House File 2389 H-8039 Amend House File 2389 as follows: 1 1. By striking everything after the enacting clause and 2 inserting: 3 < DIVISION I 4 FAMILY PLANNING AND ABORTION REDUCTION POLICY 5 Section 1. FAMILY PLANNING AND ABORTION REDUCTION POLICY. 6 1. a. In 2011, nearly two million eight hundred thousand 7 pregnancies, or forty-five percent of pregnancies, were 8 unintended, meaning that the pregnancy occurred when a woman 9 wanted to become pregnant in the future but not at the time she 10 became pregnant, or the woman became pregnant when she did not 11 want to become pregnant then or at any time in the future. 12 b. The rate of unintended pregnancies is higher among 13 women with incomes below two hundred percent of the federal 14 poverty level (FPL), women eighteen to twenty-four years of 15 age, cohabiting women, and women of color, and is lowest among 16 higher-income women, white women, college graduates, and 17 married women. With respect to the outcome of an unintended 18 pregnancy, in 2011, women with incomes below one hundred 19 percent of the FPL had an unplanned birth rate nearly seven 20 times that of women at or above two hundred percent of the FPL. 21 2. a. Between 2008 and 2011, the unintended pregnancy 22 rate in the United States declined by eighteen percent, the 23 lowest level in three decades. During this time, the rates 24 of both abortion and unplanned births fell substantially by 25 thirteen percent and eighteen percent, respectively. Abortion 26 rates have continued to decline and although states enacted new 27 restrictions on abortions between 2012 and 2014, these states 28 only accounted for thirty-eight percent of the total abortion 29 rate decline between 2011 and 2014. Conversely, sixty-two 30 percent of the decline in the abortion rate was attributable 31 to states and jurisdictions that did not pass restrictive 32 abortion laws during this same time period. This suggests that 33 the decline in the abortion rate during both periods was not 34 due to an increase in unplanned births or increased abortion 35 -1- HF 2389.3237 (3) 89 pf/rh 1/ 14 #1.

restrictions. 1 b. During these periods, however, there was improvement 2 in contraceptive use, including the use of highly effective 3 long-acting reversible contraceptives. Based on this data, 4 researchers have concluded that the decline in abortions was 5 driven by the steep decline in unintended pregnancy, which in 6 turn was most plausibly explained by improved contraceptive 7 use, not because fewer women decided to end an unwanted 8 pregnancy. 9 3. a. According to the centers for disease control and 10 prevention of the United States department of health and human 11 services (CDC), two million three hundred thousand cases of 12 chlamydia, gonorrhea, and syphilis were reported in the United 13 States in 2017, the highest number ever, and two hundred 14 thousand more than in 2016. Of these cases, the population 15 aged fifteen to twenty-four accounted for more than one-half 16 of all new sexually transmitted infections (STIs) each year, 17 even though that population makes up only one-quarter of the 18 sexually active population. Sexually transmitted infections 19 are disproportionately more common in young and marginalized 20 people. 21 b. If left undiagnosed and untreated, STIs can have serious 22 health consequences, resulting in infertility, life-threatening 23 ectopic pregnancies, stillbirths in infants, and miscarriages, 24 and an increased risk for human immunodeficiency virus 25 transmission. Additionally, STIs may result in adverse 26 pregnancy outcomes including preterm birth, low-birth 27 weight, and children with physical and mental developmental 28 disabilities. 29 c. The CDC identifies budgetary cuts in STI prevention 30 efforts, societal stigma, insufficient awareness of the 31 importance of screening among some health care providers, lack 32 of comprehensive sex education, and barriers to health care 33 services as playing roles in the increase in STIs. 34 4. a. The CDC and the United States office of population 35 -2- HF 2389.3237 (3) 89 pf/rh 2/ 14

