Massachusetts 2023-2024 Regular Session

Massachusetts Senate Bill S2637 Compare Versions

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

Old	New	Differences
1	1	SENATE . . . . . . . . . . . . . . No. 2637
2	2	The Commonwealth of Massachusetts
3	3	_______________
4	4	In the One Hundred and Ninety-Third General Court
5	5	(2023-2024)
6	6	_______________
7	7	SENATE, March 14, 2024.
8	8	The committee on Financial Services to whom was referred the petition (accompanied by
9	9	bill, Senate, No. 616) of Julian Cyr for legislation relative to patient cost, benefit and coverage
10	10	information, choice, and price transparency, report the accompanying bill (Senate, No. 2637).
11	11	For the committee,
12	12	Paul R. Feeney 1 of 6
13	13	FILED ON: 2/7/2024
14	14	SENATE . . . . . . . . . . . . . . No. 2637
15	15	The Commonwealth of Massachusetts
16	16	_______________
17	17	In the One Hundred and Ninety-Third General Court
18	18	(2023-2024)
19	19	_______________
20	20	An Act relating to patient cost, benefit and coverage information, choice, and price transparency.
21	21	Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
22	22	of the same, as follows:
23	23	1 SECTION 1. Chapter 94C of the General Laws, is hereby amended by inserting after
24	24	2section 21C the following new section:-
25	25	3 Section 21D (a) For the purposes of this section, the following terms shall have the
26	26	4following meanings unless the context clearly requires otherwise:
27	27	5 “Cost-sharing information”, the amount an enrollee is required to pay in order to receive
28	28	6a drug that is covered under the enrollee’s health plan.
29	29	7 “Enrollee” a person who is receiving a health care benefit and assumes financial
30	30	8responsibility for outstanding costs associated with a prescription drug to treat a health condition
31	31	9for themself or a dependent member of their household.
32	32	10 ''Health care benefit'', a full or partial payment for health care services or the right under a
33	33	11contract or a certificate or policy of insurance to have a full or partial payment made by a health
34	34	12plan, as defined in this section, for a specified health care service. 2 of 6
35	35	13 “Health plan” any individual, general, blanket, or group policy of health, accident or
36	36	14sickness insurance issued by an insurer licensed under chapter one hundred and seventy-five or
37	37	15the laws of any other jurisdiction, as defined by Section 1 of Chapter 176M of the Massachusetts
38	38	16General Laws.
39	39	17 “Interoperability element”, hardware, software, integrated technologies or related
40	40	18licenses, technical information, privileges, rights, intellectual property, upgrades, or services that
41	41	19may be necessary to provide the data set forth in subsection (b)(3) in the requested format and
42	42	20consistent with subsection(b)(1).
43	43	21 “Patient” the enrollee or dependent family member of the enrollee who is treated by a
44	44	22prescribing physician.
45	45	23 “Personal Representative” a person, who has been identified and authorized as a third-
46	46	24party representative by the enrollee or by the commonwealth on behalf of the enrollee, to assist
47	47	25with decision making during their medical appointment, such as: a child accompanying an
48	48	26elderly parent, a healthcare proxy, a parent of a minor child, or a spouse.
49	49	27 “Pharmacy benefit manager” (a) For the purposes of this section, the term ''pharmacy
50	50	28benefit manager'' shall mean any person or entity that administers the (i) prescription drug,
51	51	29prescription device or pharmacist services or (ii) prescription drug and device and pharmacist
52	52	30services portion of a health benefit plan on behalf of plan sponsors, including, but not limited to,
53	53	31self-insured employers, insurance companies and labor unions. A health benefit plan that does
54	54	32not contract with a pharmacy benefit manager shall be considered a pharmacy benefit manager
55	55	33for the purposes of this section, unless specifically exempted. 3 of 6
56	56	34 “Prescribing practitioner” a physician, nurse practitioner, or physician’s assistant who
57	57	35writes a prescription for a patient during the course of care for a medical condition.
58	58	36 (b) Any health plan or pharmacy benefit manager shall, upon request of the patient,
59	59	37enrollee, their prescribing practitioner, or their personal representative, furnish the cost, benefit,
60	60	38and coverage data set forth in subsection (3) to the enrollee, their prescribing practitioner, or
61	61	39their personal representative and shall ensure that such cost, benefit, and coverage data is (i)
62	62	40current as of one business day after any change is made; (ii) provided in real time to the provider
63	63	41in a clinical setting; and (iii) in the same format that the request is made by the enrollee or their
64	64	42prescribing practitioner.
65	65	43 (1) The format of the request shall use established industry content and transport
66	66	44standards published by:
