HF 735 (LSB 1307YH (3) 91)

HOUSE FILE 735

BY  MOORE

A BILL FOR

An Act relating to health carriers, pharmacy benefits managers, and the calculation of cost-sharing contributions by covered persons.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  514F.10  Cost-sharing contribution —— calculation.
   1.  For purposes of this section, unless the context otherwise requires:
   a.  “Cost-sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket cost obligation imposed by a health benefit plan on a covered person.
   b.  “Covered person” means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan.
   c.  “Health benefit plan” means the same as defined in section 510B.1.
   d.  “Health carrier” means the same as defined in section 514J.102.
   e.  “Pharmacy benefits manager” means the same as defined in section 510B.1.
   2.  a.  Notwithstanding the uniformity of treatment requirements of section 514C.6, for purposes of calculating a covered person’s overall contribution to any cost-sharing requirement under a health benefit plan, a health carrier or a pharmacy benefits manager shall include any amount paid by the covered person or paid by any other person on behalf of the covered person.
   b.  If the contribution calculation under paragraph “a” will result in the ineligibility of a health savings account under section 223 of the Internal Revenue Code, the contribution calculation for the health savings account shall apply only after the covered person has satisfied the minimum deductible under section 233 of the Internal Revenue Code, except that for items or services that are preventive care pursuant to section 223(c)(2)(C) of the Internal Revenue Code, the contribution calculation under paragraph “a” shall apply regardless of whether the minimum deductible under section 233 of the Internal Revenue Code has been satisfied.
   3.  a.  This section applies to the following classes of health benefit plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2026:
   (1)  Individual or group accident A and sickness insurance providing coverage on an expense-incurred basis.
   (2)  An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.
   (3)  An individual or group health maintenance organization contract regulated under chapter 514B.
   (4)  A plan established for public employees pursuant to chapter 509A.
   b.  This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner of insurance, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.
   4.  The commissioner of insurance may adopt rules pursuant to chapter 17A to administer this section.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
   This bill relates to health carriers, pharmacy benefits managers, and the calculation of cost-sharing covered persons. “Cost-sharing” and “health carrier” are defined in the bill.
   Under the bill, when a health carrier calculates a covered person’s overall contribution to any cost-sharing requirement under a health benefit plan, the health carrier and pharmacy benefits manager shall include any amount paid by the covered person, or paid by another person on behalf of the covered person. Where the contribution calculation would result in the ineligibility of a health savings account (HSA) under section 223 of the Internal Revenue Code (IRC), the contribution calculation for the HSA shall apply only after the covered person has satisfied the minimum deductible, except that for items or services that are preventive care pursuant to section 223(c)(2)(C) of the IRC, the contribution calculation shall apply regardless of whether the minimum deductible has been satisfied.
   The bill applies to health benefit plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2026, as enumerated in the bill. The bill specifies the types of specialized health-related insurance not subject to the bill.
   The commissioner of insurance may adopt rules to administer the bill.