affairs recommend that family planning services include 1 providing contraception to help men and women plan and space 2 births, prevent unintended pregnancies, and reduce the number 3 of abortions; offer pregnancy testing and counseling; help 4 clients who want to conceive; provide basic infertility 5 services; provide preconception health service to improve 6 infant and maternal outcomes, and improve women’s and men’s 7 health; and provide STI screening and treatment services to 8 prevent tubal infertility and improve the health of women, men, 9 and infants. 10 b. In 2014, of the sixty-seven million women of reproductive 11 age, ages thirteen to forty-four, thirty-eight million were in 12 need of contraceptive care, and twenty million were in need of 13 publicly funded services and supplies due to being low-income 14 or being younger than twenty years of age. 15 c. In 2015, public expenditures for family planning client 16 services totaled two billion one hundred million dollars 17 with Medicaid accounting for seventy-five percent, state 18 appropriations accounting for twelve percent, and funding 19 through Title X of the federal Public Health Services Act 20 (Title X) accounting for ten percent. Title X subsidizes 21 services for men and women who do not meet the eligibility 22 requirements for Medicaid, maintains the national network of 23 family planning centers, and sets the standards for provision 24 of family planning services. 25 d. Although total public funding for family planning in 26 actual dollars increased by more than one billion seven hundred 27 million dollars between 1980 and 2015, after adjusting for 28 inflation, funding levels were essentially the same in 2015 as 29 in 1980. 30 e. In 2010, every one dollar invested in publicly funded 31 family planning services saved over seven dollars in Medicaid 32 expenditures that would otherwise have been necessary to pay 33 the medical costs of pregnancy, delivery, and early childhood 34 care; and the nationwide public investment in family planning 35 -3- HF 2389.3237 (3) 89 pf/rh 3/ 14

services resulted in over thirteen billion dollars in net 1 savings, helping women avoid unintended pregnancies and a range 2 of other negative reproductive health outcomes. 3 f. In 2014, publicly funded family planning services helped 4 women to avoid two million unintended pregnancies, which would 5 potentially have resulted in nearly nine hundred thousand 6 unplanned births and nearly seven hundred thousand abortions. 7 g. Publicly funded family planning has well-documented 8 health benefits for women, newborns, families, and communities. 9 The ability to delay and space out childbearing is crucial to 10 women’s social and economic advancement. A woman’s ability to 11 obtain and effectively use contraceptives has a positive impact 12 on their education and workforce participation, as well as on 13 subsequent outcomes related to income, family stability, mental 14 health and happiness, and children’s well-being. Evidence 15 suggests that the most disadvantaged women in the United States 16 do not fully share in these benefits which is why unintended 17 pregnancy prevention efforts should be grounded in broader 18 anti-poverty and social justice efforts. 19 h. Publicly funded family planning services help women to 20 avoid pregnancies they do not want and to plan pregnancies they 21 do. Supporting and expanding women’s access to family planning 22 services not only protects women’s health, it also reduces 23 abortion rates. The clear implication for policymakers who 24 wish to see fewer abortions occur is to focus on making family 25 planning services and contraceptive care more available and 26 increasing funding to these services. 27 DIVISION II 28 MEDICAID —— IOWA FAMILY PLANNING NETWORK 29 Sec. 2. MEDICAID —— IOWA FAMILY PLANNING NETWORK. 30 1. The Medicaid 1115 demonstration waiver provided family 31 planning services, at various time periods, from February 2006 32 through June 2017, to men and women ages twelve to fifty-four 33 with incomes not exceeding three hundred percent of the federal 34 poverty level, through the Iowa family planning network. 35 -4- HF 2389.3237 (3) 89 pf/rh 4/ 14

