Bill Text: IA SF86 | 2023-2024 | 90th General Assembly | Introduced

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Bill Title: A bill for an act relating to continuity of care and nonmedical switching by health carriers, health benefit plans, and utilization review organizations, and including applicability provisions.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2023-01-26 - Subcommittee recommends amendment and passage. []. [SF86 Detail]

Download: Iowa-2023-SF86-Introduced.html

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Senate File 86 - Introduced
SENATE FILE 86
BY KLIMESH
A BILL FOR
An Act relating to continuity of care and nonmedical switching
by health carriers, health benefit plans, and utilization
review organizations, and including applicability
provisions.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
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Section 1. NEW SECTION . 514F.9 Continuity of care ——
nonmedical switching.
1. Definitions. For the purpose of this section:
a. “Authorized representative” means the same as defined in
section 514J.102.
b. “Commissioner” means the commissioner of insurance.
c. “Cost sharing” means any coverage limit, copayment,
coinsurance, deductible, or other out-of-pocket expense
requirement.
d. “Coverage exemption” means a determination made by a
health carrier, health benefit plan, or utilization review
organization to cover a prescription drug that is otherwise
excluded from coverage.
e. “Coverage exemption determination” means a determination
made by a health carrier, health benefit plan, or utilization
review organization whether to cover a prescription drug that
is otherwise excluded from coverage.
f. “Covered person” means the same as defined in section
514J.102.
g. “Demonstrated bioavailability” means the same as defined
in section 155A.3.
h. “Discontinued health benefit plan” means a covered
person’s existing health benefit plan that is discontinued by a
health carrier during open enrollment for the next plan year.
i. “Formulary” means a complete list of prescription drugs
eligible for coverage under a health benefit plan.
j. “Generic name” means the same as defined in section
155A.3.
k. “Health benefit plan” means the same as defined in
section 514J.102.
l. “Health care professional” means the same as defined in
section 514J.102.
m. “Health care services” means the same as defined in
section 514J.102.
n. “Health carrier” means an entity subject to the
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insurance laws and regulations of this state, or subject
to the jurisdiction of the commissioner, including an
insurance company offering sickness and accident plans, a
health maintenance organization, a nonprofit health service
corporation, a plan established pursuant to chapter 509A
for public employees, or any other entity providing a plan
of health insurance, health care benefits, or health care
services. “Health carrier” does not include the department
of human services, or a managed care organization acting
pursuant to a contract with the department of human services to
administer the medical assistance program under chapter 249A
or the healthy and well kids in Iowa (hawk-i) program under
chapter 514I.
o. “Interchangeable biological product” means the same as
defined in section 155A.3.
p. “Open enrollment” means the yearly time period during
which an individual can enroll in a health benefit plan.
q. “Utilization review” means the same as defined in section
514F.7.
r. “Utilization review organization” means the same as
defined in section 514F.7.
2. Nonmedical switching. With respect to a health carrier
that has entered into a health benefit plan with a covered
person that covers prescription drug benefits, all of the
following apply:
a. A health carrier, health benefit plan, or utilization
review organization shall not limit or exclude coverage of
a prescription drug for any covered person who is medically
stable on such drug as determined by the prescribing health
care professional, if all of the following apply:
(1) The prescription drug was previously approved by the
health carrier for coverage for the covered person.
(2) The covered person’s prescribing health care
professional has prescribed the drug for the covered person’s
medical condition within the previous six months.
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(3) The covered person continues to be an enrollee of the
health benefit plan.
b. Coverage of a covered person’s prescription drug, as
described in paragraph “a” , shall continue through the last day
of the covered person’s eligibility under the health benefit
plan, inclusive of any open enrollment period.
c. Prohibited limitations and exclusions referred to in
paragraph “a” include but are not limited to the following:
(1) Limiting or reducing the maximum coverage of
prescription drug benefits.
(2) Increasing cost sharing for a covered prescription
drug.
(3) Moving a prescription drug to a more restrictive tier if
the health carrier uses a formulary with tiers.
