Purpose of the Bill

This bill is intended to set guidelines for how health insurance companies and pharmacy benefit managers calculate what enrollees pay towards their cost-sharing responsibilities, such as copays, coinsurance, and deductibles. It aims to ensure all payments made toward these responsibilities are counted, promoting transparency and consistency in health insurance practices.

Main Provisions

• Cost-sharing Inclusions: The bill mandates that health plans and pharmacy benefit managers must include all amounts paid by enrollees, or any other person on their behalf, when calculating contributions toward cost-sharing or out-of-pocket maximums. This includes payments for prescription drugs approved by the health plan.

• Health Savings Account and Catastrophic Plan Considerations: If applying this bill's requirements affects an enrollee’s eligibility for a Health Savings Account (HSA) or a catastrophic health plan under federal law, these calculations are to be applied only after the enrollee meets their deductible.

Significant Changes

• The bill introduces a new requirement for insurers to consider payments made towards an enrollee's cost-sharing obligations, which may not have been consistently accounted for previously. This is particularly significant for individuals who rely on assistance for medical expenses, ensuring that all contributions are recognized.

Relevant Terms

• Cost-sharing
• Out-of-pocket maximum
• Health insurance
• Pharmacy benefit manager
• Copays
• Coinsurance
• Deductibles
• Health Savings Account (HSA)
• Catastrophic health plan