Based on the provided content, here are the requested details: "Legislation Assessment for Prescription Drug Cost-Sharing Limits in 2024

2024 Session Legislation Referred Garth Shipman, Insurance Policy Advisor Bureau of Insurance August 12, 2024 1

Step One assessments BOI will present: Summary of the bill; Extent to which the proposed mandate is currently available under qualified health plans (QHPs) in Virginia; and Whether the proposed mandate exceeds the scope of the current essential health benefit (EHB) benchmark plan.

Step One assessment status Bill & Topic Referring Committee Status HB 604 (2024) Polycystic ovary syndrome House Labor and Commerce Step One data call in development HB 610 (2024) Diabetes coverage for insulin, specified equipment and supplies, and exams House Appropriations Step One data call in development HB 946 (2024) Limits on prescription drug cost- sharing payments House Labor and Commerce Step One assessment completed HB 1347 (2024) Autism spectrum disorder House Appropriations Step One data call in development SB 333 (2024) Fertility preservation treatments Senate Education and Health Step One data call in development SB 376 (2024) Limits on prescription drug cost- sharing payments Senate Commerce and Labor Step One assessment completed SB 499 (2024) Pasteurized donated human breast milk House Appropriations Step One and Step Two assessment completed within last 3 years on substantially similar bill SB 735 (2024) Prohibition on denial of referrals by primary care providers Senate Commerce and Labor Step One data call in development

HB 946 (2024)/SB 376 (2024) Limits on prescription drug cost-sharing payments

HB 946 (2024)/SB 376 (2024): Bill summary This proposed mandate would require carriers offering health plans in the individual or small group market to ensure that 50% of their plans conform to specified cost-sharing limits for prescription drugs. These limits vary based on the level of coverage (bronze, silver, gold, or platinum): Silver, gold, or platinum levels must limit a person's cost-sharing payment for prescription drugs to an amount that does not exceed $100 per 30-day supply. Bronze level must limit a person's cost-sharing payment for prescription drugs to an amount that does not exceed $150 per 30-day supply. Plans meeting these requirements must be clearly labeled and marketed alongside other plans.

HB 946 (2024)/SB 376 (2024): Carrier responses BOI conducted a survey of carriers and responses indicated that there are no plans offering a limit on cost-sharing payments for prescription drugs as required in the bill. Prescription medications are categorized into tiers. Carriers indicated that while some lower tiers are below the cost-sharing limit, that was not true for all tiers in a given plan. BOI received responses from 8 carriers representing 95% of the individual covered lives in Virginia.

HB 946 (2024)/SB 376 (2024): Step One assessment Mandating that carriers limit cost sharing of at least 50% of health plans limit they offer in the individual or small group market is not contained in the Virginia EHB benchmark plan. BOI would not characterize the mandate contained in HB 946/SB 376 as a new essential health benefit and does not anticipate there would be a defrayal cost if the mandate were enacted. The Centers of Medicare and Medicaid Services have previously indicated to BOI that cost-sharing mandates should not be part of an EHB benchmark plan.

HB 946 (2024)/SB 376 (2024): HIRC options Recommend the bills for a Step Two assessment by BOI and JLARC. Recommend the bills for the EHB benchmark plan review process. Because cost-sharing mandates are not part of EHB benchmark plans, these bills should not be considered for the EHB benchmark plan review process. Take no action or consider it in some other manner.

SB 499 (2024) Pasteurized donor human milk and human milk-derived products

SB 499 (2024): Bill summary and relevant history In December 2021, BOI presented HIRC with a Step 2 assessment of HB 2049/SB 1650 (2019) which addressed coverage of pasteurized donated human breast milk (PDHM). This assessment was done within the three-year period immediately preceding the then-current session of the General Assembly. SB 499 (2024) mandates are substantially similar to HB 2049/SB 1650. SB 499 requires coverage of PDHM and human-milk derived products by private insurance plans and Virginia s Medicaid program. HB 2049/SB 1650 required coverage of PDHM, to include human milk fortifiers, by private insurance plans and Virginia s Medicaid program.

SB 499 (2024): Prior carrier responses Based on the prior Step One assessment for HB 2049/SB 1650 (2019), health insurance plans in Virginia generally do not cover PDHM or fortifier. Based on previously presented JLARC research for HB 2049/SB 1650 (2019), PDHM and fortifier can be provided as needed to infants with the cost currently absorbed by hospitals. There may be some limitation of utilization based on varying ability to absorb this cost across hospitals

SB 499 (2024): Prior Step One assessment Coverage for PDHM and fortifiers as mandated by HB 2049/SB 1650 (2019) is not contained in the Virginia EHB benchmark plan. BOI similarly would conclude that coverage for PDHM and human-milk derived products as mandated by SB 499 (2024) is not contained in the Virginia EHB benchmark plan. BOI would characterize PDHM and fortifier coverage mandated in HB 2049/SB 1650 (2019) as a new benefit for which costs to the Commonwealth could be incurred. BOI similarly would characterize coverage for PDHM and human-milk derived products mandated in SB 499 (2024) as a new benefit for which costs to the Commonwealth could be incurred.

SB 499 (2024): HIRC options Direct BOI to update the prior Step Two assessment based on current enrollment and benefit costs. Recommend the proposed mandate for PDHM coverage under SB 499 be evaluated as a part of the current EHB Benchmark review. Take no action related to this proposed mandate or consider it in some other manner.

Expedited Assessments

Requests received Step Two assessments are completed [u]pon request of the [Health Insurance Reform] Commission per 30-343(C) of the Code. Historically, these have been preceded by a Step One assessment, but that is not required. HIRC and BOI received a request for expedited Step Two assessments for three bills. Bill & Topic Referring Committee HB 230 (2024) Cost sharing limits for diagnostic and supplemental breast examinations House Labor and Commerce HB 513 (2024) Coverage for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS) House Labor and Commerce HB 760 (2024) Limits on insulin and diabetes equipment and supplies cost-sharing payments House Labor and Commerce

Additional information For HB 230, BOI previously conducted a Step One assessment of a similar bill (HB 1815 from 2023) and concluded that these services are generally covered by carriers with cost sharing, and that there was the possibility of cost defrayal if HB 1815 was enacted. HIRC did not take any action on HB 1815 after the Step One assessment. BOI does not believe there would be a cost defrayal for HB 230 because HB 230 removes cost sharing for services already provided. For HB 513, a BOI survey of carriers indicates that there is existing coverage for medically necessary treatments associated with PANDAS and PANS. There is no Current Procedural Terminology (CPT) codes for PANDAS and PANS. Some carriers cover all named treatments in the bill as medically necessary and other carriers consider some named treatments to be experimental (i.e., not medically necessary). PANDAS/PANS coverage is not included in the current EHB benchmark plan and this would be a new benefit for which costs to the Commonwealth could be incurred.

Expedited assessments: HIRC options Recommend one or more bills for a Step One assessment by BOI. Recommend one or more bills for a Step Two assessment by BOI and JLARC. Recommend one or more bills for the EHB benchmark plan review process. Take no action related to one or more of these bills or consider them in some other manner.