Massachusetts 2023-2024 Regular Session

Massachusetts Senate Bill S616 Compare Versions

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

Old	New	Differences
1	1	1 of 1
2	2	SENATE DOCKET, NO. 375 FILED ON: 1/13/2023
3	3	SENATE . . . . . . . . . . . . . . No. 616
4	4	The Commonwealth of Massachusetts
5	5	_________________
6	6	PRESENTED BY:
7	7	Julian Cyr
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 :Julian CyrCape and Islands 1 of 6
16	16	SENATE DOCKET, NO. 375 FILED ON: 1/13/2023
17	17	SENATE . . . . . . . . . . . . . . No. 616
18	18	By Mr. Cyr, a petition (accompanied by bill, Senate, No. 616) of Julian Cyr for legislation
19	19	relative to patient cost, benefit and coverage information, choice, and price transparency.
20	20	Financial Services.
21	21	[SIMILAR MATTER FILED IN PREVIOUS SESSION
22	22	SEE SENATE, NO. 650 OF 2021-2022.]
23	23	The Commonwealth of Massachusetts
24	24	_______________
25	25	In the One Hundred and Ninety-Third General Court
26	26	(2023-2024)
27	27	_______________
28	28	An Act relating to patient cost, benefit and coverage information, choice, and price transparency.
29	29	Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
30	30	of the same, as follows:
31	31	1 SECTION 1. Chapter 94C of the General Laws, is hereby amended by inserting after
32	32	2section 21C the following new section:-
33	33	3 Section 21D (a) For the purposes of this section, the following terms shall have the
34	34	4following meanings unless the context clearly requires otherwise:
35	35	5 “Cost-sharing information”, the amount an enrollee is required to pay in order to receive
36	36	6a drug that is covered under the enrollee’s health plan.
37	37	7 “Enrollee” a person who is receiving a health care benefit and assumes financial
38	38	8responsibility for outstanding costs associated with a prescription drug to treat a health condition
39	39	9for themself or a dependent member of their household. 2 of 6
40	40	10 ''Health care benefit'', a full or partial payment for health care services or the right under a
41	41	11contract or a certificate or policy of insurance to have a full or partial payment made by a health
42	42	12plan, as defined in this section, for a specified health care service.
43	43	13 “Health plan” any insurance company authorized to provide health insurance in this state
44	44	14or any legal entity which is self-insured and providing health care benefits to its employees.
45	45	15 “Interoperability element”, hardware, software, integrated technologies or related
46	46	16licenses, technical information, privileges, rights, intellectual property, upgrades, or services that
47	47	17may be necessary to provide the data set forth in subsection (b)(3) in the requested format and
48	48	18consistent with subsection(b)(1).
49	49	19 “Patient” the enrollee or dependent family member of the enrollee who is treated by a
50	50	20prescribing physician.
51	51	21 “Personal Representative” a person, who has been identified by the enrollee or by the
52	52	22commonwealth on behalf of the enrollee, to assist with decision making during their medical
53	53	23appointment, such as: a child accompanying an elderly parent, a healthcare proxy, a parent of a
54	54	24minor child, or a spouse.
55	55	25 “Pharmacy benefit manager” (a) For the purposes of this section, the term ''pharmacy
56	56	26benefit manager'' shall mean any person or entity that administers the (i) prescription drug,
57	57	27prescription device or pharmacist services or (ii) prescription drug and device and pharmacist
58	58	28services portion of a health benefit plan on behalf of plan sponsors, including, but not limited to,
59	59	29self-insured employers, insurance companies and labor unions. A health benefit plan that does
60	60	30not contract with a pharmacy benefit manager shall be considered a pharmacy benefit manager
61	61	31for the purposes of this section, unless specifically exempted. 3 of 6
62	62	32 “Prescribing practitioner” a physician, nurse practitioner, or physician’s assistant who
63	63	33writes a prescription for a patient during the course of care for a medical condition.
64	64	34 (b) Any health plan or pharmacy benefit manager shall, upon request of the patient,
65	65	35enrollee, their prescribing practitioner, or their personal representative, furnish the cost, benefit,
66	66	36and coverage data set forth in subsection (3) to the enrollee, their prescribing practitioner, or
67	67	37their personal representative and shall ensure that such cost, benefit, and coverage data is (i)
68	68	38current as of one business day after any change is made; (ii) provided in real time; and (iii) in the
69	69	39same format that the request is made by the enrollee or their prescribing practitioner.
70	70	40 (1) The format of the request shall use established industry content and transport
71	71	41standards published by:
