Massachusetts 2023-2024 Regular Session

Massachusetts House Bill H999 Compare Versions

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

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1	1	1 of 1
2	2	HOUSE DOCKET, NO. 404 FILED ON: 1/12/2023
3	3	HOUSE . . . . . . . . . . . . . . . No. 999
4	4	The Commonwealth of Massachusetts
5	5	_________________
6	6	PRESENTED BY:
7	7	William J. Driscoll, Jr.
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 empowering health care consumers.
13	13	_______________
14	14	PETITION OF:
15	15	NAME:DISTRICT/ADDRESS :DATE ADDED:William J. Driscoll, Jr.7th Norfolk1/12/2023Lindsay N. Sabadosa1st Hampshire1/26/2023Joanne M. ComerfordHampshire, Franklin and Worcester1/26/2023Paul J. Donato35th Middlesex1/27/2023Jack Patrick Lewis7th Middlesex1/30/2023Michael P. Kushmerek3rd Worcester2/1/2023Michael D. BradySecond Plymouth and Norfolk2/10/2023Patrick Joseph Kearney4th Plymouth2/10/2023David M. Rogers24th Middlesex2/10/2023Patrick M. O'ConnorFirst Plymouth and Norfolk2/17/2023Denise C. Garlick13th Norfolk2/17/2023 1 of 13
16	16	HOUSE DOCKET, NO. 404 FILED ON: 1/12/2023
17	17	HOUSE . . . . . . . . . . . . . . . No. 999
18	18	By Representative Driscoll of Milton, a petition (accompanied by bill, House, No. 999) of
19	19	William J. Driscoll, Jr. and others relative to empowering health care consumers by further
20	20	regulating policies, contracts, agreements, plans or certificates of insurance. 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 empowering health care consumers.
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 175 of the General Laws is hereby amended by inserting after
30	30	2section 47II the following section:-
31	31	3 Section 47JJ.
32	32	4 (a) Any policy, contract, agreement, plan or certificate of insurance issued, delivered or
33	33	5renewed within the Commonwealth on or after January 1, 2018, shall:
34	34	6 (1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding
35	35	7whether the plan uses a formulary. The notice shall include an explanation of what a formulary
36	36	8is, how the plan determines which prescription drugs are included or excluded, and how often the
37	37	9plan reviews the contents of the formulary. 2 of 13
38	38	10 (2) Post the formulary or formularies for each product offered by the plan on the plan’s
39	39	11internet web site in a manner that is accessible and searchable by potential enrollees, enrollees,
40	40	12and providers.
41	41	13 (3) Update the formularies posted pursuant to paragraph (2) with any change to those
42	42	14formularies within 72 hours after making the change.
43	43	15 (4) Use a standard template developed pursuant to subsection (b) to display the formulary
44	44	16or formularies for each product offered by the plan.
45	45	17 (5) Include all of the following on any published formulary for any product offered by the
46	46	18plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):
47	47	19 (i) Any prior authorization, step therapy requirements, or utilization management
48	48	20requirements for each specific drug included on the formulary.
49	49	21 (ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on
50	50	22the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier
51	51	23in the evidence of coverage.
52	52	24 (iii) For prescription drugs covered under the plans medical benefit and typically
53	53	25administered by a provider, plans must disclose to enrollees and potential enrollees, all covered
54	54	26drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the
55	55	27consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that
56	56	28is staffed at least during normal business hours.
57	57	29 (iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is
58	58	30subject to a coinsurance and dispensed at an in-network pharmacy the plan must: 3 of 13
59	59	31 (A) disclose the dollar amount of the enrollee’s cost-sharing, or
60	60	32 (B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of
61	61	33each specific drug included on the formulary, as follows:
62	62	34 Under $100 – $.
63	63	35 $100-$250 – $$.
64	64	36 $251-$500 – $$$.
65	65	37 $500-$1,000 – $$$$.
66	66	38 Over $1,000 -- $$$$$
67	67	39 (v) If the carrier allows the option for mail order pharmacy, the carrier separately must
68	68	40list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug
69	69	41through a mail order facility utilizing the same ranges as provided in subclause (B).
70	70	42 (vi) A description of how medications will specifically be included in or excluded from
71	71	43the deductible, including a description of out-of-pocket costs that may not apply to the deductible
72	72	44for a medication.
73	73	45 (b) The Division of Insurance shall develop a standard formulary template which a health
74	74	46care service plan shall use to comply with paragraph (4).
75	75	47 SECTION 2. Chapter 176A of the General Laws is hereby amended by inserting after
76	76	48section 8KK the following section:-
77	77	49 Section 8LL. 4 of 13
78	78	50 (a) Any contract between a subscriber and the corporation under an individual or group
79	79	51hospital service plan delivered or issued or renewed within the commonwealth on or after
80	80	52January 1, 2018, shall:
81	81	53 (1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding
82	82	54whether the plan uses a formulary. The notice shall include an explanation of what a formulary
83	83	55is, how the plan determines which prescription drugs are included or excluded, and how often the
84	84	56plan reviews the contents of the formulary.