67	67	45 (i) a standards developing organization accredited by the American National Standards
68	68	46Institute, included but not limited to, the National Council for Prescription Drug Programs, ASC
69	69	47X12, Health Level 7; or
70	70	48 (ii) a relevant federal or state agency or government body, included but not limited to the
71	71	49Center for Medicare & Medicaid Services or the Office of the National Coordinator for Health
72	72	50Information technology, The Commonwealth of Massachusetts Department of Public Health,
73	73	51Division of Insurance, Health Policy Commission, or Center for Health Information and
74	74	52Analysis.
75	75	53 (2) The following shall not be considered acceptable electronic formats pursuant to this
76	76	54section: 4 of 6
77	77	55 (i) a facsimile;
78	78	56 (ii) a proprietary payor or patient portal, unless it satisfies all of the requirements of
79	79	57section
80	80	58 (3) Upon such request, the following data shall be provided for any prescription drug
81	81	59covered under the enrollee’s health plan:
82	82	60 (i) the patient’s current eligibility information for such prescription drug;
83	83	61 (ii) a list of any clinically-appropriate alternatives to such prescription drug covered
84	84	62under the enrollee’s current health plan;
85	85	63 (iii) cost-sharing information for such prescription drug and such clinically-appropriate
86	86	64alternatives, including a description of any variance in cost-sharing based on pharmacy, whether
87	87	65retail or mail order, or health care provider dispensing or administering such prescription drug or
88	88	66such alternatives;
89	89	67 (iv) any applicable utilization management requirements for such prescription drug or
90	90	68such clinically-appropriate alternatives, including prior authorization, step therapy, quantity
91	91	69limits, and site-of-service restrictions
92	92	70 (4) Any health plan or pharmacy benefit manager shall furnish the data set forth in
93	93	71subsection (b)(3), whether the request is made using the prescription drug’s unique billing code,
94	94	72such as a National Drug Code or Healthcare Common Procedure Coding System code or
95	95	73descriptive term, such as the brand or generic name of the prescription drug. 5 of 6
96	96	74 (i) A health plan or pharmacy benefit manager shall not deny or delay a request as a
97	97	75method of blocking the data set forth in subsection (b)(3) from being shared based on how the
98	98	76drug was requested.
99	99	77 (c) Unless expressly prohibited by federal HIPAA law, any health plan or pharmacy
100	100	78benefit manager furnishing the data set forth in subsection (b)(3), shall not:
101	101	79 (1) restrict, prohibit, or otherwise hinder, in any way, a prescribing practitioner or health
102	102	80care professional from communicating or sharing:
103	103	81 (i) any of the data set forth in subsection (b)(3);
104	104	82 (ii) additional information on any lower-cost or clinically-appropriate alternatives,
105	105	83whether or not they are covered under the enrollee’s plan; or
106	106	84 (iii) additional payment or cost-sharing information that may reduce the patient’s out-of-
107	107	85pocket costs, such as cash price or patient assistance and support programs whether sponsored by
108	108	86a manufacturer, foundation, or other entity;
109	109	87 (2) Except as may be required by law, interfere with, prevent, or materially discourage
110	110	88access, exchange, or use of the data set forth in subsection (b)(3), which may include charging
111	111	89fees, not responding to a request at the time made where such a response is reasonably possible,
112	112	90implementing technology in nonstandard ways or instituting enrollee consent requirements,
113	113	91processes, policies, procedures, or renewals that are likely to substantially increase the
114	114	92complexity or burden of accessing, exchanging, or using such data; nor 6 of 6
115	115	93 (3) penalize a prescribing practitioner or professional for disclosing such information to
116	116	94an enrollee or their personal representative, or for prescribing, administering, or ordering a
117	117	95clinically appropriate or lower-cost alternative.
118	118	96 (4) Any health plan or pharmacy benefit manager shall treat an enrollee’s identified
119	119	97personal representative as the enrollee for purposes of this section, provided that nothing in this
120	120	98section shall expand the legal relationship between an enrollee authorized representative and
121	121	99health plan.
122	122	100 (5) If under applicable law a person has authority to act on behalf of an enrollee in
123	123	101making decisions related to health care, a health plan or pharmacy benefit manager, or its
124	124	102affiliates or entities acting on its behalf, must treat such person as a personal representative under
125	125	103this section.
126	126	104 (d) Reimbursement for fees imposed for data access pursuant to this section may be
127	127	105negotiated and contracted between a health plan or pharmacy benefit manager and a prescribing
128	128	106provider upon mutual agreement.