described in sections 21 and 29 of
162	162	21 this chapter.
163	163	22 (F) The time frame for the resolution of an appeal under
164	164	23 section 22 of this chapter.
165	165	24 (b) The commissioner may do the following:
166	166	25 (1) Charge a license application fee and renewal fees established
167	167	26 under subsection (a)(2) in an amount not to exceed five hundred
168	168	27 dollars ($500) to be deposited in the department of insurance fund
169	169	28 established by IC 27-1-3-28.
170	170	29 (2) Examine or audit the books and records of a pharmacy benefit
171	171	30 manager one (1) time per year to determine if the pharmacy
172	172	31 benefit manager is in compliance with this chapter.
173	173	32 (3) Adopt rules under IC 4-22-2 to:
174	174	33 (A) implement this chapter; and
175	175	34 (B) specify requirements for the following:
176	176	35 (i) Prohibited market conduct practices.
177	177	36 (ii) Data reporting in connection with violations of state law.
178	178	37 (iii) Maximum allowable cost list compliance and
179	179	38 enforcement requirements, including the requirements of
180	180	39 sections 22 and 23 of this chapter.
181	181	40 (iv) Prohibitions and limits on pharmacy benefit manager
182	182	41 practices that require licensure under IC 25-22.5.
183	183	42 (v) Pharmacy benefit manager affiliate information sharing.
184	184	2025 IN 1252—LS 7280/DI 141 5
185	185	1 (vi) Lists of health plans administered by a pharmacy benefit
186	186	2 manager in Indiana.
187	187	3 (vii) Pharmacy benefit management services included
188	188	4 under section 11.5(4) of this chapter.
189	189	5 (c) Financial information and proprietary information submitted by
190	190	6 a pharmacy benefit manager to the department is confidential.
191	191	7 SECTION 8. IC 27-1-24.5-27.7 IS ADDED TO THE INDIANA
192	192	8 CODE AS A NEW SECTION TO READ AS FOLLOWS
193	193	9 [EFFECTIVE JANUARY 1, 2026]: Sec. 27.7. (a) This section applies
194	194	10 to a health plan that is issued, delivered, amended, or renewed
195	195	11 after December 31, 2025.
196	196	12 (b) A pharmacy benefit manager shall apply the annual
197	197	13 limitation on cost sharing set forth in the federal Patient Protection
198	198	14 and Affordable Care Act under 42 U.S.C. 18022(c)(1) to all health
199	199	15 care services covered under a health plan administered by the
200	200	16 pharmacy benefit manager.
201	201	17 (c) Except as provided in subsection (d), when calculating a
202	202	18 covered individual's contribution to an applicable cost sharing
203	203	19 requirement, a pharmacy benefit manager must include any cost
204	204	20 sharing amounts paid:
205	205	21 (1) by the covered individual; or
206	206	22 (2) on behalf of the covered individual by another person.
207	207	23 (d) If application of subsection (c) would result in a covered
208	208	24 individual becoming ineligible for a health savings account under
209	209	25 Section 223 of the Internal Revenue Code, the requirement under
210	210	26 subsection (c) applies with respect to the deductible of a high
211	211	27 deductible health plan after the covered individual satisfies the
212	212	28 minimum deductible under Section 223 of the Internal Revenue
213	213	29 Code. However, subsection (c) applies to items or services that are
214	214	30 preventative care under Section 223(c)(2)(C) of the Internal
215	215	31 Revenue Code regardless of whether the minimum deductible
216	216	32 under Section 223 of the Internal Revenue Code is satisfied.
217	217	33 (e) A pharmacy benefit manager may not directly or indirectly:
218	218	34 (1) set;
219	219	35 (2) alter;
220	220	36 (3) implement; or
221	221	37 (4) condition;
222	222	38 the terms of health plan coverage, including the benefit design,
223	223	39 based in part or entirely on information about the availability or
224	224	40 amount of financial or product assistance available for a
225	225	41 prescription drug.
226	226	42 SECTION 9. IC 27-1-51 IS ADDED TO THE INDIANA CODE AS
227	227	2025 IN 1252—LS 7280/DI 141 6
228	228	1 A NEW CHAPTER TO READ AS FOLLOWS [EFFECTIVE
229	229	2 JANUARY 1, 2026]:
230	230	3 Chapter 51. Cost Sharing for Health Insurance Coverage
231	231	4 Sec. 1. This chapter applies to a policy of health insurance
232	232	5 coverage that is issued, delivered, amended, or renewed after
233	233	6 December 31, 2025.
234	234	7 Sec. 2. As used in this chapter, "administrator" means a person
235	235	8 who, directly or indirectly and on behalf of an insurer:
236	236	9 (1) underwrites;
237	237	10 (2) collects charges or premiums from or adjusts or settles
238	238	11 claims on:
239	239	12 (A) residents of Indiana; or
240	240	13 (B) residents of another state from offices in Indiana;
241	241	14 in connection with health insurance coverage offered or provided
242	242	15 by an insurer.
