Rhode Island 2023 Regular Session

Rhode Island Senate Bill S0726 Compare Versions

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

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5	5	2023 -- S 0726
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7	7	LC002457
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9	9	S TATE OF RHODE IS LAND
10	10	IN GENERAL ASSEMBLY
11	11	JANUARY SESSION, A.D. 2023
12	12	____________
13	13
14	14	A N A C T
15	15	RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES
16	16	Introduced By: Senators Valverde, DiMario, Miller, Murray, Lauria, Ujifusa, Euer,
17	17	Lawson, Gu, and Kallman
18	18	Date Introduced: March 22, 2023
19	19	Referred To: Senate Health & Human Services
20	20
21	21
22	22	It is enacted by the General Assembly as follows:
23	23	SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness Insurance 1
24	24	Policies" is hereby amended by adding thereto the following section: 2
25	25	27-18-50.2. Specialty drugs. 3
26	26	(a) The general assembly makes the following findings: 4
27	27	(1) In 2015, an estimated six hundred thirty-five thousand (635,000) Rhode Island residents 5
28	28	had at least one chronic disease, and an estimated two hundred forty-nine thousand (249,000) 6
29	29	residents had two (2) or more chronic diseases, which significantly increases their likelihood to 7
30	30	depend on prescription specialty drugs; 8
31	31	(2) In 2016, twenty-five percent (25%) of Rhode Island residents stopped taking a 9
32	32	prescription drug as prescribed due to cost; 10
33	33	(3) Most specialty drugs do not have biosimilars, generic equivalents, or substitutes to 11
34	34	create competition and help lower their prices; 12
35	35	(4) In 2022, the Center for Medicare and Medicaid Services defines any drug for which the 13
36	36	negotiated price is six hundred seventy dollars ($670) per month or more, as a specialty drug. 14
37	37	(b) As used in this section, the following words shall have the following meanings: 15
38	38	(1) "Complex or chronic medical condition" means a physical, behavioral, or 16
39	39	developmental condition that is persistent or otherwise long-lasting in its effects or a disease that 17
40	40	advances over time, and: 18
41	41	(i) May have no known cure; 19
42	42
43	43
44	44	LC002457 - Page 2 of 8
45	45	(ii) Is progressive; or 1
46	46	(iii) Can be debilitating or fatal if left untreated or undertreated. 2
47	47	"Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis, 3
48	48	hepatitis c, and rheumatoid arthritis. 4
49	49	(2) "Pre-service authorization" means a cost containment method that an insurer, a 5
50	50	nonprofit health service plan, or a health maintenance organization uses to review and preauthorize 6
51	51	coverage for drugs prescribed by a health care provider for a covered individual to control 7
52	52	utilization, quality, and claims. 8
53	53	(3) "Rare medical condition" means a disease or condition that affects fewer than: 9
54	54	(i) Two hundred thousand (200,000) individuals in the United States; or 10
55	55	(ii) Approximately one in one thousand five hundred (1,500) individuals worldwide. 11
56	56	"Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and 12
57	57	multiple myeloma. 13
58	58	(4) "Specialty drug" means a prescription drug that: 14
59	59	(i) Is prescribed for an individual with a complex or chronic medical condition or a rare 15
60	60	medical condition; and 16
61	61	(ii) Has a wholesale acquisition cost or negotiated price that exceeds the Medicare Part D 17
62	62	specialty tier threshold, as updated from time to time. 18
63	63	(c) Every individual or group health insurance contract, plan or policy that provides 19
64	64	prescription coverage and is delivered, issued for delivery or renewed in this state on or after 20
65	65	January 1, 2024, shall not impose a copayment or coinsurance requirement on a covered specialty 21
66	66	drug that exceeds one hundred fifty dollars ($150) for up to a thirty (30)-day supply of the specialty 22
67	67	drug. A pre-service authorization may be used to provide coverage for specialty drugs. Coverage 23
68	68	for prescription specialty drugs shall not be subject to any deductible, unless prohibiting a 24
69	69	deductible requirement would cause a health plan to not qualify as a high deductible health plan. 25
70	70	(d) Nothing in this section prevents an insurer, health maintenance plan, or nonprofit 26
71	71	medical plan from reducing a covered individual's cost sharing to an amount less than one hundred 27
72	72	fifty dollars ($150) for a thirty (30)-day supply of a specialty drug. 28
73	73	(e) The health insurance commissioner shall promulgate any rules and regulations 29