(4) Removing a prescription drug from a formulary, unless
the United States food and drug administration has issued a
statement about the drug that calls into question the clinical
safety of the drug, or the manufacturer of the drug has
notified the United States food and drug administration of a
manufacturing discontinuance or potential discontinuance of the
drug as required by section 506C of the Federal Food, Drug, and
Cosmetic Act, as codified in 21 U.S.C. §356c.
d. This subsection shall not be construed to prohibit
a substitution, a formulary change, or a preference by a
health carrier for a prescribed drug product that has the same
generic name and demonstrated bioavailability, or that is an
interchangeable biological product.
3. Coverage exemption determination process.
a. To ensure continuity of care, a health carrier, health
plan, or utilization review organization shall provide a
covered person and prescribing health care professional
with access to a clear and convenient process to request a
coverage exemption determination. A health carrier, health
plan, or utilization review organization may use its existing
medical exceptions process to satisfy this requirement. The
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process shall be easily accessible on the internet site of the
health carrier, health benefit plan, or utilization review
organization.
b. A health carrier, health benefit plan, or utilization
review organization shall respond to a coverage exemption
determination request within five calendar days of receipt. In
cases where exigent circumstances exist, the health carrier,
health benefit plan, or utilization review organization shall
respond within seventy-two hours of receipt. If a response by
the health carrier, health benefit plan, or utilization review
organization is not received within the applicable time period,
the coverage exemption shall be deemed granted.
c. A coverage exemption shall be expeditiously granted for a
discontinued health benefit plan if a covered person enrolls in
a comparable plan offered by the same health carrier, and all
of the following conditions apply:
(1) The covered person is medically stable on a prescription
drug as determined by the prescribing health care professional.
(2) The prescribing health care professional continues
to prescribe the drug for the covered person for the covered
person’s medical condition.
(3) In comparison to the discontinued health benefit plan,
the new health benefit plan does any of the following:
(a) Limits or reduces the maximum coverage of prescription
drug benefits.
(b) Increases cost sharing for the prescription drug.
(c) Moves the prescription drug to a more restrictive tier
if the health carrier uses a formulary with tiers.
(d) Excludes the prescription drug from the health benefit
plan’s formulary.
d. Upon granting of a coverage exemption for a drug
prescribed by a covered person’s prescribing health care
professional, a health carrier, health benefit plan, or
utilization review organization shall authorize coverage no
more restrictive than that offered in a discontinued health
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benefit plan, or than that offered prior to implementation of
restrictive changes to the health benefit plan’s formulary
after the current plan year began.
e. If a determination is made to deny a request for a
coverage exemption, the health carrier, health benefit plan,
or utilization review organization shall provide the covered
person or the covered person’s authorized representative and
the authorized person’s prescribing health care professional
with the reason for denial and information regarding the
procedure to appeal the denial. Any determination to deny a
coverage exemption may be appealed by a covered person or the
covered person’s authorized representative.
f. A health carrier, health benefit plan, or utilization
review organization shall uphold or reverse a determination to
deny a coverage exemption within five calendar days of receipt
of an appeal of denial. In cases where exigent circumstances
exist, a health carrier, health benefit plan, or utilization
review organization shall uphold or reverse a determination to
deny a coverage exemption within seventy-two hours of receipt.
If the determination to deny a coverage exemption is not upheld
or reversed on appeal within the applicable time period, the
denial shall be deemed reversed and the coverage exemption
shall be deemed approved.
g. If a determination to deny a coverage exemption is
upheld on appeal, the health carrier, health benefit plan,
or utilization review organization shall provide the covered
person or the covered person’s authorized representative and
the covered person’s prescribing health care professional with
the reason for upholding the denial on appeal and information
regarding the procedure to request external review of the
denial pursuant to chapter 514J. Any denial of a request for a
coverage exemption that is upheld on appeal shall be considered
a final adverse determination for purposes of chapter 514J and
is eligible for a request for external review by a covered
person or the covered person’s authorized representative
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pursuant to chapter 514J.
4. Limitations. This section shall not be construed to do
any of the following:
a. Prevent a health care professional from prescribing
another drug covered by the health carrier that the health care
professional deems medically necessary for the covered person.
b. Prevent a health carrier from doing any of the following:
(1) Adding a prescription drug to its formulary.
(2) Removing a prescription drug from its formulary if the
drug manufacturer has removed the drug for sale in the United
States.
5. Enforcement. The commissioner may take any enforcement
action under the commissioner’s authority to enforce compliance
with this section.