243	243	16 Sec. 3. As used in this chapter, "cost sharing" means any
244	244	17 copayment, coinsurance, deductible, or other similar charge that
245	245	18 is:
246	246	19 (1) required of a covered individual for a health care service
247	247	20 covered by a policy of health insurance coverage, including a
248	248	21 prescription drug; and
249	249	22 (2) paid:
250	250	23 (A) by; or
251	251	24 (B) on behalf of;
252	252	25 the covered individual.
253	253	26 Sec. 4. As used in this chapter, "covered individual" means an
254	254	27 individual who is entitled to health insurance coverage.
255	255	28 Sec. 5. As used in this chapter, "health care service" means a
256	256	29 service or good furnished for the purpose of preventing,
257	257	30 alleviating, curing, or healing:
258	258	31 (1) human illness;
259	259	32 (2) physical disability; or
260	260	33 (3) injury.
261	261	34 Sec. 6. (a) As used in this chapter, "health insurance coverage"
262	262	35 means:
263	263	36 (1) an individual or group policy of accident and sickness
264	264	37 insurance (as defined in IC 27-8-5-1);
265	265	38 (2) an individual contract (as defined in IC 27-13-1-21) or a
266	266	39 group contract (as defined in IC 27-13-1-16) that provides
267	267	40 coverage for basic health care services (as defined in
268	268	41 IC 27-13-1-4); and
269	269	42 (3) any other health plan that is issued on an individual or
270	270	2025 IN 1252—LS 7280/DI 141 7
271	271	1 group basis;
272	272	2 that is subject to state law and rules regulating insurance or
273	273	3 subject to the jurisdiction of the department. The term includes
274	274	4 coverage of a dependent of the covered individual under a policy
275	275	5 or contract described in subdivisions (1) through (3).
276	276	6 (b) The term does not include a self-funded health benefit plan
277	277	7 that complies with the federal Employee Retirement Income
278	278	8 Security Act (ERISA) of 1974 (29 U.S.C. 1001 et seq.).
279	279	9 Sec. 7. As used in this chapter, "insurer" means an insurer that
280	280	10 provides health insurance coverage to a covered individual.
281	281	11 Sec. 8. As used in this chapter, "person" means a natural
282	282	12 person, corporation, mutual company, unincorporated association,
283	283	13 partnership, joint venture, limited liability company, trust, estate,
284	284	14 foundation, not-for-profit corporation, unincorporated
285	285	15 organization, government, or governmental subdivision or agency.
286	286	16 Sec. 9. An insurer and an administrator shall apply the annual
287	287	17 limitation on cost sharing set forth in the federal Patient Protection
288	288	18 and Affordable Care Act under 42 U.S.C. 18022(c)(1) to all health
289	289	19 care services covered under a policy or contract of health
290	290	20 insurance coverage offered or issued by the insurer.
291	291	21 Sec. 10. (a) Except as provided in subsection (b), when
292	292	22 calculating a covered individual's contribution to an applicable
293	293	23 cost sharing requirement, an insurer and administrator must
294	294	24 include any cost sharing amounts paid:
295	295	25 (1) by the covered individual; and
296	296	26 (2) on behalf of the covered individual by another person.
297	297	27 (b) If application of subsection (a) would result in a covered
298	298	28 individual becoming ineligible for a health savings account under
299	299	29 Section 223 of the Internal Revenue Code, the requirement under
300	300	30 subsection (a) applies with respect to the deductible of a high
301	301	31 deductible health plan after the covered individual satisfies the
302	302	32 minimum deductible under Section 223 of the Internal Revenue
303	303	33 Code. However, subsection (a) applies to items or services that are
304	304	34 preventative care under Section 223(c)(2)(C) of the Internal
305	305	35 Revenue Code regardless of whether the minimum deductible
306	306	36 under Section 223 of the Internal Revenue Code is satisfied.
307	307	37 Sec. 11. An insurer and an administrator may not directly or
308	308	38 indirectly:
309	309	39 (1) set;
310	310	40 (2) alter;
311	311	41 (3) implement; or
312	312	42 (4) condition;
313	313	2025 IN 1252—LS 7280/DI 141 8
314	314	1 the terms of health insurance coverage, including the benefit
315	315	2 design, based in part or entirely on information about the
316	316	3 availability or amount of financial or product assistance available
317	317	4 for a prescription drug.
318	318	5 Sec. 12. Before December 31 of each year, each insurer and
319	319	6 administrator shall certify to the commissioner that the insurer or
320	320	7 administrator has fully and completely complied with the
321	321	8 requirements of this chapter during the previous calendar year.
322	322	9 The certification must be signed by the chief executive officer or
323	323	10 chief financial officer of the insurer or administrator.
324	324	11 Sec. 13. The commissioner may adopt rules under IC 4-22-2 to
325	325	12 implement this chapter.
326	326	2025 IN 1252—LS 7280/DI 141