85	85	57 (2) Post the formulary or formularies for each product offered by the plan on the plan’s
86	86	58internet web site in a manner that is accessible and searchable by potential enrollees, enrollees,
87	87	59and providers.
88	88	60 (3) Update the formularies posted pursuant to paragraph (2) with any change to those
89	89	61formularies within 72 hours after making the change.
90	90	62 (4) Use a standard template developed pursuant to subsection (b) to display the formulary
91	91	63or formularies for each product offered by the plan.
92	92	64 (5) Include all of the following on any published formulary for any product offered by the
93	93	65plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):
94	94	66 (i) Any prior authorization, step therapy requirements, or utilization management
95	95	67requirements for each specific drug included on the formulary.
96	96	68 (ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on
97	97	69the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier
98	98	70in the evidence of coverage. 5 of 13
99	99	71 (iii) For prescription drugs covered under the plans medical benefit and typically
100	100	72administered by a provider, plans must disclose to enrollees and potential enrollees, all covered
101	101	73drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the
102	102	74consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that
103	103	75is staffed at least during normal business hours.
104	104	76 (iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is
105	105	77subject to a coinsurance and dispensed at an in-network pharmacy the plan must:
106	106	78 (A) disclose the dollar amount of the enrollee’s cost-sharing, or
107	107	79 (B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of
108	108	80each specific drug included on the formulary, as follows:
109	109	81 Under $100 – $.
110	110	82 $100-$250 – $$.
111	111	83 $251-$500 – $$$.
112	112	84 $500-$1,000 – $$$$.
113	113	85 Over $1,000 -- $$$$$
114	114	86 (v) If the carrier allows the option for mail order pharmacy, the carrier separately must
115	115	87list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug
116	116	88through a mail order facility utilizing the same ranges as provided in subclause (B). 6 of 13
117	117	89 (vi) A description of how medications will specifically be included in or excluded from
118	118	90the deductible, including a description of out-of-pocket costs that may not apply to the deductible
119	119	91for a medication.
120	120	92 (b) The Division of Insurance shall develop a standard formulary template which a health
121	121	93care service plan shall use to comply with paragraph (4).
122	122	94 SECTION 3. Chapter 176B of the General Laws is hereby amended by inserting after
123	123	95section 4KK the following section:-
124	124	96 Section 4LL.
125	125	97 (a) Any subscription certificate under an individual or group medical service agreement
126	126	98delivered, issued or renewed within the commonwealth on or after January 1, 2018, shall:
127	127	99 (1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding
128	128	100whether the plan uses a formulary. The notice shall include an explanation of what a formulary
129	129	101is, how the plan determines which prescription drugs are included or excluded, and how often the
130	130	102plan reviews the contents of the formulary.
131	131	103 (2) Post the formulary or formularies for each product offered by the plan on the plan’s
132	132	104internet web site in a manner that is accessible and searchable by potential enrollees, enrollees,
133	133	105and providers.
134	134	106 (3) Update the formularies posted pursuant to paragraph (2) with any change to those
135	135	107formularies within 72 hours after making the change.
136	136	108 (4) Use a standard template developed pursuant to subsection (b) to display the formulary
137	137	109or formularies for each product offered by the plan. 7 of 13
138	138	110 (5) Include all of the following on any published formulary for any product offered by the
139	139	111plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):
140	140	112 (i) Any prior authorization, step therapy requirements, or utilization management
141	141	113requirements for each specific drug included on the formulary.
142	142	114 (ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on
143	143	115the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier
144	144	116in the evidence of coverage.
145	145	117 (iii) For prescription drugs covered under the plans medical benefit and typically
146	146	118administered by a provider, plans must disclose to enrollees and potential enrollees, all covered
147	147	119drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the
148	148	120consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that
149	149	121is staffed at least during normal business hours.
150	150	122 (iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is
151	151	123subject to a coinsurance and dispensed at an in-network pharmacy the plan must:
152	152	124 (A) disclose the dollar amount of the enrollee’s cost-sharing, or
153	153	125 (B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of
154	154	126each specific drug included on the formulary, as follows:
155	155	127 Under $100 – $.
156	156	128 $100-$250 – $$.
157	157	129 $251-$500 – $$$. 8 of 13
158	158	130 $500-$1,000 – $$$$.
159	159	131 Over $1,000 -- $$$$$
160	160	132 (v) If the carrier allows the option for mail order pharmacy, the carrier separately must
161	161	133list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug
162	162	134through a mail order facility utilizing the same ranges as provided in subclause (B).
163	163	135 (vi) A description of how medications will specifically be included in or excluded from
164	164	136the deductible, including a description of out-of-pocket costs that may not apply to the deductible
165	165	137for a medication.
166	166	138 (b) The Division of Insurance shall develop a standard formulary template which a health
167	167	139care service plan shall use to comply with paragraph (4).
168	168	140 SECTION 4. Chapter 176G of the General Laws is hereby amended by inserting after
169	169	141section 4CC the following section:-
170	170	142 Section 4DD.
