STATE OF NEW YORK ________________________________________________________________________ 1350 2023-2024 Regular Sessions IN SENATE January 11, 2023 ___________ Introduced by Sen. RIVERA -- read twice and ordered printed, and when printed to be committed to the Committee on Rules AN ACT to amend the insurance law, in relation to calculating an insured individual's overall contribution to any out-of-pocket maximum or any cost-sharing requirement; and to amend a chapter of the laws of 2022 amending the insurance law relating to calculating an insured individ- ual's overall contribution to any out-of-pocket maximum or any cost- sharing requirement, as proposed in legislative bills numbers S. 5299-A and A. 1741-A, in relation to the effectiveness thereof The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Paragraph 37 of subsection (i) of section 3216 of the 2 insurance law, as added by a chapter of the laws of 2022 amending the 3 insurance law relating to calculating an insured individual's overall 4 contribution to any out-of-pocket maximum or any cost-sharing require- 5 ment, as proposed in legislative bills numbers S. 5299-A and A. 1741-A, 6 is amended to read as follows: 7 (37) Any policy that provides coverage for prescription drugs shall 8 apply any third-party payments, financial assistance, discount, voucher 9 or other price reduction instrument for out-of-pocket expenses made on 10 behalf of an insured individual for the cost of a prescription [drugs] 11 drug to the insured's deductible, copayment, coinsurance, out-of-pocket 12 maximum, or any other cost-sharing requirement when calculating such 13 insured individual's overall contribution to any out-of-pocket maximum 14 or any cost-sharing requirement. If under federal law, application of 15 this requirement would result in health savings account ineligibility 16 under 26 USC 223, this requirement shall apply for health savings 17 account-qualified high deductible health plans with respect to the 18 deductible of such a plan after the enrollee has satisfied the minimum 19 deductible under 26 USC 223, except for with respect to items or 20 services that are preventive care pursuant to 26 USC 223(c)(2)(C), in EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD04217-01-3
S. 1350 2 1 which case the requirements of this paragraph shall apply regardless of 2 whether the minimum deductible under 26 USC 223 has been satisfied. 3 This paragraph only applies to a prescription drug that is either (A) a 4 brand-name drug without an AB rated generic equivalent, as determined by 5 the United States Food and Drug Administration; or (B) a brand-name drug 6 with an AB rated generic equivalent, as determined by the United States 7 Food and Drug Administration, and the insured has access to the brand- 8 name drug through prior authorization by the insurer or through the 9 insurer's appeal process, including any step-therapy process; or (C) a 10 generic drug the insurer will cover, with or without prior authorization 11 or an appeal process. 12 § 2. Paragraph 21 of subsection (l) of section 3221 of the insurance 13 law, as added by a chapter of the laws of 2022 amending the insurance 14 law relating to calculating an insured individual's overall contribution 15 to any out-of-pocket maximum or any cost-sharing requirement, as 16 proposed in legislative bills numbers S. 5299-A and A. 1741-A, is 17 amended to read as follows: 18 (21) Every group or blanket policy delivered or issued for delivery in 19 this state that provides coverage for a prescription [drugs] drug shall 20 apply any third-party payments, financial assistance, discount, voucher 21 or other price reduction instrument for out-of-pocket expenses made on 22 behalf of an insured individual for the cost of prescription drugs to 23 the insured's deductible, copayment, coinsurance, out-of-pocket maximum, 24 or any other cost-sharing requirement when calculating such insured 25 individual's overall contribution to any out-of-pocket maximum or any 26 cost-sharing requirement. If under federal law, application of this 27 requirement would result in health savings account ineligibility under 28 26 USC 223, this requirement shall apply for health savings account-qua- 29 lified high deductible health plans with respect to the deductible of 30 such a plan after the enrollee has satisfied the minimum deductible 31 under 26 USC 223, except for with respect to items or services that are 32 preventive care pursuant to 26 USC 223(c)(2)(C), in which case the 33 requirements of this paragraph shall apply regardless of whether the 34 minimum deductible under 26 USC 223 has been satisfied. This paragraph 35 only applies to a prescription drug that is either (A) a brand-name drug 36 without an AB rated generic equivalent, as determined by the United 37 States Food and Drug Administration; or (B) a brand-name drug with an AB 38 rated generic equivalent, as determined by the United States Food and 39 Drug Administration, and the insured has access to the brand-name drug 40 through prior authorization by the insurer or through the insurer's 41 appeal process, including any step-therapy process; or (C) a generic 42 drug the insurer will cover, with or without prior authorization or an 43 appeal process. 44 § 3. Subsection (tt) of section 4303 of the insurance law, as added by 45 a chapter of the laws of 2022 amending the insurance law relating to 46 calculating an insured individual's overall contribution to any out-of- 47 pocket maximum or any cost-sharing requirement, as proposed in legisla- 48 tive bills numbers S. 5299-A and A. 1741-A, is amended to read as 49 follows: 50 (tt) Every contract issued by a medical expense indemnity corporation, 51 hospital service corporation, or health service corporation that 52 provides coverage for a prescription [drugs] drug shall apply any third- 53 party payments, financial assistance, discount, voucher or other price 54 reduction instrument for out-of-pocket expenses made on behalf of an 55 insured individual for the cost of prescription drugs to the insured's 56 deductible, copayment, coinsurance, out-of-pocket maximum, or any other
S. 1350 3 1 cost-sharing requirement when calculating such insured individual's 2 overall contribution to any out-of-pocket maximum or any cost-sharing 3 requirement. If under federal law, application of this requirement would 4 result in health savings account ineligibility under 26 USC 223, this 5 requirement shall apply for health savings account-qualified high deduc- 6 tible health plans with respect to the deductible of such a plan after 7 the enrollee has satisfied the minimum deductible under 26 USC 223, 8 except for with respect to items or services that are preventive care 9 pursuant to 26 USC 223(c)(2)(C), in which case the requirements of this 10 paragraph shall apply regardless of whether the minimum deductible under 11 26 USC 223 has been satisfied. This subsection only applies to a 12 prescription drug that is either (A) a brand-name drug without an AB 13 rated generic equivalent, as determined by the United States Food and 14 Drug Administration; or (B) a brand-name drug with an AB rated generic 15 equivalent, as determined by the United States Food and Drug Adminis- 16 tration, and the insured has access to the brand-name drug through prior 17 authorization by the insurer or through the insurer's appeal process, 18 including any step-therapy process; or (C) a generic drug the insurer 19 will cover, with or without prior authorization or an appeal process. 20 § 4. Section 4 of a chapter of the laws of 2022 amending the insur- 21 ance law relating to calculating an insured individual's overall 22 contribution to any out-of-pocket maximum or any cost-sharing require- 23 ment, as proposed in legislative bills numbers S. 5299-A and A. 1741-A, 24 is amended to read as follows: 25 § 4. This act shall take effect on the first of [January] July next 26 succeeding the date on which it shall have become a law and shall apply 27 to all policies and contracts issued, renewed, modified, altered or 28 amended on or after such date. 29 § 5. This act shall take effect immediately; provided, however, that 30 sections one, two and three of this act shall take effect on the same 31 date and in the same manner as a chapter of the laws of 2022 amending 32 the insurance law relating to calculating an insured individual's over- 33 all contribution to any out-of-pocket maximum or any cost-sharing 34 requirement, as proposed in legislative bills numbers S. 5299-A and A. 35 1741-A, takes effect.