Creates provisions relating to cost-sharing under health benefit plans

SECOND REGULAR SESSION
SENATE BILL NO. 840
103RD GENERAL ASSEMBLY
INTRODUCED BY SENATOR BERNSKOETTER.
5302S.01I KRISTINA MARTIN, Secretary
AN ACT
To 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 1
one new section, to be known as section 376.448, to read as 2
follows:3
376.448. 1. As used in this section, the following 1
terms mean: 2
(1) "Cost-sharing", any co-payment, coinsurance, 3
deductible, amount paid by an enrollee for health care 4
services in excess of a coverage limitation, or similar 5
charge required by or on behalf of an enrollee in order to 6
receive a specific health care service covered by a health 7
benefit plan, whether covered under medical benefits or 8
pharmacy benefits. The term "cost-sharing" shall include 9
cost-sharing as defined in 42 U.S.C. Section 18022(c); 10
(2) "Enrollee", the same meaning given to the term in 11
section 376.1350; 12
(3) "Generic drug", the same meaning given to the term 13
in 42 CFR 423.4; 14
(4) "Health benefit plan", the same meaning given to 15
the term in section 376.1350; 16
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(5) "Health care service", the same meaning given to 17
the term in section 376.1350; 18
(6) "Health carrier", the same meaning given to the 19
term in section 376.1350; 20
(7) "Pharmacy benefits manager", the same meaning 21
given to the term in section 376.388. 22
2. When calculating an enrollee's overall contribution 23
to any out-of-pocket maximum or any cost-sharing requirement 24
under a health benefit plan, a health carrier or pharmacy 25
benefits manager shall include any amounts paid by the 26
enrollee or paid on behalf of the enrollee for any 27
medication where a generic drug substitute for such 28
medication is not available. 29
3. A health carrier or pharmacy benefits manager shall 30
not vary an enrollee's out-of-pocket maximum or any cost- 31
sharing requirement based on, or otherwise design benefits 32
in a manner that takes into account, the availability of any 33
cost-sharing assistance program for any medication where a 34
generic drug substitute for such medication is not available. 35
4. If, under federal law, application of the 36
requirement under subsection 2 of this section would result 37
in health savings account ineligibility under Section 223 of 38
the Internal Revenue Code of 1986, as amended, the 39
requirement under subsection 2 of this section shall apply 40
to health savings account-qualified high deductible health 41
plans with respect to any cost-sharing of such a plan after 42
the enrollee has satisfied the minimum deductible under 43
Section 223, except with respect to items or services that 44
are preventive care under Section 223(c)(2)(C) of the 45
Internal Revenue Code of 1986, as amended, in which case the 46
requirement of subsection 2 of this section shall apply 47
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regardless of whether the minimum deductible under Section 48
223 has been satisfied. 49
5. Nothing in this section shall prohibit a health 50
carrier or health benefit plan from utilizing step therapy 51
in accordance with section 376.2034. 52
6. The provisions of this section shall not apply to 53
health benefit plans that are covered under the Labor 54
Management Relations Act of 1947, 29 U.S.C. Section 141, et 55
seq., as amended. 56
7. The provisions of this section shall apply to 57
health benefit plans entered into, amended, extended, or 58
renewed on or after August 28, 2026. 59
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