74	74	necessary to implement and administer this section in accordance with any federal requirements 30
75	75	and shall use the commissioner's enforcement powers to obtain compliance with the provisions of 31
76	76	this section. 32
77	77	SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service 33
78	78	Corporations" is hereby amended by adding thereto the following section: 34
79	79
80	80
81	81	LC002457 - Page 3 of 8
82	82	27-19-42.1. Specialty drugs. 1
83	83	(a) The general assembly makes the following findings: 2
84	84	(1) In 2015, an estimated six hundred thirty-five thousand (635,000) Rhode Island residents 3
85	85	had at least one chronic disease, and an estimated two hundred forty-nine thousand (249,000) 4
86	86	residents had two (2) or more chronic diseases, which significantly increases their likelihood to 5
87	87	depend on prescription specialty drugs; 6
88	88	(2) In 2016, twenty-five percent (25%) of Rhode Island residents stopped taking a 7
89	89	prescription drug as prescribed due to cost; 8
90	90	(3) Most specialty drugs do not have biosimilars, generic equivalents, or substitutes to 9
91	91	create competition and help lower their prices; 10
92	92	(4) In 2022, the Center for Medicare and Medicaid Services defines any drug for which the 11
93	93	negotiated price is six hundred seventy dollars ($670) per month or more, as a specialty drug. 12
94	94	(b) As used in this section, the following words shall have the following meanings: 13
95	95	(1) "Complex or chronic medical condition" means a physical, behavioral, or 14
96	96	developmental condition that is persistent or otherwise long-lasting in its effects or a disease that 15
97	97	advances over time, and: 16
98	98	(i) May have no known cure; 17
99	99	(ii) Is progressive; or 18
100	100	(iii) Can be debilitating or fatal if left untreated or undertreated. 19
101	101	"Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis, 20
102	102	hepatitis c, and rheumatoid arthritis. 21
103	103	(2) "Pre-service authorization" means a cost containment method that an insurer, a 22
104	104	nonprofit health service plan, or a health maintenance organization uses to review and preauthorize 23
105	105	coverage for drugs prescribed by a health care provider for a covered individual to control 24
106	106	utilization, quality, and claims. 25
107	107	(3) "Rare medical condition" means a disease or condition that affects fewer than: 26
108	108	(i) Two hundred thousand (200,000) individuals in the United States; or 27
109	109	(ii) Approximately one in one thousand five hundred (1,500) individuals worldwide. 28
110	110	"Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and 29
111	111	multiple myeloma. 30
112	112	(4) "Specialty drug" means a prescription drug that: 31
113	113	(i) Is prescribed for an individual with a complex or chronic medical condition or a rare 32
114	114	medical condition; and 33
115	115	(ii) Has a wholesale acquisition cost or negotiated price that exceeds the Medicare Part D 34
116	116
117	117
118	118	LC002457 - Page 4 of 8
119	119	specialty tier threshold, as updated from time to time. 1
120	120	(c) Every individual or group health insurance contract, plan or policy that provides 2
121	121	prescription coverage and is delivered, issued for delivery or renewed in this state on or after 3
122	122	January 1, 2024, shall not impose a copayment or coinsurance requirement on a covered specialty 4
123	123	drug that exceeds one hundred fifty dollars ($150) for up to a thirty (30)-day supply of the specialty 5
124	124	drug. A pre-service authorization may be used to provide coverage for specialty drugs. Coverage 6
125	125	for prescription specialty drugs shall not be subject to any deductible, unless prohibiting a 7
126	126	deductible requirement would cause a health plan to not qualify as a high deductible health plan. 8
127	127	(d) Nothing in this section prevents an insurer, health maintenance plan, or nonprofit 9
128	128	medical plan from reducing a covered individual's cost sharing to an amount less than one hundred 10
129	129	fifty dollars ($150) for a thirty (30)-day supply of a specialty drug. 11
130	130	(e) The health insurance commissioner may promulgate any rules and regulations 12
131	131	necessary to implement and administer this section in accordance with any federal requirements 13
132	132	and shall use the commissioner's enforcement powers to obtain compliance with the provisions of 14
133	133	this section. 15
134	134	SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service 16
135	135	Corporations" is hereby amended by adding thereto the following section: 17
