Creates provisions relating to cost-sharing under health benefit plans

SECOND REGULAR SESSION
HOUSE BILL NO. 1681
103RD GENERAL ASSEMBL Y
INTRODUCED BY REPRESENT A TIVE SEITZ.
5031H.01I JOSEPH ENGLER, Chief Clerk
AN ACT
T o amend chapter 376, RSMo, by adding thereto one new section relating to cost-sharing
under health benefit plans.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Chapter 376, RSMo, is amended by adding thereto one new section, to be
2 known as section 376.448, to read as follows:
376.448. 1. As used in this section, the following terms mean:
2 (1) "Cost-sharing", any co-payment, coinsurance, deductible, amount paid by
3 an enrol lee for health care services in excess of a coverage limitation, or similar charge
4 r equir ed by or on behalf of an enr ollee in order to receive a specific health car e service
5 cover ed by a health benefit plan, whether cover ed under medical benefits or pharmacy
6 benefits. The term "cost-sharing" shall include cost-sharing as defined in 42 U.S.C.
7 Section 18022(c);
8 (2) "Enro llee", the same meaning given to the term in section 376.1350;
9 (3) "Generic drug", the same meaning given to the term in 42 CFR 423.4;
10 (4) "Health benefit plan", the same meaning given to the term in section
11 376.1350;
12 (5) "Health care service", the same meaning given to the term in section
13 376.1350;
14 (6) "Health carrier", the same meaning given to the term in section 376.1350;
15 (7) "Pharmacy benefits manager", the same meaning given to the term in section
16 376.388.
EXPLANA TION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is
intended to be omitted from the law . Matter in bold-face type in the above bill is proposed language.
17 2. When calculating an enr ollee's overall contribution to any out-of-pocket
18 maximum or any cost-sharing requ irem ent under a health benefit plan, a health carrier
19 or pharmacy benefits manager shall include any amounts paid by the enr ollee or paid
20 on behalf of the enr ollee for any medication wher e a generic drug substitute for such
21 medication is not available.
22 3. A health carrier or pharmacy benefits manager shall not vary an enr ollee's
23 out-of-pocket maximum or any cost-sharing r equir ement based on, or otherwise design
24 benefits in a manner that takes into account, the availability of any cost-sharing
25 assistance progra m for any medication wher e a generic drug substitute for such
26 medication is not available.
27 4. If, under federal law , application of the req uirement under subsection 2 of this
28 section would res ult in health savings account ineligibility under Section 223 of the
29 Internal Revenue Code of 1986, as amended, the requ irem ent under subsection 2 of this
30 section shall apply to health savings account-qualified high deductible health plans with
31 r espect to any cost-sharing of such a plan after the enro llee has satisfied the minimum
32 deductible under Section 223, except with re spect to items or services that are
33 pr eventive car e under Section 223(c)(2)(C) of the Internal Revenue Code of 1986, as
34 amended, in which case the re quir ement of subsection 2 of this section shall apply
35 r egardless of whether the minimum deductible under Section 223 has been satisfied.
36 5. Nothing in this section shall pr ohibit a health carrier or health benefit plan
37 fr om utilizing step therapy in accordance with section 376.2034.
38 6. The pr ovisions of this section shall not apply to health benefit plans that ar e
39 cover ed under the Labor Management Relations Act of 1947, 29 U.S.C. Section 141 et
40 seq., as amended.
41 7. The provi sions of this section shall apply to health benefit plans enter ed into,
42 amended, extended, or renew ed on or after August 28, 2026.
✔
HB 1681 2