Sec. 2. APPLICABILITY. This Act applies to a health benefit
plan that is delivered, issued for delivery, continued, or
renewed in this state on or after January 1, 2024.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
This bill relates to the continuity of care for a covered
person and nonmedical switching by health carriers, health
benefit plans, and utilization review organizations.
The bill provides that during a covered person’s
eligibility under a health benefit plan, inclusive of any open
enrollment period, a health plan carrier, health benefit plan,
or utilization review organization shall not limit or exclude
coverage of a prescription drug for the covered person if the
covered person is medically stable on the drug as determined
by the prescribing health care professional, the drug was
previously approved by the health carrier for coverage for
the person, and the covered person’s prescribing health care
professional has prescribed the drug for the person’s medical
condition within the previous six months. The bill includes,
as prohibited limitations or exclusions, reducing the maximum
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coverage of prescription drug benefits, increasing cost sharing
for a covered drug, moving a drug to a more restrictive tier,
and removing a drug from a formulary. A prescription drug
may, however, be removed from a formulary if the United States
food and drug administration issues a statement regarding the
clinical safety of the drug, or the manufacturer of the drug
notifies the United States food and drug administration of
a manufacturing discontinuance or potential discontinuance
of the drug as required by section 506c of the Federal Food,
Drug, and Cosmetic Act. The bill shall not be construed to
prohibit a substitution, a formulary change, or a preference
by a health carrier for a prescribed drug product that has the
same generic name and demonstrated bioavailability, or that is
an interchangeable biological product. “Health benefit plan”,
“health carrier”, and “utilization review organization” are
defined in the bill.
The bill requires a covered person and prescribing health
care professional to have access to a process to request a
coverage exemption determination. The bill defines “coverage
exemption determination” as a determination made by a
health carrier, health benefit plan, or utilization review
organization whether to cover a prescription drug that is
otherwise excluded from coverage.
A coverage exemption determination request must be approved
or denied by the health carrier, health benefit plan, or
utilization review organization within five calendar days,
or within 72 hours if exigent circumstances exist. If a
determination is not received within the applicable time period
the coverage exemption is deemed granted.
The bill requires a coverage exemption to be expeditiously
granted for a health benefit plan that is discontinued for the
next plan year if a covered person enrolls in a comparable
plan offered by the same health carrier, and in comparison
to the discontinued health benefit plan, the new health
benefit plan limits or reduces the maximum coverage for a
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prescription drug, increases cost sharing for the prescription
drug, moves the prescription drug to a more restrictive
tier, or excludes the prescription drug from the formulary.
If a coverage exemption is granted, the bill requires an
authorization of coverage that is no more restrictive than
that offered in the discontinued health benefit plan, or than
that offered prior to implementation of restrictive changes
to the health benefit plan’s formulary after the current plan
year began. If a determination is made to deny a request for
a coverage exemption, the reason for denial and the procedure
to appeal the denial must be provided to the requestor. Any
determination to deny a coverage exemption may be appealed to
the health carrier, health benefit plan, or utilization review
organization. A determination to uphold or reverse denial
of a coverage exemption must be made within five calendar
days of receipt of an appeal, or within 72 hours if exigent
circumstances exist. If a determination is not made within the
applicable time period, the denial is deemed reversed and the
coverage exemption is deemed approved.
If a determination to deny a coverage exemption is upheld on
appeal, the reason for upholding the denial and the procedure
to request external review of the denial pursuant to Code
chapter 514J must be provided to the individual who filed the
appeal. Any denial of a request for a coverage exemption that
is upheld on appeal is considered a final adverse determination
for purposes of Code chapter 514J and is eligible for a request
for external review by a covered person or the covered person’s
authorized representative pursuant to Code chapter 514J.
The bill shall not be construed to prevent a health care
professional from prescribing another drug covered by the
health carrier that the health care professional deems
medically necessary for the covered person.
The bill shall not be construed to prevent a health carrier
from adding a drug to its formulary, or from removing a drug
from its formulary if the drug manufacturer removes the drug
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for sale in the United States.
The bill allows the commissioner to take any necessary
enforcement action under the commissioner’s authority to
enforce compliance with the bill.
The bill is applicable to health benefit plans that are
delivered, issued for delivery, continued, or renewed in this
state on or after January 1, 2024.
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