136	136	(a) The general assembly makes the following findings: 18
137	137	(1) In 2015, an estimated six hundred thirty-five thousand (635,000) Rhode Island residents 19
138	138	had at least one chronic disease, and an estimated two hundred forty-nine thousand (249,000) 20
139	139	residents had two (2) or more chronic diseases, which significantly increases their likelihood to 21
140	140	depend on prescription specialty drugs; 22
141	141	(2) In 2016, twenty-five percent (25%) of Rhode Island residents stopped taking a 23
142	142	prescription drug as prescribed due to cost; 24
143	143	(3) Most specialty drugs do not have biosimilars, generic equivalents, or substitutes to 25
144	144	create competition and help lower their prices; 26
145	145	(4) In 2022, the Center for Medicare and Medicaid Services defines any drug for which the 27
146	146	negotiated price is six hundred seventy dollars ($670) per month or more, as a specialty drug. 28
147	147	(b) As used in this section, the following words shall have the following meanings: 29
148	148	(1) "Complex or chronic medical condition" means a physical, behavioral, or 30
149	149	developmental condition that is persistent or otherwise long-lasting in its effects or a disease that 31
150	150	advances over time, and: 32
151	151	(i) May have no known cure; 33
152	152	(ii) Is progressive; or 34
153	153
154	154
155	155	LC002457 - Page 5 of 8
156	156	(iii) Can be debilitating or fatal if left untreated or undertreated. 1
157	157	"Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis, 2
158	158	hepatitis c, and rheumatoid arthritis. 3
159	159	(2) "Pre-service authorization" means a cost containment method that an insurer, a 4
160	160	nonprofit health service plan, or a health maintenance organization uses to review and preauthorize 5
161	161	coverage for drugs prescribed by a health care provider for a covered individual to control 6
162	162	utilization, quality, and claims. 7
163	163	(3) "Rare medical condition" means a disease or condition that affects fewer than: 8
164	164	(i) Two hundred thousand (200,000) individuals in the United States; or 9
165	165	(ii) Approximately one in one thousand five hundred (1,500) individuals worldwide. 10
166	166	"Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and 11
167	167	multiple myeloma. 12
168	168	(4) "Specialty drug" means a prescription drug that: 13
169	169	(i) Is prescribed for an individual with a complex or chronic medical condition or a rare 14
170	170	medical condition; and 15
171	171	(ii) Has a wholesale acquisition cost or negotiated price that exceeds the Medicare Part D 16
172	172	specialty tier threshold, as updated from time to time. 17
173	173	(c) Every individual or group health insurance contract, plan or policy that provides 18
174	174	prescription coverage and is delivered, issued for delivery or renewed in this state on or after 19
175	175	January 1, 2024, shall not impose a copayment or coinsurance requirement on a covered specialty 20
176	176	drug that exceeds one hundred fifty dollars ($150) for up to a thirty (30)-day supply of the specialty 21
177	177	drug. A pre-service authorization may be used to provide coverage for specialty drugs. Coverage 22
178	178	for prescription specialty drugs shall not be subject to any deductible, unless prohibiting a 23
179	179	deductible requirement would cause a health plan to not qualify as a high deductible health plan. 24
180	180	(d) Nothing in this section prevents an insurer, health maintenance plan, or nonprofit 25
181	181	medical plan from reducing a covered individual's cost sharing to an amount less than one hundred 26
182	182	fifty dollars ($150) for a thirty (30)-day supply of a specialty drug. 27
183	183	(e) The health insurance commissioner shall promulgate any rules and regulations 28
184	184	necessary to implement and administer this section in accordance with any federal requirements 29
185	185	and shall use the commissioner's enforcement powers to obtain compliance with the provisions of 30
186	186	this section. 31
187	187	SECTION 4. Chapter 27-41 of the General Laws entitled "Health Maintenance 32
188	188	Organizations" is hereby amended by adding thereto the following section: 33
189	189	27-41-38.3. Specialty drugs. 34
190	190
191	191
192	192	LC002457 - Page 6 of 8
193	193	(a) The general assembly makes the following findings: 1
194	194	(1) In 2015, an estimated six hundred thirty-five thousand (635,000) Rhode Island residents 2
195	195	had at least one chronic disease, and an estimated two hundred forty-nine thousand (249,000) 3
196	196	residents had two (2) or more chronic diseases, which significantly increases their likelihood to 4
