gencourt

SB 17-FN - AS AMENDED BY THE SENATE

03/06/2025 0531s

2025 SESSION

25-0269

05/08

SENATE BILL 17-FN

AN ACT relative to insurance cost-sharing calculations.

SPONSORS: Sen. Innis, Dist 7

COMMITTEE: Health and Human Services

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AMENDED ANALYSIS

This bill requires an insurer to apply an amount paid by a third party, including an independent charity, to the enrollee's cost sharing requirements, except in the case of a covered prescription drug for which there is a generic alternative or interchangeable biological product.

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Explanation: Matter added to current law appears in bold italics.

Matter removed from current law appears [in brackets and struckthrough.]

Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.

03/06/2025 0531s 25-0269

0508/

STATE OF NEW HAMPSHIRE

In the Year of Our Lord Two Thousand Twenty Five

AN ACT relative to insurance cost-sharing calculations.

Be it Enacted by the Senate and House of Representatives in General Court convened:

1 New Section; Accident and Health Insurance; Applying Patient Assistance for Prescription Drugs to Cost Sharing. Amend RSA 415:18 by inserting after section 415:18-ee the following new section:

415:18-ff Applying Patient Assistance for Prescription Drugs to Cost Sharing.

I. In this section:

(a) “Cost-sharing” means any coinsurance, copayment, deductible or out-of-pocket maximum.

(b) "Interchangeable biological product" means a biological product that the federal Food and Drug Administration:

(1) Has licensed and determined meets the standards for interchangeability pursuant to 42 U.S.C. section 262(k)(4); or

(2) Has determined is therapeutically equivalent as set forth in the latest edition of or supplement to the federal Food and Drug Administration's Approved Drug Products with Therapeutic Equivalence Evaluations.

II. Each insurer that issues or renews any policy of individual or group accident or health insurance which provides coverage for prescription drugs, or which contracts with an entity providing such prescription drug coverage, including but not limited to pharmacy benefit manager companies, shall apply any amounts paid at the time of a claim on behalf of an enrollee by a third party, including but not limited to an independent charity, to the enrollee’s cost sharing requirements, except in the case of a covered prescription drug for which there is a generic alternative or interchangeable biological product.

III. If the assistance payment is not processed in coordination with the enrollee’s health insurance coverage at the point of sale, then an insurer or its contracted entity providing prescription drug coverage may require a pharmacy processing an assistance payment from an independent charity patient assistance program on behalf of an enrollee to disclose to the enrollee’s insurer:

(a) The name of the enrollee on whose behalf a payment was made;

(b) The name of the covered prescription drug for which the payment was made;

(d) Any other terms and conditions that are attached to the assistance program under which payment was made.

IV. For a health care contract that meets the definition of a "high deductible plan" set forth in 26 U.S.C. section 223(c)(2) or a catastrophic health plan, as defined under the Patient Protection and Affordable Care Act of 2009, a carrier shall be exempt from the provisions of this section until the enrollee has satisfied the minimum deductible under Section 223 of the Federal Internal Revenue Code.

2 Effective Date. This act shall take effect on January 1, 2026.

LBA

25-0269

12/18/24

SB 17-FN- FISCAL NOTE

AS INTRODUCED

AN ACT relative to insurance cost-sharing calculations.

FISCAL IMPACT: This bill does not provide funding, nor does it authorize new positions.


Estimated State Impact
	FY 2025	FY 2026	FY 2027	FY 2028
Revenue	$0	Indeterminable Increase	Indeterminable Increase	Indeterminable Increase
Revenue Fund(s)	General Fund Insurance Premium Tax Revenue
Expenditures*	$0	$0	$0	$0
Funding Source(s)	None
Appropriations*	$0	$0	$0	$0
Funding Source(s)	None
Expenditure = Cost of bill Appropriation = Authorized funding to cover cost of bill

Estimated Political Subdivision Impact
	FY 2025	FY 2026	FY 2027	FY 2028
County Revenue	$0	$0	$0	$0
County Expenditures	$0	Indeterminable Increase	Indeterminable Increase	Indeterminable Increase
Local Revenue	$0	$0	$0	$0
Local Expenditures	$0	Indeterminable Increase	Indeterminable Increase	Indeterminable Increase

METHODOLOGY:

This bill provides that, when calculating an enrollee's contribution to cost-sharing requirements, the insurer or pharmacy benefits manager shall include any amount paid by the enrollee or paid on their behalf. The bill includes a limited exception for health savings account-qualified high deductible health plans if application of the requirement would result in account ineligibility under the Internal Revenue Code.

The Insurance Department indicates this bill, if enacted, would amend RSAs 415, 420-A, and 420-B by requiring that when insurers or pharmacy benefit managers (PBM) calculate an enrollee’s contribution to cost-sharing requirements both the amount paid by the enrollee and amounts paid on behalf of the enrollee are included except in the case that qualified high deductible health plans would be ineligible if this requirement is applied. This provision applies to both medical and pharmacy benefits. Prescription drugs for which there is a generic alternative would also be excluded unless approval based on prior authorization or appeal applies.

The Department acknowledges that the language in the bill considers prescription drugs (e.g., small molecule drugs) and their respective generic equivalents. However, the bill does not specifically recognize the branded biologics market and its biosimilar equivalents, which are often branded as well. Across a continuum of prescription drugs, the latter substances may be more likely to be associated with manufacturer co-pay assistance coupons, as they are usually higher-cost drugs. The Department states that insurers employ precise actuarial methods to estimate premium costs, based on the previous years’ claims experience. These estimates are used to design plans to achieve an optimal balance of premium and cost sharing attributes to meet a myriad of market characteristics. If extraneous revenue sources are applied to assisting enrollees in meeting their cost-sharing responsibilities, and/or these costs are met with non-real dollars, this would disrupt the economics of cost-estimation among the affected health insurers, and consequently, drive premiums upward. The extent of the increased premium pressure is indeterminable at this time, as the sources of the extraneous cost sharing subsidies is not tractable. An increase in insurance premiums will lead to an increase in insurance premium tax revenue to the state general fund and increased expenditures to county and local governments to the extent these entities pay insurance premiums for health and pharmacy benefits.

The Department of Administrative Services indicates that because RSA 415, RSA 420-A and RSA 420-B only apply to fully insured commercial health insurance plans, the impact on the State of NH Employee and Retiree Health Benefit Plan (HBP) would be zero. The HBP is a self-funded health plan covering participants eligible for the active employee HBP and the nonMedicare Retiree HBP where the cost of claims is paid by the State. The Medicare eligible Retiree Health Benefit Plan is a fully insured Medicare Advantage with Prescription Drug (MA-PD) plan that is governed by the laws and rules of the federal Centers for Medicare and Medicaid Services (CMS). Therefore, the State HBP is not governed by the laws of NH Insurance Department.

AGENCIES CONTACTED:

Departments of Insurance and Administrative Services