171	171	143 (a) Any individual or group health maintenance contract issued on or after January 1,
172	172	1442018, shall:
173	173	145 (1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding
174	174	146whether the plan uses a formulary. The notice shall include an explanation of what a formulary
175	175	147is, how the plan determines which prescription drugs are included or excluded, and how often the
176	176	148plan reviews the contents of the formulary. 9 of 13
177	177	149 (2) Post the formulary or formularies for each product offered by the plan on the plan’s
178	178	150internet web site in a manner that is accessible and searchable by potential enrollees, enrollees,
179	179	151and providers.
180	180	152 (3) Update the formularies posted pursuant to paragraph (2) with any change to those
181	181	153formularies within 72 hours after making the change.
182	182	154 (4) Use a standard template developed pursuant to subsection (b) to display the formulary
183	183	155or formularies for each product offered by the plan.
184	184	156 (5) Include all of the following on any published formulary for any product offered by the
185	185	157plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):
186	186	158 (i) Any prior authorization, step therapy requirements, or utilization management
187	187	159requirements for each specific drug included on the formulary.
188	188	160 (ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on
189	189	161the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier
190	190	162in the evidence of coverage.
191	191	163 (iii) For prescription drugs covered under the plans medical benefit and typically
192	192	164administered by a provider, plans must disclose to enrollees and potential enrollees, all covered
193	193	165drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the
194	194	166consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that
195	195	167is staffed at least during normal business hours.
196	196	168 (iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is
197	197	169subject to a coinsurance and dispensed at an in-network pharmacy the plan must: 10 of 13
198	198	170 (A) disclose the dollar amount of the enrollee’s cost-sharing, or
199	199	171 (B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of
200	200	172each specific drug included on the formulary, as follows:
201	201	173 Under $100 – $.
202	202	174 $100-$250 – $$.
203	203	175 $251-$500 – $$$.
204	204	176 $500-$1,000 – $$$$.
205	205	177 Over $1,000 -- $$$$$
206	206	178 (v) If the carrier allows the option for mail order pharmacy, the carrier separately must
207	207	179list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug
208	208	180through a mail order facility utilizing the same ranges as provided in subclause (B).
209	209	181 (vi) A description of how medications will specifically be included in or excluded from
210	210	182the deductible, including a description of out-of-pocket costs that may not apply to the deductible
211	211	183for a medication.
212	212	184 (b) The Division of Insurance shall develop a standard formulary template which a health
213	213	185care service plan shall use to comply with paragraph (4).
214	214	186 SECTION 5. Chapter 32A of the General Laws is hereby amended by inserting after
215	215	187section 27 the following section:-
216	216	188 Section 28. 11 of 13
217	217	189 (a) Any coverage offered by the commission to any active or retired employee of the
218	218	190commonwealth who is insured under the group insurance commission on or after January 1,
219	219	1912018, shall:
220	220	192 (1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding
221	221	193whether the plan uses a formulary. The notice shall include an explanation of what a formulary
222	222	194is, how the plan determines which prescription drugs are included or excluded, and how often the
223	223	195plan reviews the contents of the formulary.
224	224	196 (2) Post the formulary or formularies for each product offered by the plan on the plan’s
225	225	197internet web site in a manner that is accessible and searchable by potential enrollees, enrollees,
226	226	198and providers.
227	227	199 (3) Update the formularies posted pursuant to paragraph (2) with any change to those
228	228	200formularies within 72 hours after making the change.
229	229	201 (4) Use a standard template developed pursuant to subsection (b) to display the formulary
230	230	202or formularies for each product offered by the plan.
231	231	203 (5) Include all of the following on any published formulary for any product offered by the
232	232	204plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):
233	233	205 (i) Any prior authorization, step therapy requirements, or utilization management
234	234	206requirements for each specific drug included on the formulary.
235	235	207 (ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on
236	236	208the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier
237	237	209in the evidence of coverage. 12 of 13
238	238	210 (iii) For prescription drugs covered under the plans medical benefit and typically
239	239	211administered by a provider, plans must disclose to enrollees and potential enrollees, all covered
240	240	212drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the
241	241	213consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that
242	242	214is staffed at least during normal business hours.
243	243	215 (iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is
244	244	216subject to a coinsurance and dispensed at an in-network pharmacy the plan must:
245	245	217 (A) disclose the dollar amount of the enrollee’s cost-sharing, or
246	246	218 (B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of
247	247	219each specific drug included on the formulary, as follows:
248	248	220 Under $100 – $.
249	249	221 $100-$250 – $$.
250	250	222 $251-$500 – $$$.
251	251	223 $500-$1,000 – $$$$.
252	252	224 Over $1,000 -- $$$$$
253	253	225 (v) If the carrier allows the option for mail order pharmacy, the carrier separately must
254	254	226list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug
255	255	227through a mail order facility utilizing the same ranges as provided in subclause (B). 13 of 13
256	256	228 (vi) A description of how medications will specifically be included in or excluded from
257	257	229the deductible, including a description of out-of-pocket costs that may not apply to the deductible
258	258	230for a medication.
259	259	231 (b) The Division of Insurance shall develop a standard formulary template which a health
260	260	232care service plan shall use to comply with paragraph (4).