Services provided by the Iowa family planning network during 1 this time did all of the following: 2 a. Resulted in an estimated midpoint number of averted 3 births, including by extension the reduction in unintended or 4 unwanted pregnancies and repeat teen births, of thirty-six 5 thousand one hundred sixty-nine. 6 b. Resulted in an estimated midpoint reduction in Medicaid 7 costs attributable to costs avoided for each averted birth 8 including costs for deliveries, births, and first years of life 9 of four hundred eighty-five million dollars, not including the 10 continuing costs for children who remain on Medicaid beyond 11 their first birthday. Approximately forty percent of children 12 who had a Medicaid-paid birth will remain on Medicaid for five 13 or more years. 14 c. Resulted in a total estimated net savings in Medicaid 15 costs of over four hundred seventy-six million dollars. 16 d. Provided a cost-effective mechanism to allow men and 17 women access to family planning services which resulted in 18 averted births and reduced costs to the state with the ninety 19 percent federal match for such services. 20 2. Conversely, data reported regarding the state family 21 planning program established July 1, 2017, and funded 22 exclusively with state general fund moneys, indicates that from 23 April through June of 2018, there was a seventy-three percent 24 decline in services compared with April through June 2017, the 25 last three months of the Iowa family planning network, and 26 patient enrollment in the new program fell by more than half. 27 3. If family planning services were once again provided 28 under the Medicaid program through a Medicaid state plan 29 amendment, with the same benefits, eligibility requirements, 30 and other provisions included in the former Iowa family 31 planning network demonstration waiver, the state would be able 32 to do all of the following: 33 a. Utilize the additional state funds available to 34 expand efforts to continue to reduce abortions and improve 35 -5- HF 2389.3237 (3) 89 pf/rh 5/ 14

reproductive and overall health for men and women in the state 1 through broad-based family planning services, age-appropriate 2 sexual health education efforts such as the personal 3 responsibility and education program, programs for pregnant and 4 parenting teens, increased access to family planning services 5 including contraceptives to men and women, Medicaid-enhanced 6 prenatal services for members determined to be at high risk, 7 and the Title X family planning program. 8 b. Utilize the entire family planning services provider 9 network to expand access to reach those in need of publicly 10 funded services, including those women for whom rates of 11 unintended pregnancies are higher including low-income, 12 younger, and less-formally educated women, and women of color. 13 c. Continue to provide necessary family planning services 14 that have resulted in declining unintended pregnancies and 15 fewer abortions, and that would result in additional resources 16 being available to enhance the quality of life for children 17 after they are born including through the head start program, 18 prekindergarten programs, child care assistance, properly 19 funded schools, foster and adoptive programs, hawk-i, and other 20 programs that support and enrich the lives of children and 21 families in the state. 22 Sec. 3. IOWA FAMILY PLANNING NETWORK —— MEDICAID STATE 23 PLAN AMENDMENT. The department of human services shall submit 24 a Medicaid state plan amendment to the centers for Medicare 25 and Medicaid services of the United States department of 26 health and human services for approval to establish the Iowa 27 family planning network with the same benefits, eligibility 28 requirements, and other provisions included in the Medicaid 29 Iowa family planning network waiver as approved by the centers 30 for Medicare and Medicaid services of the United States 31 department of health and human services in effect on June 30, 32 2017. 33 Sec. 4. EFFECTIVE DATE. This division of this Act, being 34 deemed of immediate importance, takes effect upon enactment. 35 -6- HF 2389.3237 (3) 89 pf/rh 6/ 14

DIVISION III 1 REPEAL OF STATE FAMILY PLANNING SERVICES PROGRAM 2 Sec. 5. REPEAL. Section 217.41B, Code 2022, is repealed. 3 Sec. 6. CONTINGENT EFFECTIVE DATE. The following takes 4 effect upon receipt of approval by the department of human 5 services from the centers for Medicare and Medicaid services 6 of the United States department of health and human services 7 of the Medicaid state plan amendment submitted pursuant to 8 division II of this Act to establish the Iowa family planning 9 network: 10 The section of this division of this Act repealing section 11 217.41B, Code 2022. 12 DIVISION IV 13 SELF-ADMINISTERED HORMONAL CONTRACEPTIVES 14 Sec. 7. Section 155A.3, Code 2022, is amended by adding the 15 following new subsections: 16 NEW SUBSECTION . 10A. “Department” means the department of 17 public health. 18 NEW SUBSECTION . 45A. “Self-administered hormonal 19 contraceptive” means a self-administered hormonal contraceptive 20 that is approved by the United States food and drug 21 administration to prevent pregnancy. “Self-administered 22 hormonal contraceptive” includes an oral hormonal contraceptive, 23 a hormonal vaginal ring, and a hormonal contraceptive patch, 24 but does not include any drug intended to induce an abortion as 25 defined in section 146.1. 26 NEW SUBSECTION . 45B. “Standing order” means a preauthorized 27 medication order with specific instructions from the medical 28 director of the department to dispense a medication under 29 clearly defined circumstances. 30 Sec. 8. NEW SECTION . 155A.49 Pharmacist dispensing of 31 self-administered hormonal contraceptives —— standing order —— 32 requirements —— limitations of liability. 33 1. Notwithstanding any provision of law to the contrary, a 34 pharmacist may dispense, at one time, up to a one-year supply 35 -7- HF 2389.3237 (3) 89 pf/rh 7/ 14

