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1 HOUSE BILL NO. 783
2 INTRODUCED BY S. ROSENZWEIG, J. GILLETTE
3
4 A BILL FOR AN ACT ENTITLED: “AN ACT REQUIRING COVERAGE OF CERTAIN TREATMENTS AND
5 MEDICATIONS RELATING TO DIABETES, OBESITY, OR POLYCYSTIC OVARY SYNDROME; PROVIDING
6 THE TYPES OF TREATMENTS AND MEDICATIONS THAT MUST BE COVERED; PROVIDING WHAT
7 MEDICAL NECESSITY INCLUDES; PROVIDING EXCLUSIONS; APPLYING TO CERTAIN INSURED
8 GROUPS; AND AMENDING SECTIONS 2-18-704, 33-31-111, AND 33-35-306, MCA.”
9
10 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MONTANA:
11
12 NEW SECTION. Section 1.
13 (1) (a) Each individual disability policy, certificate of insurance, and membership contract that is
14 delivered, issued for delivery, renewed, extended, or modified in this state must provide coverage for:
15 (i) glucagon-like peptide-1 receptor agonists if it is determined to be medically necessary; and
16 (ii) polycystic ovary syndrome if it is determined to be medically necessary.
17 (b) For the purposes of subsection (1)(a), the term "medically necessary" includes but is not limited
18 to a diagnosis of diabetes or class 3 obesity or polycystic ovary syndrome.
19 (2) Coverage under this section may be subject to deductibles, coinsurance, and copayment
20 provisions. Special deductible, coinsurance, copayment, or other limitations that are not generally applicable to
21 other medical services covered under the plan may not be imposed on coverage of glucagon-like peptide-1
22 receptor agonists. A health insurance issuer may use cost containment measures, which may include but are
23 not limited to step therapy and prior authorization.
24 (3) This section does not apply to disability income, hospital indemnity, medicare supplement,
25 specified disease, or long-term care policies.
26
27 Section 2-18-704, MCA, is amended to read:
28 "2-18-704. (1) An insurance contract or plan issued under this part must ****
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1 contain provisions that permit:
2 (a) the member of a group who retires from active service under the appropriate retirement
3 provisions of a defined benefit plan provided by law or, in the case of the defined contribution plan provided in
4 Title 19, chapter 3, part 21, a member with at least 5 years of service and who is at least age 50 while in
5 covered employment to remain a member of the group until the member becomes eligible for medicare under
6 the federal Health Insurance for the Aged Act, 42 U.S.C. 1395, unless the member is a participant in another
7 group plan with substantially the same or greater benefits at an equivalent cost or unless the member is
8 employed and, by virtue of that employment, is eligible to participate in another group plan with substantially the
9 same or greater benefits at an equivalent cost;
10 (b) the surviving spouse of a member to remain a member of the group as long as the spouse is
11 eligible for retirement benefits accrued by the deceased member as provided by law unless the spouse is
12 eligible for medicare under the federal Health Insurance for the Aged Act or unless the spouse has or is eligible
13 for equivalent insurance coverage as provided in subsection (1)(a);
14 (c) the surviving children of a member to remain members of the group as long as they are eligible
15 for retirement benefits accrued by the deceased member as provided by law unless they have equivalent
16 coverage as provided in subsection (1)(a) or are eligible for insurance coverage by virtue of the employment of
17 a surviving parent or legal guardian.
18 (2) An insurance contract or plan issued under this part must contain the provisions of subsection
19 (1) for remaining a member of the group and also must permit:
20 (a) the spouse of a retired member the same rights as a surviving spouse under subsection (1)(b);
21 (b) the spouse of a retiring member to convert a group policy as provided in 33-22-508; and
22 (c) continued membership in the group by anyone eligible under the provisions of this section,
23 notwithstanding the person's eligibility for medicare under the federal Health Insurance for the Aged Act.
24 (3) (a) A state insurance contract or plan must contain provisions that permit a legislator to remain
25 a member of the state's group plan until the legislator becomes eligible for medicare under the federal Health
26 Insurance for the Aged Act if the legislator:
27 (i) terminates service in the legislature and is a vested member of a state retirement system
28 provided by law; and ****
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1 (ii) notifies the department of administration in writing within 90 days of the end of the legislator's
2 legislative term.
3 (b) A former legislator may not remain a member of the group plan under the provisions of
4 subsection (3)(a) if the person:
5 (i) is a member of a plan with substantially the same or greater benefits at an equivalent cost; or
6 (ii) is employed and, by virtue of that employment, is eligible to participate in another group plan
7 with substantially the same or greater benefits at an equivalent cost.