197	197	depend on prescription specialty drugs; 5
198	198	(2) In 2016, twenty-five percent (25%) of Rhode Island residents stopped taking a 6
199	199	prescription drug as prescribed due to cost; 7
200	200	(3) Most specialty drugs do not have biosimilars, generic equivalents, or substitutes to 8
201	201	create competition and help lower their prices; 9
202	202	(4) In 2022, the Center for Medicare and Medicaid Services defines any drug for which the 10
203	203	negotiated price is six hundred seventy dollars ($670) per month or more, as a specialty drug. 11
204	204	(b) As used in this section, the following words shall have the following meanings: 12
205	205	(1) "Complex or chronic medical condition" means a physical, behavioral, or 13
206	206	developmental condition that is persistent or otherwise long-lasting in its effects or a disease that 14
207	207	advances over time, and: 15
208	208	(i) May have no known cure; 16
209	209	(ii) Is progressive; or 17
210	210	(iii) Can be debilitating or fatal if left untreated or undertreated. 18
211	211	"Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis, 19
212	212	hepatitis c, and rheumatoid arthritis. 20
213	213	(2) "Pre-service authorization" means a cost containment method that an insurer, a 21
214	214	nonprofit health service plan, or a health maintenance organization uses to review and preauthorize 22
215	215	coverage for drugs prescribed by a health care provider for a covered individual to control 23
216	216	utilization, quality, and claims. 24
217	217	(3) "Rare medical condition" means a disease or condition that affects fewer than: 25
218	218	(i) Two hundred thousand (200,000) individuals in the United States; or 26
219	219	(ii) Approximately one in one thousand five hundred (1,500) individuals worldwide. 27
220	220	"Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and 28
221	221	multiple myeloma. 29
222	222	(4) "Specialty drug" means a prescription drug that: 30
223	223	(i) Is prescribed for an individual with a complex or chronic medical condition or a rare 31
224	224	medical condition; and 32
225	225	(ii) Has a wholesale acquisition cost or negotiated price that exceeds the Medicare Part D 33
226	226	specialty tier threshold, as updated from time to time. 34
227	227
228	228
229	229	LC002457 - Page 7 of 8
230	230	(c) Every individual or group health insurance contract, plan or policy that provides 1
231	231	prescription coverage and is delivered, issued for delivery or renewed in this state on or after 2
232	232	January 1, 2024, shall not impose a copayment or coinsurance requirement on a covered specialty 3
233	233	drug that exceeds one hundred fifty dollars ($150) for up to a thirty (30)-day supply of the specialty 4
234	234	drug. A pre-service authorization may be used to provide coverage for specialty drugs. Coverage 5
235	235	for prescription specialty drugs shall not be subject to any deductible, unless prohibiting a 6
236	236	deductible requirement would cause a health plan to not qualify as a high deductible health plan. 7
237	237	(d) Nothing in this section prevents an insurer, health maintenance plan, or nonprofit 8
238	238	medical plan from reducing a covered individual's cost sharing to an amount less than one hundred 9
239	239	fifty dollars ($150) for a thirty (30)-day supply of a specialty drug. 10
240	240	(e) The health insurance commissioner shall promulgate any rules and regulations 11
241	241	necessary to implement and administer this section in accordance with any federal requirements 12
242	242	and shall use the commissioner's enforcement powers to obtain compliance with the provisions of 13
243	243	this section. 14
244	244	SECTION 5. This act shall take effect upon passage. 15
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251	251	EXPLANATION
252	252	BY THE LEGISLATIVE COUNCIL
253	253	OF
254	254	A N A C T
255	255	RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES
256	256	***
257	257	This act would limit the copayment or coinsurance requirement on specialty drugs to one 1
258	258	hundred fifty dollars ($150) for a thirty (30)-day supply regarding any specialty drug in any 2
259	259	individual or health insurance contract, plan or policy issued, delivered or renewed on or after 3
260	260	January 1, 2024. Specialty drugs would be defined as a drug prescribed to an individual with a 4
261	261	complex or chronic medical condition or a rare medical condition. 5
262	262	This act would take effect upon passage. 6
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264	264	LC002457
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