Health insurance; require health benefit plans to follow new procedure related to step therapy protocol for CRF-COPD treatment.

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To: Insurance
MISSISSIPPI LEGISLATURE REGULAR SESSION 2026

By: Senator(s) Blackwell

SENATE BILL NO. 2010

AN ACT TO CREATE NEW SECTION 83-9-36.3, MISSISSIPPI CODE OF 1
1972, TO REQUIRE A HEALTH BENEFIT PLAN TO IMPLEMENT A CLEAR AND 2
TRANSPARENT PROCESS FOR A PARTICIPANT, BENEFICIARY OR THE 3
PRESCRIBING HEALTH CARE PROVIDER ON BEHALF OF THE PARTICIPANT OR 4
BENEFICIARY, WITH CRF-COPD TO REQUEST AN EXCEPTION TO A STEP 5
THERAPY PROTOCOL; TO SET CERTAIN PROCEDURES RELATED THERETO; TO 6
PROVIDE CERTAIN EXCEPTIONS TO A TREATMENT STEP THERAPY PROTOCOL 7
FOR TREATMENT OF CRF-COPD; TO REQUIRE HEALTH BENEFIT PLANS TO MAKE 8
CERTAIN INFORMATION REGARDING SUCH PROCEDURES AVAILABLE ON THEIR 9
WEBSITE; TO REQUIRE HEALTH BENEFIT PLANS TO RESPOND TO A 10
REQUESTING PRESCRIBER WITHIN SEVENTY-TWO HOURS AFTER RECEIVING AN 11
INITIAL EXCEPTION REQUEST; TO REQUIRE HEALTH BENEFIT PLANS TO 12
RESPOND TO SUCH A REQUEST WITHIN ONE BUSINESS DAY WHEN THE STEP 13
THERAPY PROTOCOL MAY JEOPARDIZE THE LIFE OR HEALTH OF THE 14
BENEFICIARY; TO AMEND SECTION 83-9-36, MISSISSIPPI CODE OF 1972, 15
TO CONFORM TO THE PROVISIONS OF THE ACT; AND FOR RELATED PURPOSES. 16
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI: 17
SECTION 1. The following shall be codified as Section 18
83-9-36.3, Mississippi Code of 1972: 19
83-9-36.3. (1) For purposes of this section, the following 20
definitions shall apply: 21
(a) "Health benefit plan" has the meaning given to that 22
term in Section 83-9-6.3. Such term shall include those plans 23
that provide coverage for invasive or noninvasive mechanical 24
ventilation to treat chronic respiratory failure consequent to 25
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chronic obstructive pulmonary disease (CRF-COPD), requiring a step 26
therapy protocol. 27
(b) "Treatment step therapy protocol" means a treatment 28
utilization management protocol or program under which a group 29
health plan or health insurance issuer offering group health 30
insurance coverage of respiratory care treatments requires a 31
participant or beneficiary to try an alternative, plan-preferred 32
treatment and fail on this treatment before the plan or health 33
insurance issuer approves coverage for the non-preferred therapy 34
prescribed by the beneficiary's medical provider. 35
(2) A health benefit plan shall: 36
(a) Implement a clear and transparent process for a 37
participant or beneficiary, or the prescribing health care 38
provider on behalf of the participant or beneficiary, with 39
CRF-COPD to request an exception to such a step therapy protocol; 40
(b) Where the participant, beneficiary or prescribing 41
health care provider's request for an exception to the treatment 42
step therapy protocols satisfies the criteria and requirements of 43
subsection (3) of this section, cover the requested treatment in 44
accordance with the terms established by the health plan or 45
coverage for patient cost-sharing rates or amounts at the time of 46
the participant's or beneficiary's enrollment in the health plan 47
or health insurance coverage. 48
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(3) The circumstances requiring an exception to a treatment 49
step therapy protocol, pursuant to a request under subsection (2) 50
of this section, are any of the following: 51
(a) Any treatments otherwise required under the 52
protocol have not been shown to be as effective as other available 53
options in the treatment of the disease or condition or the 54
participant or beneficiary, when prescribed consistent with 55
clinical indications, clinical guidelines or other peer-reviewed 56
evidence; 57
(b) Delay of proven effective treatment would lead to 58
severe or irreversible consequences, and the treatment initially 59
required under the protocol is reasonably expected to be less 60
effective based upon the documented physical or mental 61
characteristics of the participant or beneficiary and the known 62
characteristics of such treatment; 63
(c) Any treatments otherwise required under the 64
protocol are contraindicated for the participant or beneficiary or 65
have caused, or are likely to cause, based on clinical, 66
peer-reviewed evidence, an adverse reaction or other physical harm 67
to the participant or beneficiary; 68
(d) Any treatment otherwise required under the protocol 69
has prevented, will prevent, or is likely to prevent a participant 70
or beneficiary from achieving or maintaining reasonable and safe 71
functional ability in performing occupational responsibilities or 72
activities of daily living; or 73
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(e) The patient's disease state is classified as 74
life-threatening. 75
(4) The process required by subsection (2) of this section 76
shall: 77
(a) Provide the prescribing health care provider or 78
beneficiary or designated third-party advocate an opportunity to 79
present such provider's clinical rationale and relevant medical 80
information for the group health plan or health insurance issuer 81
to evaluate such request for exception; 82
(b) Clearly set forth all required information and the 83
specific criteria that will be used to determine whether an 84
exception is warranted, which may require disclosure of the 85
medical history or other health records of the participant or 86
beneficiary demonstrating that the participant or beneficiary 87
seeking an exception: 88
(i) Has tried other qualifying treatments without 89
success; or 90
(ii) Has received the requested treatment for a 91
clinically appropriate amount of time to establish stability, in 92
relation to the condition being treated and guidelines given by 93
the prescribing physician. Other clinical information that may be 94
relevant to conducting the exception review may require 95
disclosure; 96
(c) Not require the submission of any information or 97
supporting documentation beyond what is strictly necessary to 98
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determine whether any of the circumstances listed in subsection 99
(3) of this section exist. 100
(5) The health benefit plan shall make information regarding 101