8 (c) A legislator who remains a member of the group under the provisions of subsection (3)(a) and
9 subsequently terminates membership may not rejoin the group plan unless the person again serves as a
10 legislator.
11 (4) (a) A state insurance contract or plan must contain provisions that permit continued
12 membership in the state's group plan by a member of the judges' retirement system who leaves judicial office
13 but continues to be an inactive vested member of the judges' retirement system as provided by 19-5-301. The
14 judge shall notify the department of administration in writing within 90 days of the end of the judge's judicial
15 service of the judge's choice to continue membership in the group plan.
16 (b) A former judge may not remain a member of the group plan under the provisions of this
17 subsection (4) if the person:
18 (i) is a member of a plan with substantially the same or greater benefits at an equivalent cost;
19 (ii) is employed and, by virtue of that employment, is eligible to participate in another group plan
20 with substantially the same or greater benefits at an equivalent cost; or
21 (iii) becomes eligible for medicare under the federal Health Insurance for the Aged Act.
22 (c) A judge who remains a member of the group under the provisions of this subsection (4) and
23 subsequently terminates membership may not rejoin the group plan unless the person again serves in a
24 position covered by the state's group plan.
25 (5) A person electing to remain a member of the group under subsection (1), (2), (3), or (4) shall
26 pay the full premium for coverage and for that of the person's covered dependents.
27 (6) An insurance contract or plan issued under this part that provides for the dispensing of
28 prescription drugs by an out-of-state mail service pharmacy, as defined in 37-7-702: ****
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1 (a) must permit any member of a group to obtain prescription drugs from a pharmacy located in
2 Montana that is willing to match the price charged to the group or plan and to meet all terms and conditions,
3 including the same professional requirements that are met by the mail service pharmacy for a drug, without
4 financial penalty to the member; and
5 (b) may only be with an out-of-state mail service pharmacy that is registered with the board under
6 Title 37, chapter 7, part 7, and that is registered in this state as a foreign corporation.
7 (7) An insurance contract or plan issued under this part must include coverage for:
8 (a) treatment of inborn errors of metabolism, as provided for in 33-22-131;
9 (b) therapies for Down syndrome, as provided in 33-22-139;
10 (c) treatment for children with hearing loss as provided in 33-22-128(1) and (2);
11 (d) fertility preservation services as required under 33-22-2103;
12 (e) the care and treatment of mental illness in accordance with the provisions of Title 33, chapter
13 22, part 7;
14 (f) telehealth services, as provided for in 33-22-138; and
15 (g) refills of prescription eyedrops as provided in 33-22-154.
16 (8) (a) An insurance contract or plan issued under this part that provides coverage for an individual
17 in a member's family must provide coverage for well-child care for children from the moment of birth through 7
18 years of age. Benefits provided under this coverage are exempt from any deductible provision that may be in
19 force in the contract or plan.
20 (b) Coverage for well-child care under subsection (8)(a) must include:
21 (i) a history, physical examination, developmental assessment, anticipatory guidance, and
22 laboratory tests, according to the schedule of visits adopted under the early and periodic screening, diagnosis,
23 and treatment services program provided for in 53-6-101; and
24 (ii) routine immunizations according to the schedule for immunization recommended by the
25 advisory committee on immunization practices of the U.S. department of health and human services.
26 (c) Minimum benefits may be limited to one visit payable to one provider for all of the services
27 provided at each visit as provided for in this subsection (8).
28 (d) For purposes of this subsection (8): ****
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1 (i) "developmental assessment" and "anticipatory guidance" mean the services described in the
2 Guidelines for Health Supervision II, published by the American academy of pediatrics; and
3 (ii) "well-child care" means the services described in subsection (8)(b) and delivered by a
4 physician or a health care professional supervised by a physician.
5 (9) Upon renewal, an insurance contract or plan issued under this part under which coverage of a
6 dependent terminates at a specified age must continue to provide coverage for any dependent, as defined in
7 the insurance contract or plan, until the dependent reaches 26 years of age. For insurance contracts or plans
8 issued under this part, the premium charged for the additional coverage of a dependent, as defined in the
9 insurance contract or plan, may be required to be paid by the insured and not by the employer.
10 (10) Prior to issuance of an insurance contract or plan under this part, written informational
11 materials describing the contract's or plan's cancer screening coverages must be provided to a prospective
12 group or plan member.
13 (11) The state employee group benefit plans and the Montana university system group benefits
14 plans must provide coverage for hospital inpatient care for a period of time as is determined by the attending
15 physician and, in the case of a health maintenance organization, the primary care physician, in consultation
16 with the patient to be medically necessary following a mastectomy, a lumpectomy, or a lymph node dissection
17 for the treatment of breast cancer.