of a self-administered hormonal contraceptive to a patient, 1 pursuant to a standing order established by the medical 2 director of the department in accordance with this section. 3 2. A pharmacist who dispenses a self-administered hormonal 4 contraceptive in accordance with this section shall not 5 require any other prescription drug order authorized by a 6 practitioner prior to dispensing the self-administered hormonal 7 contraceptive to a patient. 8 3. The medical director of the department may establish a 9 standing order authorizing the dispensing of self-administered 10 hormonal contraceptives by a pharmacist who does all of the 11 following: 12 a. Complies with the standing order established pursuant to 13 this section. 14 b. Retains a record of each patient to whom a 15 self-administered hormonal contraceptive is dispensed under 16 this section and submits the record to the department. 17 4. The standing order shall require a pharmacist who 18 dispenses self-administered hormonal contraceptives under this 19 section to do all of the following: 20 a. Complete a standardized training program and continuing 21 education requirements approved by the board in consultation 22 with the department that are related to prescribing 23 self-administered hormonal contraceptives and include education 24 regarding all contraceptive methods approved by the United 25 States food and drug administration. 26 b. Obtain a completed self-screening risk assessment, 27 approved by the department in collaboration with the board and 28 the board of medicine, from each patient prior to dispensing 29 the self-administered hormonal contraceptive to the patient. 30 c. Provide the patient with all of the following: 31 (1) Written information regarding all of the following: 32 (a) The importance of completing an appointment with the 33 patient’s primary care or women’s health care practitioner 34 to obtain preventative care, including but not limited to 35 -8- HF 2389.3237 (3) 89 pf/rh 8/ 14

recommended tests and screenings. 1 (b) The effectiveness and availability of long-acting 2 reversible contraceptives as an alternative to 3 self-administered hormonal contraceptives. 4 (2) A copy of the record of the pharmacist’s encounter with 5 the patient that includes all of the following: 6 (a) The patient’s completed self-screening risk assessment. 7 (b) A description of the contraceptive dispensed, or the 8 basis for not dispensing a contraceptive. 9 (3) Patient counseling regarding all of the following: 10 (a) The appropriate administration and storage of the 11 self-administered hormonal contraceptive. 12 (b) Potential side effects and risks of the 13 self-administered hormonal contraceptive. 14 (c) The need for backup contraception. 15 (d) When to seek emergency medical attention. 16 (e) The risk of contracting a sexually transmitted 17 infection or disease, and ways to reduce such a risk. 18 5. The standing order established pursuant to this section 19 shall prohibit a pharmacist who dispenses a self-administered 20 hormonal contraceptive under this section from doing any of the 21 following: 22 a. Requiring a patient to schedule an appointment with 23 the pharmacist for the prescribing or dispensing of a 24 self-administered hormonal contraceptive. 25 b. Dispensing self-administered hormonal contraceptives to 26 a patient for more than twenty-four months after the date a 27 self-administered hormonal contraceptive is initially dispensed 28 to the patient without the patient’s attestation that the 29 patient has consulted with a primary care or women’s health 30 care practitioner during the preceding twenty-four months. 31 c. Dispensing a self-administered hormonal contraceptive to 32 a patient if the results of the self-screening risk assessment 33 completed by a patient pursuant to subsection 4, paragraph 34 “b” , indicate it is unsafe for the pharmacist to dispense the 35 -9- HF 2389.3237 (3) 89 pf/rh 9/ 14

