Massachusetts 2023-2024 Regular Session

Massachusetts House Bill H1131 Compare Versions

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

Old	New	Differences
1	1	1 of 1
2	2	HOUSE DOCKET, NO. 1778 FILED ON: 1/18/2023
3	3	HOUSE . . . . . . . . . . . . . . . No. 1131
4	4	The Commonwealth of Massachusetts
5	5	_________________
6	6	PRESENTED BY:
7	7	Jeffrey N. Roy
8	8	_________________
9	9	To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General
10	10	Court assembled:
11	11	The undersigned legislators and/or citizens respectfully petition for the adoption of the accompanying bill:
12	12	An Act relating to patient cost, benefit and coverage information, choice, and price transparency.
13	13	_______________
14	14	PETITION OF:
15	15	NAME:DISTRICT/ADDRESS :DATE ADDED:Jeffrey N. Roy10th Norfolk1/12/2023 1 of 6
16	16	HOUSE DOCKET, NO. 1778 FILED ON: 1/18/2023
17	17	HOUSE . . . . . . . . . . . . . . . No. 1131
18	18	By Representative Roy of Franklin, a petition (accompanied by bill, House, No. 1131) of Jeffrey
19	19	N. Roy relative to patient cost, benefit, and coverage information, choice, and price transparency.
20	20	Financial Services.
21	21	The Commonwealth of Massachusetts
22	22	_______________
23	23	In the One Hundred and Ninety-Third General Court
24	24	(2023-2024)
25	25	_______________
26	26	An Act relating to patient cost, benefit and coverage information, choice, and price transparency.
27	27	Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
28	28	of the same, as follows:
29	29	1 SECTION 1. Chapter 94C of the General Laws, is hereby amended by inserting after
30	30	2section 21C the following new section:-
31	31	3 Section 21D
32	32	4 (a)for the purposes of this section, the following terms shall have the following
33	33	5meanings unless the context clearly requires otherwise:
34	34	6 “Cost-sharing information”, the amount an enrollee is required to pay in order to receive
35	35	7a drug that is covered under the enrollee’s health plan.
36	36	8 “Enrollee” a person who is receiving a health care benefit and assumes financial
37	37	9responsibility for outstanding costs associated with a prescription drug to treat a health condition
38	38	10for themself or a dependent member of their household. 2 of 6
39	39	11 ''Health care benefit'', a full or partial payment for health care services or the right under a
40	40	12contract or a certificate or policy of insurance to have a full or partial payment made by a health
41	41	13plan, as defined in this section, for a specified health care service.
42	42	14 “Health plan” any insurance company authorized to provide health insurance in this state
43	43	15or any legal entity which is self-insured and providing health care benefits to its employees.
44	44	16 “Interoperability element”, hardware, software, integrated technologies or related
45	45	17licenses, technical information, privileges, rights, intellectual property, upgrades, or services that
46	46	18may be necessary to provide the data set forth in subsection (b)(3) in the requested format and
47	47	19consistent with subsection(b)(1).
48	48	20 “Patient” the enrollee or dependent family member of the enrollee who is treated by a
49	49	21prescribing physician.
50	50	22 “Personal Representative” a person, who has been identified by the enrollee or by the
51	51	23commonwealth on behalf of the enrollee, to assist with decision making during their medical
52	52	24appointment, such as: a child accompanying an elderly parent, a healthcare proxy, a parent of a
53	53	25minor child, or a spouse.
54	54	26 “Pharmacy benefit manager” (a) For the purposes of this section, the term ''pharmacy
55	55	27benefit manager'' shall mean any person or entity that administers the (i) prescription drug,
56	56	28prescription device or pharmacist services or (ii) prescription drug and device and pharmacist
57	57	29services portion of a health benefit plan on behalf of plan sponsors, including, but not limited to,
58	58	30self-insured employers, insurance companies and labor unions. A health benefit plan that does
59	59	31not contract with a pharmacy benefit manager shall be considered a pharmacy benefit manager
60	60	32for the purposes of this section, unless specifically exempted. 3 of 6
61	61	33 “Prescribing practitioner” a physician, nurse practitioner, or physician’s assistant who
62	62	34writes a prescription for a patient during the course of care for a medical condition.
63	63	35 (b)any health plan or pharmacy benefit manager shall, upon request of the patient,
64	64	36enrollee, their prescribing practitioner, or their personal representative, furnish the cost, benefit,
65	65	37and coverage data set forth in subsection (3) to the enrollee, their prescribing practitioner, or
66	66	38their personal representative and shall ensure that such cost, benefit, and coverage data is (i)
67	67	39current as of one business day after any change is made; (ii) provided in real time; and (iii) in the