18 (12) (a) (i) The state employee group benefit plans and the Montana university system group
19 benefits plans must provide coverage for medically necessary and prescribed outpatient self-management
20 training and education for the treatment of diabetes. Any education must be provided by a licensed health care
21 professional with expertise in diabetes. At a minimum, the benefit must consist of:
22 (A) 20 visits of training and education in diabetes self-management provided in either an individual
23 or group setting if the person has not received the training and education previously; and
24 (B) 12 visits of followup diabetes self-management training and education services in subsequent
25 years for an insured who has previously received and exhausted the initial 20 visits of education.
26 (ii) For the purposes of this subsection (12)(a), the term "visit" refers to a period of 30 minutes.
27 (b) The state employee group benefit plans and the Montana university system group benefits
28 plans must provide coverage for diabetic equipment and supplies that at a minimum includes insulin, syringes, ****
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1 injection aids, devices for self-monitoring of glucose levels (including those for the visually impaired), test strips,
2 visual reading and urine test strips, one insulin pump for each warranty period, accessories to insulin pumps,
3 one prescriptive oral agent for controlling blood sugar levels for each class of drug approved by the United
4 States food and drug administration, and glucagon emergency kits.
5 (c) Nothing in subsection (12)(a) or (12)(b) prohibits the state or the Montana university group
6 benefit plans from providing a greater benefit or an alternative benefit of substantially equal value, in which
7 case subsection (12)(a) or (12)(b), as appropriate, does not apply.
8 (d) Annual copayment and deductible provisions are subject to the same terms and conditions
9 applicable to all other covered benefits within a given policy.
10 (e) This subsection (12) does not apply to disability income, hospital indemnity, medicare
11 supplement, accident-only, vision, dental, specific disease, or long-term care policies offered by the state or the
12 Montana university system as benefits to employees, retirees, and their dependents.
13 (13) (a) Except as provided in subsection (16), the state employee group benefit plans and the
14 Montana university system group benefits plans that provide coverage to the spouse or dependents of a peace
15 officer as defined in 45-2-101, a game warden as defined in 19-8-101, a firefighter as defined in 19-13-104, or a
16 volunteer firefighter as defined in 19-17-102 shall renew the coverage of the spouse or dependents if the peace
17 officer, game warden, firefighter, or volunteer firefighter dies within the course and scope of employment.
18 Except as provided in subsection (13)(b), the continuation of the coverage is at the option of the spouse or
19 dependents. Renewals of coverage under this section must provide for the same level of benefits as is
20 available to other members of the group. Premiums charged to a spouse or dependent under this section must
21 be the same as premiums charged to other similarly situated members of the group. Dependent special
22 enrollment must be allowed under the terms of the insurance contract or plan. The provisions of this subsection
23 (13)(a) are applicable to a spouse or dependent who is insured under a COBRA continuation provision.
24 (b) The state employee group benefit plans and the Montana university system group benefits
25 plans subject to the provisions of subsection (13)(a) may discontinue or not renew the coverage of a spouse or
26 dependent only if:
27 (i) the spouse or dependent has failed to pay premiums or contributions in accordance with the
28 terms of the state employee group benefit plans and the Montana university system group benefits plans or if ****
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1 the plans have not received timely premium payments;
2 (ii) the spouse or dependent has performed an act or practice that constitutes fraud or has made
3 an intentional misrepresentation of a material fact under the terms of the coverage; or
4 (iii) the state employee group benefit plans and the Montana university system group benefits
5 plans are ceasing to offer coverage in accordance with applicable state law.
6 (14) The state employee group benefit plans and the Montana university system group benefits
7 plans must comply with the provisions of 33-22-153 and [section 1].
8 (15) An insurance contract or plan issued under this part and a group benefits plan issued by the
9 Montana university system must provide mental health coverage that meets the provisions of Title 33, chapter
10 22, part 7.
11 (16) The employing state agency of a law enforcement officer as defined in 2-15-2040 who is
12 covered under the state employee group benefit plan shall:
13 (a) if the officer is catastrophically injured in the line of duty as defined in 2-15-2040, enroll the
14 officer and the officer's covered spouse or dependent children in COBRA continuation coverage when that
15 officer is terminated from employment as a result of the catastrophic injury. The officer and the officer's spouse
16 or dependent children may opt out of COBRA continuation coverage within 60 days of enrollment.
17 (b) enroll the officer's covered spouse or dependent children in COBRA continuation coverage if
18 the officer dies in the line of duty as defined in 2-15-2040. The officer's spouse or dependent children may opt
19 out of COBRA coverage within 60 days of the date of enrollment.