72	72	42 (i) a standards developing organization accredited by the American National Standards
73	73	43Institute, included but not limited to, the National Council for Prescription Drug Programs, ASC
74	74	44X12, Health Level 7; or
75	75	45 (ii) a relevant federal or state agency or government body, included but not limited to the
76	76	46Center for Medicare & Medicaid Services or the Office of the National Coordinator for Health
77	77	47Information technology, The Commonwealth of Massachusetts Department of Public Health,
78	78	48Division of Insurance, Health Policy Commission, or Center for Health Information and
79	79	49Analysis.
80	80	50 (2) A facsimile, proprietary payor or patient portal, or other electronic form other than as
81	81	51required by section (b) shall not be considered acceptable electronic formats pursuant to this
82	82	52section. 4 of 6
83	83	53 (3) Upon such request, the following data shall be provided for any prescription drug
84	84	54covered under the enrollee’s health plan:
85	85	55 (i) the patient’s current eligibility information for such prescription drug;
86	86	56 (ii) a list of any clinically-appropriate alternatives to such prescription drug covered
87	87	57under the enrollee’s current health plan;
88	88	58 (iii) cost-sharing information for such prescription drug and such clinically-appropriate
89	89	59alternatives, including a description of any variance in cost-sharing based on pharmacy, whether
90	90	60retail or mailorder, or health care provider dispensing or administering such prescription drug or
91	91	61such alternatives;
92	92	62 (iv) any applicable utilization management requirements for such prescription drug or
93	93	63such clinically-appropriate alternatives, including prior authorization, step therapy, quantity
94	94	64limits, and site-of-service restrictions
95	95	65 (4) Any health plan or pharmacy benefit manager shall furnish the data set forth in
96	96	66subsection (b)(3), whether the request is made using the prescription drug’s unique billing code,
97	97	67such as a National Drug Code or Healthcare Common Procedure Coding System code or
98	98	68descriptive term, such as the brand or generic name of the prescription drug.
99	99	69 (i) A health plan or pharmacy benefit manager shall not deny or delay a request as a
100	100	70method of blocking the data set forth in subsection (b)(3) from being shared based on how the
101	101	71drug was requested.
102	102	72 (c) Any health plan or pharmacy benefit manager furnishing the data set forth in
103	103	73subsection (b)(3), shall not: 5 of 6
104	104	74 (1) restrict, prohibit, or otherwise hinder, in any way, a prescribing practitioner or health
105	105	75care professional from communicating or sharing:
106	106	76 (i) any of the data set forth in subsection (b)(3);
107	107	77 (ii) additional information on any lower-cost or clinically-appropriate alternatives,
108	108	78whether or not they are covered under the enrollee’s plan; or
109	109	79 (iii) additional payment or cost-sharing information that may reduce the patient’s out-of-
110	110	80pocket costs, such as cash price or patient assistance and support programs whether sponsored by
111	111	81a manufacturer, foundation, or other entity;
112	112	82 (2) Except as may be required by law, interfere with, prevent, or materially discourage
113	113	83access, exchange, or use of the data set forth in subsection (b)(3), which may include charging
114	114	84fees, not responding to a request at the time made where such a response is reasonably possible,
115	115	85implementing technology in nonstandard ways or instituting enrollee consent requirements,
116	116	86processes, policies, procedures, or renewals that are likely to substantially increase the
117	117	87complexity or burden of accessing, exchanging, or using such data; nor
118	118	88 (3) penalize a prescribing practitioner or professional for disclosing such information to
119	119	89an enrollee or their personal representative, or for prescribing, administering, or ordering a
120	120	90clinically appropriate or lower-cost alternative.
121	121	91 (4) Any health plan or pharmacy benefit manager shall treat an enrollee’s identified
122	122	92personal representative as the enrollee for purposes of this section.
123	123	93 (5) If under applicable law a person has authority to act on behalf of an enrollee in
124	124	94making decisions related to health care, a health plan or pharmacy benefit manager, or its 6 of 6
125	125	95affiliates or entities acting on its behalf, must treat such person as a personal representative under
126	126	96this section.
127	127	97 (d) Reimbursement for fees imposed for data access pursuant to this section may be
128	128	98negotiated and contracted between a health plan or pharmacy benefit manager and a prescribing
129	129	99provider upon mutual agreement