self-administered hormonal contraceptive to the patient, in 1 which case the pharmacist shall refer the patient to a primary 2 care or women’s health care practitioner. 3 6. A pharmacist who dispenses a self-administered hormonal 4 contraceptive and the medical director of the department who 5 establishes a standing order in compliance with this section 6 shall be immune from criminal and civil liability arising 7 from any damages caused by the dispensing, administering, 8 or use of a self-administered hormonal contraceptive or the 9 establishment of the standing order. The medical director of 10 the department shall be considered to be acting within the 11 scope of the medical director’s office and employment for 12 purposes of chapter 669 in the establishment of a standing 13 order in compliance with this section. 14 7. The department, in collaboration with the board and 15 the board of medicine, and in consideration of the guidelines 16 established by the American congress of obstetricians and 17 gynecologists, shall adopt rules pursuant to chapter 17A to 18 administer this chapter. 19 Sec. 9. Section 514C.19, Code 2022, is amended to read as 20 follows: 21 514C.19 Prescription contraceptive coverage. 22 1. Notwithstanding the uniformity of treatment requirements 23 of section 514C.6 , a group policy , or contract , or plan 24 providing for third-party payment or prepayment of health or 25 medical expenses shall not do either of the following comply 26 as follows : 27 a. Exclude Such policy, contract, or plan shall not 28 exclude or restrict benefits for prescription contraceptive 29 drugs or prescription contraceptive devices which prevent 30 conception and which are approved by the United States 31 food and drug administration, or generic equivalents 32 approved as substitutable by the United States food and drug 33 administration, if such policy , or contract , or plan provides 34 benefits for other outpatient prescription drugs or devices. 35 -10- HF 2389.3237 (3) 89 pf/rh 10/ 14

However, such policy, contract, or plan shall specifically 1 provide for payment of a one-year supply of self-administered 2 hormonal contraceptives, as prescribed by a practitioner as 3 defined in section 155A.3, or as prescribed by standing order 4 and dispensed by a pharmacist pursuant to section 155A.47, 5 including self-administered hormonal contraceptives dispensed 6 at one time. 7 b. Exclude Such policy, contract, or plan shall not exclude 8 or restrict benefits for outpatient contraceptive services 9 which are provided for the purpose of preventing conception if 10 such policy , or contract , or plan provides benefits for other 11 outpatient services provided by a health care professional. 12 2. A person who provides a group policy , or contract , or 13 plan providing for third-party payment or prepayment of health 14 or medical expenses which is subject to subsection 1 shall not 15 do any of the following: 16 a. Deny to an individual eligibility, or continued 17 eligibility, to enroll in or to renew coverage under the terms 18 of the policy , or contract , or plan because of the individual’s 19 use or potential use of such prescription contraceptive drugs 20 or devices, or use or potential use of outpatient contraceptive 21 services. 22 b. Provide a monetary payment or rebate to a covered 23 individual to encourage such individual to accept less than the 24 minimum benefits provided for under subsection 1 . 25 c. Penalize or otherwise reduce or limit the reimbursement 26 of a health care professional because such professional 27 prescribes contraceptive drugs or devices, or provides 28 contraceptive services. 29 d. Provide incentives, monetary or otherwise, to a health 30 care professional to induce such professional to withhold 31 from a covered individual contraceptive drugs or devices, or 32 contraceptive services. 33 3. This section shall not be construed to prevent a 34 third-party payor from including deductibles, coinsurance, or 35 -11- HF 2389.3237 (3) 89 pf/rh 11/ 14