20 (c) pay the COBRA premium for 4 months of COBRA continuation coverage for the officer and the
21 officer's covered spouse or dependent children enrolled in COBRA continuation coverage pursuant to
22 subsections (16)(a) or (16)(b), after which time the officer and the officer's spouse or dependent children shall
23 pay the COBRA premium. (See compiler's comments for contingent termination of certain text.)"
24
25 Section 33-31-111, MCA, is amended to read:
26 "33-31-111. (1) Except as otherwise
27 provided in this chapter, the insurance or health service corporation laws do not apply to a health maintenance
28 organization authorized to transact business under this chapter. This provision does not apply to an insurer or ****
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1 health service corporation licensed and regulated pursuant to the insurance or health service corporation laws
2 of this state except with respect to its health maintenance organization activities authorized and regulated
3 pursuant to this chapter.
4 (2) Solicitation of enrollees by a health maintenance organization granted a certificate of authority
5 or its representatives is not a violation of any law relating to solicitation or advertising by health professionals.
6 (3) A health maintenance organization authorized under this chapter is not practicing medicine and
7 is exempt from Title 37, chapter 3, relating to the practice of medicine.
8 (4) This chapter does not exempt a health maintenance organization from the applicable certificate
9 of need requirements under Title 50, chapter 5, parts 1 and 3.
10 (5) This section does not exempt a health maintenance organization from the prohibition of
11 pecuniary interest under 33-3-308 or the material transaction disclosure requirements under 33-3-701 through
12 33-3-704. A health maintenance organization must be considered an insurer for the purposes of 33-3-308 and
13 33-3-701 through 33-3-704.
14 (6) This section does not exempt a health maintenance organization from:
15 (a) prohibitions against interference with certain communications as provided under Title 33,
16 chapter 1, part 8;
17 (b) the provisions of Title 33, chapter 22, parts 7 and 19;
18 (c) the requirements of 33-22-134 and 33-22-135;
19 (d) network adequacy and quality assurance requirements provided under chapter 36; or
20 (e) the requirements of Title 33, chapter 18, part 9.
21 (7) Other chapters and provisions of this title apply to health maintenance organizations as follows:
22 Title 33, chapter 1, parts 6, 12, and 13; 33-2-1114; 33-2-1211 and 33-2-1212; Title 33, chapter 2, parts 13, 19,
23 23, and 24; 33-3-401; 33-3-422; 33-3-431; Title 33, chapter 3, part 6; Title 33, chapter 10; Title 33, chapter 12;
24 33-15-308; Title 33, chapter 17; Title 33, chapter 19; 33-22-107; 33-22-114; 33-22-128; 33-22-129; 33-22-131;
25 33-22-136 through 33-22-139; 33-22-141 and 33-22-142; 33-22-152 through 33-22-159; [section 1], 33-22-180;
26 33-22-244; 33-22-246 and 33-22-247; 33-22-514 and 33-22-515; 33-22-521; 33-22-523 and 33-22-524; 33-22-
27 526; 33-22-2103; and Title 33, chapter 32."
28 ****
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1 Section 33-35-306, MCA, is amended to read:
2 "33-35-306. (1) In addition to this chapter, self-
3 funded multiple employer welfare arrangements are subject to the following provisions:
4 (a) 33-1-111;
5 (b) Title 33, chapter 1, part 4, but the examination of a self-funded multiple employer welfare
6 arrangement is limited to those matters to which the arrangement is subject to regulation under this chapter;
7 (c) Title 33, chapter 1, part 7;
8 (d) Title 33, chapter 2, parts 23 and 24;
9 (e) 33-3-308;
10 (f) Title 33, chapter 7;
11 (g) Title 33, chapter 18, except 33-18-242;
12 (h) Title 33, chapter 19;
13 (i) 33-22-107, 33-22-114, 33-22-128, 33-22-129, 33-22-131, 33-22-134, 33-22-135, 33-22-138,
14 33-22-139, 33-22-141, 33-22-142, and 33-22-152 through 33-22-155, and [section 1];
15 (j) 33-22-316;
16 (k) 33-22-512, 33-22-515, 33-22-525, and 33-22-526;
17 (l) Title 33, chapter 22, parts 7 and 21; and
18 (m) 33-22-707.
19 (2) Except as provided in this chapter, other provisions of Title 33 do not apply to a self-funded
20 multiple employer welfare arrangement that has been issued a certificate of authority that has not been
21 revoked."
22
23 NEW SECTION. Section 5. [Section 1] is intended to be codified as an
24 integral part of Title 33, chapter 22, part 1, and the provisions of Title 33, chapter 22, part 1, apply to [section 1].
25 - END -