the process required under subsection (2) of this section readily 102
available on the internet website of the group health plan or 103
health insurance issuer. Such information shall include: 104
(a) The requirements for requesting an exception to a 105
treatment step therapy protocol pursuant to this section; and 106
(b) Any forms, supporting information, and contact 107
information, as appropriate. 108
(6) The process required under subsection (2)(a) of this 109
section shall provide for the disposition of requests received 110
under such paragraph in accordance with the following: 111
(a) Subject to paragraph (b) of this subsection, not 112
later than seventy-two (72) hours after receiving an initial 113
exception request, the plan or issuer shall respond to the 114
requesting prescriber with either a determination of exception 115
eligibility or a request for additional required information, 116
strictly necessary to make a determination of whether the 117
conditions specified in subsection (3) of this section are met. 118
The plan or issuer shall respond to the requesting provider with a 119
determination of exception eligibility no later than seventy-two 120
(72) hours after receipt of the additional required information; 121
or 122
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(b) In the case of a request under circumstances in 123
which the applicable equipment step therapy protocol may seriously 124
jeopardize the life or health of the participant or beneficiary, 125
the plan or issuer shall conduct a review of the request and 126
respond to the requesting prescriber with either a determination 127
or exception eligibility or a request for additional required 128
information strictly necessary to make a determination of whether 129
the conditions specified in subsection (3) of this section are 130
met, in accordance with the following: 131
(i) If the plan or issuer can make a determination 132
of exception eligibility without additional information, such 133
determination shall be made on an expedited basis and no later 134
than one (1) business day after receipt of such request, or 135
(ii) If the plan or issuer requires additional 136
information before making a determination of exception 137
eligibility, the plan or issuer shall respond to the requesting 138
provider with a request for such information within one (1) 139
business day of the request for a determination, and shall respond 140
with a determination of exception eligibility as quickly as the 141
condition or disease requires and no later than one (1) business 142
day after receipt of the additional required information. 143
(7) This act shall apply with respect to any licensed 144
provider in the State of Mississippi that provides coverage of a 145
treatment pursuant to a policy that meets the definition of 146
treatment step therapy protocol in this act, regardless of whether 147
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such policy is described by such group health plan or health 148
insurance coverage as a step therapy protocol. 149
SECTION 2. Section 83-9-36, Mississippi Code of 1972, is 150
amended as follows: 151
83-9-36. (1) When medications for the treatment of any 152
medical condition are restricted for use by an insurer by a step 153
therapy or fail-first protocol, the prescribing practitioner shall 154
have access to a clear and convenient process to expeditiously 155
request an override of that restriction from the insurer. An 156
override of that restriction shall be expeditiously granted by the 157
insurer under the following circumstances: 158
(a) The prescribing practitioner can demonstrate, based 159
on sound clinical evidence, that the preferred treatment required 160
under step therapy or fail-first protocol has been ineffective in 161
the treatment of the insured's disease or medical condition; or 162
(b) Based on sound clinical evidence or medical and 163
scientific evidence: 164
(i) The prescribing practitioner can demonstrate 165
that the preferred treatment required under the step therapy or 166
fail-first protocol is expected or likely to be ineffective based 167
on the known relevant physical or mental characteristics of the 168
insured and known characteristics of the drug regimen; or 169
(ii) The prescribing practitioner can demonstrate 170
that the preferred treatment required under the step therapy or 171
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fail-first protocol will cause or will likely cause an adverse 172
reaction or other physical harm to the insured. 173
(2) The duration of any step therapy or fail-first protocol 174
shall not be longer than a period of thirty (30) days when the 175
treatment is deemed clinically ineffective by the prescribing 176
practitioner. When the prescribing practitioner can demonstrate, 177
through sound clinical evidence, that the originally prescribed 178
medication is likely to require more than thirty (30) days to 179
provide any relief or an amelioration to the insured, the step 180
therapy or fail-first protocol may be extended up to seven (7) 181
additional days. 182
(3) As used in this section: 183
(a) "Insurer" means any hospital, health, or medical 184
expense insurance policy, hospital or medical service contract, 185
employee welfare benefit plan, contract or agreement with a health 186
maintenance organization or a preferred provider organization, 187
health and accident insurance policy, or any other insurance 188
contract of this type, including a group insurance plan. However, 189
the term "insurer" does not include a preferred provider 190
organization that is only a network of providers and does not 191
define health care benefits for the purpose of coverage under a 192
health care benefits plan. 193
(b) "Practitioner" has the same meaning as defined in 194
Section 73-21-73. 195
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ST: Health insurance; require health benefit
plans to follow new procedure related to step
therapy protocol for CRF-COPD treatment.
(4) The provisions of Section 83-9-8.1 shall supersede the 196
provisions of this section to the extent of any conflict between 197
Section 83-9-8.1 and this section. 198
(5) The provisions of this section shall not apply to 199
Section 1 of this act. 200
SECTION 3. This act shall take effect and be in force from 201
and after July 1, 2026. 202