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Bill H.4958
SECTION 1. Chapter 32A of the General Laws is hereby amended by inserting after section 17Z the following new section:-
Section 17AA. (a) Coverage offered by the commission to an active or retired employee of
the commonwealth insured under the group insurance commission shall provide coverage for prescribed or dispensed opioid antagonists and opioid agonists, including partial agonists, used in the treatment of opioid use disorder; provided, however that the coverage for such prescribed, administered, ordered or dispensed opioid antagonists and opioid agonists, including partial agonists, shall be deemed medically necessary and shall not require prior authorization; and provided further that a prescription from a health care practitioner shall not be required for coverage of opioid antagonists and opioid agonists, including partial agonists. An opioid antagonist and an opioid agonist, including partial agonists, shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits; provided, however, that cost-sharing shall be required if the applicable plan is governed by the Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service.
(b) The commission shall provide coverage for an opioid antagonist and an opioid agonist, including partial agonists, used in the treatment of opioid use disorder as a medical benefit when dispensed or administered by the health care facility, including substance use treatment facility, in which the opioid antagonist or opioid agonist, including partial agonists, used in the treatment of opioid use disorder was prescribed, administered, or ordered and shall provide coverage as a pharmacy benefit for an opioid antagonist and an opioid agonist, including partial agonists, used in the treatment of opioid use disorder dispensed by a pharmacist; provided, however, that the rate to be reimbursed under the medical benefit shall not exceed the commission’s average in-network pharmacy benefit rate and the health care facility shall not balance bill the patient. If dispensed directly to or administered to the patient, the commission shall ensure cost to the health care facility is covered through reimbursement or other mechanism as determined by the commission in consultation with the department of public health, the division of insurance, and the division of medical assistance.
SECTION 2. Chapter 118E of the General Laws is hereby amended by inserting after section 10Z the following new section:-
Section 10AA. (a) The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization, accountable care organization or primary care clinician plan shall provide coverage for prescribed or dispensed opioid antagonists and opioid agonists, including partial agonists, used in the treatment of opioid use disorder; provided, however that the coverage for such prescribed, administered, ordered or dispensed opioid antagonists and opioid agonists, including partial agonists, shall be deemed medically necessary and shall not require prior authorization; and provided further that a prescription from a health care practitioner shall not be required for coverage of opioid antagonists and opioid agonists, including partial agonists. An opioid antagonist and an opioid agonist, including partial agonists, shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits; provided, however, that cost-sharing shall be required if the applicable plan is governed by the Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service.
(b) The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization, accountable care organization or primary care clinician plan shall provide coverage for an opioid antagonist and an opioid agonist, including partial agonists, used in the treatment of opioid use disorder as a medical benefit when dispensed or administered by the health care facility, including substance use treatment facility, in which the opioid antagonist or opioid agonist, including partial agonists, used in the treatment of opioid use disorder was prescribed, administered, or ordered and shall provide coverage as a pharmacy benefit for an opioid antagonist and an opioid agonist, including partial agonists, used in the treatment of opioid use disorder dispensed by a pharmacist; provided, however, that the rate to be reimbursed under the medical benefit shall not exceed the carrier’s average in-network pharmacy benefit rate and the health care facility shall not balance bill the patient. If dispensed directly to or administered to the patient, the division shall ensure cost to the health care facility is covered through reimbursement or other mechanism as determined by the commission in consultation with the department of public health and the division of insurance.
SECTION 3. Chapter 175 of the General Laws, is hereby amended by inserting before section 47CCC the following new section:-
Section 47AAA. (a) Any blanket or general policy of insurance described in subdivision (A), (C), or (D) of section one hundred and ten which is issued or subsequently renewed by agreement between the insurer and the policyholder, within or without the commonwealth, during the period within which this premium is effective, or any policy of accident or sickness insurance as described in section one hundred and eight which provides hospital expense and surgical expense insurance and which is delivered or issued for delivery or subsequently renewed by agreement between the insurer and the policyholder in the commonwealth, during the period within which this provision is effective, or any employers' health and welfare fund which provides hospital expense and surgical expense benefits and which is issued or renewed to any person or group of persons in the commonwealth, during the period within which this provision is effective, shall provide coverage for prescribed or dispensed opioid antagonists and opioid agonists, including partial agonists, used in the treatment of opioid use disorder; provided, however that the coverage for such prescribed, administered, ordered or dispensed opioid antagonists and opioid agonists, including partial agonists, shall be deemed medically necessary and shall not require prior authorization; and provided further that a prescription from a health care practitioner shall not be required for coverage of opioid antagonists and opioid agonists, including partial agonists. An opioid antagonist and an opioid agonist, including partial agonists, shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits; provided, however, that cost-sharing shall be required if the applicable plan is governed by the Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service.
(b) Any blanket or general policy of insurance described in subdivision (A), (C), or (D) of section one hundred and ten which is issued or subsequently renewed by agreement between the insurer and the policyholder, within or without the commonwealth, during the period within which this premium is effective, or any policy of accident or sickness insurance as described in section one hundred and eight which provides hospital expense and surgical expense insurance and which is delivered or issued for delivery or subsequently renewed by agreement between the insurer and the policyholder in the commonwealth, during the period within which this provision is effective, or any employers' health and welfare fund which provides hospital expense and surgical expense benefits and which is issued or renewed to any person or group of persons in the commonwealth, during the period within which this provision is effective, shall provide coverage for an opioid antagonist and an opioid agonist, including partial agonists, used in the treatment of opioid use disorder as a medical benefit when dispensed or administered by the health care facility, including substance use treatment facility, in which the opioid antagonist or opioid agonist, including partial agonists, used in the treatment of opioid use disorder was prescribed, administered, or ordered and shall provide coverage as a pharmacy benefit for an opioid antagonist and an opioid agonist, including partial agonists, used in the treatment of opioid use disorder dispensed by a pharmacist; provided, however, that the rate to be reimbursed under the medical benefit shall not exceed the carrier’s average in-network pharmacy benefit rate and the health care facility shall not balance bill the patient. If dispensed directly to or administered to the patient, the division shall ensure cost to the health care facility is covered through reimbursement or other mechanism as determined by the division in consultation with the department of public health and the division of medical assistance.
