SB 970

SECOND REGULAR SESSION
  SENATE COMMITTEE SUBSTITUTE FOR
  SENATE BILL NO. 970
  103RD GENERAL ASSEMBLY
 5021S.02C  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:
1Section A. Chapter 376, RSMo, is amended by adding thereto
2  one new section, to be known as section 376.448, to read as
3  follows:
1376.448.  1. As used in this section, the following
2  terms mean:
3(1)      "Cost-sharing", any co-payment, coinsurance,
4  deductible, amount paid by an enrollee for health care
5  services in excess of a coverage limitation, or similar
6  charge required by or on behalf of an enrollee in order to
7  receive a specific health care service covered by a health
8  benefit plan, whether covered under medical benefits or
9  pharmacy benefits.  The term "cost-sharing" shall include
10  cost-sharing as defined in 42 U.S.C. Section 18022(c);
11(2)      "Enrollee", the same meaning given to the term in
12  section 376.1350;
13(3)      "Generic drug", the same meaning given to the term
14  in 42 CFR 423.4;
15(4)      "Health benefit plan", the same meaning given to
16  the term in section 376.1350;
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17      (5)      "Health care service", the same meaning given to
18 the term in section 376.1350;
19      (6)      "Health carrier", the same meaning given to the
20 term in section 376.1350;
21      (7)      "Pharmacy benefits manager", the same meaning
22 given to the term in section 376.388.
23      2.      When calculating an enrollee's overall contribution
24 to any out-of-pocket maximum or any cost-sharing requirement
25 under a health benefit plan, a health carrier or pharmacy
26 benefits manager shall include any amounts paid by the
27 enrollee or paid on behalf of the enrollee for any
28 medication where a generic drug substitute for such
29 medication is not available.
30      3.      A health carrier or pharmacy benefits manager shall
31 not vary an enrollee's out-of-pocket maximum or any cost-
32 sharing requirement based on, or otherwise design benefits
33 in a manner that takes into account, the availability of any
34 cost-sharing assistance program for any medication where a
35 generic drug substitute for such medication is not available.
36      4.      If, under federal law, application of the
37 requirement under subsection 2 of this section would result
38 in health savings account ineligibility under Section 223 of
39 the Internal Revenue Code of 1986, as amended, the
40 requirement under subsection 2 of this section shall apply
41 to health savings account-qualified high deductible health
42 plans with respect to any cost-sharing of such a plan after
43 the enrollee has satisfied the minimum deductible under
44 Section 223, except with respect to items or services that
45 are preventive care under Section 223(c)(2)(C) of the
46 Internal Revenue Code of 1986, as amended, in which case the
47 requirement of subsection 2 of this section shall apply
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48 regardless of whether the minimum deductible under Section
49 223 has been satisfied.
50      5.      Nothing in this section shall prohibit a health
51 carrier or health benefit plan from utilizing step therapy
52 in accordance with section 376.2034.
53      6.      The provisions of this section shall not apply to
54 health benefit plans that are covered under the Labor
55 Management Relations Act of 1947, 29 U.S.C. Section 141, et
56 seq., as amended.
57      7.      The provisions of this section shall apply to
58 health benefit plans entered into, amended, extended, or
59 renewed on or after August 28, 2026.
60      8.      No changes to the provisions of the Employee
61 Retirement Income Security Act of 1974 as codified in 29
62 U.S.C. Chapter 18 and in effect on January 1, 2026, shall
63 alter or in any way weaken the exemption in subsection 6 of
64 this section.
65      9.      As specified in subsection 3 of this section, the
66 provisions of this section shall only apply to the instances
67 where a generic drug substitute for the medication is not
68 available.
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