copayments under the policy , or contract, or plan as follows: 1 a. A deductible, coinsurance, or copayment for benefits 2 for prescription contraceptive drugs shall not be greater than 3 such deductible, coinsurance, or copayment for any outpatient 4 prescription drug for which coverage under the policy , or 5 contract , or plan is provided. 6 b. A deductible, coinsurance, or copayment for benefits for 7 prescription contraceptive devices shall not be greater than 8 such deductible, coinsurance, or copayment for any outpatient 9 prescription device for which coverage under the policy , or 10 contract , or plan is provided. 11 c. A deductible, coinsurance, or copayment for benefits for 12 outpatient contraceptive services shall not be greater than 13 such deductible, coinsurance, or copayment for any outpatient 14 health care services for which coverage under the policy , or 15 contract , or plan is provided. 16 4. This section shall not be construed to require a 17 third-party payor under a policy , or contract , or plan 18 to provide benefits for experimental or investigational 19 contraceptive drugs or devices, or experimental or 20 investigational contraceptive services, except to the extent 21 that such policy , or contract , or plan provides coverage for 22 other experimental or investigational outpatient prescription 23 drugs or devices, or experimental or investigational outpatient 24 health care services. 25 5. This section shall not be construed to limit or otherwise 26 discourage the use of generic equivalent drugs approved by the 27 United States food and drug administration, whenever available 28 and appropriate. This section , when a brand name drug is 29 requested by a covered individual and a suitable generic 30 equivalent is available and appropriate, shall not be construed 31 to prohibit a third-party payor from requiring the covered 32 individual to pay a deductible, coinsurance, or copayment 33 consistent with subsection 3 , in addition to the difference of 34 the cost of the brand name drug less the maximum covered amount 35 -12- HF 2389.3237 (3) 89 pf/rh 12/ 14

for a generic equivalent. 1 6. A person who provides an individual policy , or contract , 2 or plan providing for third-party payment or prepayment of 3 health or medical expenses shall make available a coverage 4 provision that satisfies the requirements in subsections 5 1 through 5 in the same manner as such requirements are 6 applicable to a group policy , or contract , or plan under those 7 subsections. The policy , or contract , or plan shall provide 8 that the individual policyholder may reject the coverage 9 provision at the option of the policyholder. 10 7. a. This section applies to the following classes of 11 third-party payment provider contracts , or policies , or plan 12 delivered, issued for delivery, continued, or renewed in this 13 state on or after July 1, 2000 January 1, 2023 : 14 (1) Individual or group accident and sickness insurance 15 providing coverage on an expense-incurred basis. 16 (2) An individual or group hospital or medical service 17 contract issued pursuant to chapter 509 , 514 , or 514A . 18 (3) An individual or group health maintenance organization 19 contract regulated under chapter 514B . 20 (4) Any other entity engaged in the business of insurance, 21 risk transfer, or risk retention, which is subject to the 22 jurisdiction of the commissioner. 23 (5) A plan established pursuant to chapter 509A for public 24 employees. 25 b. This section shall not apply to accident-only, 26 specified disease, short-term hospital or medical, hospital 27 confinement indemnity, credit, dental, vision, Medicare 28 supplement, long-term care, basic hospital and medical-surgical 29 expense coverage as defined by the commissioner, disability 30 income insurance coverage, coverage issued as a supplement 31 to liability insurance, workers’ compensation or similar 32 insurance, or automobile medical payment insurance. 33 8. This section shall not be construed to require a 34 third-party payor to provide payment to a practitioner for the 35 -13- HF 2389.3237 (3) 89 pf/rh 13/ 14

dispensing of a self-administered hormonal contraceptive to 1 replace a self-administered hormonal contraceptive that has 2 been dispensed to a covered person and that has been misplaced, 3 stolen, or destroyed. This section shall not be construed to 4 require a third-party payor to replace covered prescriptions 5 that are misplaced, stolen, or destroyed. 6 9. For the purposes of this section: 7 a. “Self-administered hormonal contraceptive” means a 8 self-administered hormonal contraceptive that is approved 9 by the United Sates food and drug administration to prevent 10 pregnancy. “Self-administered hormonal contraceptive” includes 11 an oral hormonal contraceptive, a hormonal vaginal ring, and 12 a hormonal contraceptive patch, but does not include any drug 13 intended to induce an abortion as defined in section 146.1. 14 b. “Standing order” means a preauthorized medication order 15 with specific instructions from the medical director of the 16 department of public health to dispense a medication under 17 clearly defined circumstances. > 18 2. Title page, line 1, by striking < medication abortions 19 including required > and inserting < a family planning and 20 abortion reduction policy, and including a repeal and effective 21 date provisions. > 22 3. Title page, by striking lines 2 and 3. 23 ______________________________ BROWN-POWERS of Black Hawk -14- HF 2389.3237 (3) 89 pf/rh 14/ 14 #2. #3.