68	68	40same format that the request is made by the enrollee or their prescribing practitioner.
69	69	41 (1)the format of the request shall use established industry content and transport
70	70	42standards published by:
71	71	43 (i)a standards developing organization accredited by the American National
72	72	44Standards Institute, included but not limited to, the National Council for Prescription Drug
73	73	45Programs, ASC X12, Health Level 7; or
74	74	46 (ii)a relevant federal or state agency or government body, included but not limited to
75	75	47the Center for Medicare & Medicaid Services or the Office of the National Coordinator for
76	76	48Health Information Technology, The Commonwealth of Massachusetts Department of Public
77	77	49Health, Division of Insurance, Health Policy Commission, or Center for Health Information and
78	78	50Analysis.
79	79	51 (2)a facsimile, proprietary payor or patient portal, or other electronic form other than
80	80	52as required by section (b) shall not be considered acceptable electronic formats pursuant to this
81	81	53section. 4 of 6
82	82	54 (3)upon such request, the following data shall be provided for any prescription drug
83	83	55covered under the enrollee’s health plan:
84	84	56 (i)the patient’s current eligibility information for such prescription drug;
85	85	57 (ii)a list of any clinically-appropriate alternatives to such prescription drug covered
86	86	58under the enrollee’s current health plan:
87	87	59 (iii)cost-sharing information for such prescription drug and such clinically-
88	88	60appropriate alternatives, including a description of any variance in cost-sharing based on
89	89	61pharmacy, whether retail or mail order, or health care provider dispensing or administering such
90	90	62prescription drug or such alternatives;
91	91	63 (iv)any applicable utilization management requirements for such prescription drug or
92	92	64such clinically-appropriate alternatives, including prior authorization, step therapy, quantity
93	93	65limits, and site-of-service restrictions
94	94	66 (4)any health plan or pharmacy benefit manager shall furnish the data set forth in
95	95	67subsection (b)(3), whether the request is made using the prescription drug’s unique billing code,
96	96	68such as a National Drug Code or Healthcare Common Procedure Coding System code or
97	97	69descriptive term, such as the brand or generic name of the prescription drug.
98	98	70 (i)a health plan or pharmacy benefit manager shall not deny or delay a request as a
99	99	71method of blocking the data set forth in subsection (b)(3) from being shared based on how the
100	100	72drug was requested.
101	101	73 (c)any health plan or pharmacy benefit manager furnishing the data set forth in
102	102	74subsection (b)(3), shall not: 5 of 6
103	103	75 (1)restrict, prohibit, or otherwise hinder, in any way, a prescribing practitioner or
104	104	76health care professional from communicating or sharing:
105	105	77 (i)any of the data set forth in subsection (b)(3);
106	106	78 (ii)additional information on any lower-cost or clinically-appropriate alternatives,
107	107	79whether or not they are covered under the enrollee’s plan; or
108	108	80 (iii)additional payment or cost-sharing information that may reduce the patient’s out-
109	109	81of-pocket costs, such as cash price or patient assistance and support programs whether sponsored
110	110	82by a manufacturer, foundation, or other entity;
111	111	83 (2)except as may be required by law, interfere with, prevent, or materially
112	112	84discourage access, exchange, or use of the data set forth in subsection (b)(3), which may include
113	113	85charging fees, not responding to a request at the time made where such a response is reasonably
114	114	86possible, implementing technology in nonstandard ways or instituting enrollee consent
115	115	87requirements, processes, policies, procedures, or renewals that are likely to substantially increase
116	116	88the complexity or burden of accessing, exchanging, or using such data; nor
117	117	89 (3)penalize a prescribing practitioner or professional for disclosing such information
118	118	90to an enrollee or their personal representative, or for prescribing, administering, or ordering a
119	119	91clinically appropriate or lower-cost alternative.
120	120	92 (4)any health plan or pharmacy benefit manager shall treat an enrollee’s identified
121	121	93personal representative as the enrollee for purposes of this section.
122	122	94 (5)if under applicable law a person has authority to act on behalf of an enrollee in
123	123	95making decisions related to health care, a health plan or pharmacy benefit manager, or its 6 of 6
124	124	96affiliates or entities acting on its behalf, must treat such person as a personal representative under
125	125	97this section.
126	126	98 (d)reimbursement for fees imposed for data access pursuant to this section may be
127	127	99negotiated and contracted between a health plan or pharmacy benefit manager and a prescribing
128	128	100provider upon mutual agreement