SECTION 4. Chapter 176A of the General Laws is hereby amended by inserting after section 8DDD the following new section:-
Section 8EEE. (a) Any contract between a subscriber and the corporation under an
individual or group hospital service plan that is delivered, issued or renewed within the
commonwealth shall provide coverage for prescribed or dispensed opioid antagonists and opioid agonists, including partial agonists, used in the treatment of opioid use disorder; provided, however that the coverage for such prescribed, administered, ordered or dispensed opioid antagonists and opioid agonists, including partial agonists, shall be deemed medically necessary and shall not require prior authorization; and provided further that a prescription from a health care practitioner shall not be required for coverage of opioid antagonists and opioid agonists, including partial agonists. An opioid antagonist and an opioid agonist, including partial agonists, shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits; provided, however, that cost-sharing shall be required if the applicable plan is governed by the Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service.
(b) Such contracts shall provide coverage for an opioid antagonist and an opioid agonist, including partial agonists, used in the treatment of opioid use disorder as a medical benefit when dispensed or administered by the health care facility, including substance use treatment facility, in which the opioid antagonist or opioid agonist, including partial agonists, used in the treatment of opioid use disorder was prescribed, administered, or ordered and shall provide coverage as a pharmacy benefit for an opioid antagonist and an opioid agonist, including partial agonists, used in the treatment of opioid use disorder dispensed by a pharmacist; provided, however, that the rate to be reimbursed under the medical benefit shall not exceed the carrier’s average in-network pharmacy benefit rate and the health care facility shall not balance bill the patient. If dispensed directly to or administered to the patient, the division shall ensure cost to the health care facility is covered through reimbursement or other mechanism as determined by the division in consultation with the department of public health and the division of medical assistance.
SECTION 5. Chapter 176B of the General Laws is hereby amended by inserting after section 4DDD the following new section:-
Section 4EEE. (a) A subscription certificate under an individual or group medical service
agreement delivered, issued or renewed within the commonwealth shall provide coverage for prescribed or dispensed opioid antagonists and opioid agonists, including partial agonists, used in the treatment of opioid use disorder; provided, however that the coverage for such prescribed, administered, ordered or dispensed opioid antagonists and opioid agonists, including partial agonists, shall be deemed medically necessary and shall not require prior authorization; and provided further that a prescription from a health care practitioner shall not be required for coverage of opioid antagonists and opioid agonists, including partial agonists. An opioid antagonist and an opioid agonist, including partial agonists, shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits; provided, however, that cost-sharing shall be required if the applicable plan is governed by the Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service.
(b) The policy, contract, agreement, plan or certificate of insurance shall provide coverage for an opioid antagonist and an opioid agonist, including partial agonists, used in the treatment of opioid use disorder as a medical benefit when dispensed or administered by the health care facility, including substance use treatment facility, in which the opioid antagonist or opioid agonist, including partial agonists, used in the treatment of opioid use disorder was prescribed, administered, or ordered and shall provide coverage as a pharmacy benefit for an opioid antagonist and an opioid agonist, including partial agonists, used in the treatment of opioid use disorder dispensed by a pharmacist; provided, however, that the rate to be reimbursed under the medical benefit shall not exceed the carrier’s average in-network pharmacy benefit rate and the health care facility shall not balance bill the patient. If dispensed directly to or administered to the patient, the division shall ensure cost to the health care facility is covered through reimbursement or other mechanism as determined by the division in consultation with the department of public health and the division of medical assistance.
SECTION 6. Chapter 176G of the General Laws is hereby amended by inserting after section 4VV the following new section:-
Section 4WW. (a) An individual or group health maintenance contract that is issued or
renewed within or without the commonwealth shall provide coverage for prescribed or dispensed opioid antagonists and opioid agonists, including partial agonists, used in the treatment of opioid use disorder; provided, however that the coverage for such prescribed, administered, ordered or dispensed opioid antagonists and opioid agonists, including partial agonists, shall be deemed medically necessary and shall not require prior authorization; and provided further that a prescription from a health care practitioner shall not be required for coverage of opioid antagonists and opioid agonists, including partial agonists. An opioid antagonist and an opioid agonist, including partial agonists, shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits; provided, however, that cost-sharing shall be required if the applicable plan is governed by the Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service.
(b) The individual or group health maintenance contract shall provide coverage for an opioid antagonist and an opioid agonist, including partial agonists, used in the treatment of opioid use disorder as a medical benefit when dispensed or administered by the health care facility, including substance use treatment facility, in which the opioid antagonist or opioid agonist, including partial agonists, used in the treatment of opioid use disorder was prescribed, administered, or ordered and shall provide coverage as a pharmacy benefit for an opioid antagonist and an opioid agonist, including partial agonists, used in the treatment of opioid use disorder dispensed by a pharmacist; provided, however, that the rate to be reimbursed under the medical benefit shall not exceed the carrier’s average in-network pharmacy benefit rate and the health care facility shall not balance bill the patient. If dispensed directly to or administered to the patient, the division shall ensure cost to the health care facility is covered through reimbursement or other mechanism as determined by the division in consultation with the department of public health and the division of medical assistance.
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