What changed in HF 626
The bill as introduced, compared with the version both chambers passed (90th General Assembly).
16 passages reworded, 0 added and 21 removed; 19 of 56 unchanged.
Removed AddedIntroduced textText as passedAmendments
Compares wording only. The printed bills also mark changes to existing law with strikes and underlines, which aren’t shown here.
Section 1.
NEW SECTION. 514F.9 Continuity of care —— nonmedical switching.
1. Definitions. For the purpose of this section:
a. “Authorized representative” means the same as defined in section 514J.102.
b. a. “Commissioner” means the commissioner of insurance.
c. b. “Cost sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirement.
d. “Coverage exemption” means a determination made by a health carrier, health benefit plan, or utilization review organization to cover a prescription drug that is otherwise excluded from coverage.
e. “Coverage exemption determination” means a determination made by a health carrier, health benefit plan, or utilization review organization whether to cover a prescription drug that is otherwise excluded from coverage.
f. c. “Covered person” means the same as defined in section 514J.102.
g. d. “Demonstrated bioavailability” means the same as defined in section 155A.3.
h. “Discontinued health benefit plan” means a covered person’s existing health benefit plan that is discontinued by a health carrier during open enrollment for the next plan year.
i. e. “Formulary” means a complete list of prescription drugs eligible for coverage under a health benefit plan.
j. f. “Generic name” means the same as defined in section 155A.3.
k. g. “Health benefit plan” means the same as defined in section 514J.102.
l. h. “Health care professional” means the same as defined in section 514J.102.
m. i. “Health care services” means the same as defined in section 514J.102.
n. j. “Health carrier” means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, including an insurance company offering sickness and accident plans, a health maintenance organization, a nonprofit health service corporation, a plan established pursuant to chapter 509A for public employees, or any other entity providing a plan of health insurance, health care benefits, or health care services. “Health carrier” does not include the department of human services, or a managed care organization acting pursuant to a contract with the department of human services to administer the medical assistance program under chapter 249A or the healthy and well kids in Iowa (hawk-i) program under chapter 514I.
o. k. “Interchangeable biological product” means the same as defined in section 155A.3.
p. “Open enrollment” means the yearly time period during which an individual can enroll in a health benefit plan.
q. l. “Utilization review” review organization” means the same as defined in section 514F.7.
r. “Utilization review organization” means the same as defined in section 514F.7.
2. Nonmedical switching. With respect to a health carrier that has entered into a health benefit plan with a covered person that covers prescription drug benefits, all of the following apply:
3 unchanged passages
a. A health carrier, health benefit plan, or utilization review organization shall not limit or exclude coverage of a prescription drug for any covered person who is medically stable on such drug as determined by the prescribing health care professional, if all of the following apply:
(1) The prescription drug was previously approved by the health carrier for coverage for the covered person.
(2) The covered person’s prescribing health care professional has prescribed the drug for the covered person’s medical condition within the previous six months.
(3) The covered person continues to be an enrollee of the health benefit plan.
b. Coverage of a covered person’s prescription drug, as described in paragraph “a”, shall continue through the last day of the covered person’s eligibility under the health benefit plan. plan, or through the last day of the health benefit plan year, whichever is earlier.
c. Prohibited limitations and exclusions referred to in paragraph “a” include but are not limited to the following:
4 unchanged passages
(1) Limiting or reducing the maximum coverage of prescription drug benefits.
(2) Increasing cost sharing for a covered prescription drug.
(3) Moving a prescription drug to a more restrictive tier if the health carrier uses a formulary with tiers.
(4) Removing a prescription drug from a formulary, unless the United States food and drug administration has issued a statement about the drug that calls into question the clinical safety of the drug, or the manufacturer of the drug has notified the United States food and drug administration of a manufacturing discontinuance or potential discontinuance of the drug as required by section 506C of the Federal Food, Drug, and Cosmetic Act, as codified in 21 U.S.C. §356c.
d. This subsection shall not be construed to prohibit a substitution, a formulary change, or a preference by a health carrier for a prescribed drug product that has the same generic name and demonstrated bioavailability, or that is an interchangeable biological product.
3. Coverage exemption determination process.
a. To ensure continuity of care, a health carrier, health plan, or utilization review organization shall provide a covered person and prescribing health care professional with access to a clear and convenient process to request a coverage exemption determination. A health carrier, health plan, or utilization review organization may use its existing medical exceptions process to satisfy this requirement. The process shall be easily accessible on the internet site of the health carrier, health benefit plan, or utilization review organization.
b. A health carrier, health benefit plan, or utilization review organization shall respond to a coverage exemption determination request within five calendar days of receipt. In cases where exigent circumstances exist, the health carrier, health benefit plan, or utilization review organization shall respond within seventy-two hours of receipt. If a response by the health carrier, health benefit plan, or utilization review organization is not received within the applicable time period, the coverage exemption shall be deemed granted.
c. A coverage exemption shall be expeditiously granted for a discontinued health benefit plan if a covered person enrolls in a comparable plan offered by the same health carrier, and all of the following conditions apply:
(1) The covered person is medically stable on a prescription drug as determined by the prescribing health care professional.
(2) The prescribing health care professional continues to prescribe the drug for the covered person for the covered person’s medical condition.
(3) In comparison to the discontinued health benefit plan, the new health benefit plan does any of the following:
(a) Limits or reduces the maximum coverage of prescription drug benefits.
(b) Increases cost sharing for the prescription drug.
(c) Moves the prescription drug to a more restrictive tier if the health carrier uses a formulary with tiers.
(d) Excludes the prescription drug from the health benefit plan’s formulary.
d. Upon granting of a coverage exemption for a drug prescribed by a covered person’s prescribing health care professional, a health carrier, health benefit plan, or utilization review organization shall authorize coverage no more restrictive than that offered in a discontinued health benefit plan, or than that offered prior to implementation of restrictive changes to the health benefit plan’s formulary after the current plan year began.
e. If a determination is made to deny a request for a coverage exemption, the health carrier, health benefit plan, or utilization review organization shall provide the covered person or the covered person’s authorized representative and the authorized person’s prescribing health care professional with the reason for denial and information regarding the procedure to appeal the denial. Any determination to deny a coverage exemption may be appealed by a covered person or the covered person’s authorized representative.
f. A health carrier, health benefit plan, or utilization review organization shall uphold or reverse a determination to deny a coverage exemption within five calendar days of receipt of an appeal of denial. In cases where exigent circumstances exist, a health carrier, health benefit plan, or utilization review organization shall uphold or reverse a determination to deny a coverage exemption within seventy-two hours of receipt. If the determination to deny a coverage exemption is not upheld or reversed on appeal within the applicable time period, the denial shall be deemed reversed and the coverage exemption shall be deemed approved.
g. If a determination to deny a coverage exemption is upheld on appeal, the health carrier, health benefit plan, or utilization review organization shall provide the covered person or the covered person’s authorized representative and the covered person’s prescribing health care professional with the reason for upholding the denial on appeal and information regarding the procedure to request external review of the denial pursuant to chapter 514J. Any denial of a request for a coverage exemption that is upheld on appeal shall be considered a final adverse determination for purposes of chapter 514J and is eligible for a request for external review by a covered person or the covered person’s authorized representative pursuant to chapter 514J.
4. 3. Limitations. This section shall not be construed to do any of the following:
a. Prevent a health care professional from prescribing another drug covered by the health carrier that the health care professional deems medically necessary for the covered person.
2 unchanged passages
b. Prevent a health carrier from doing any of the following:
(1) Adding a prescription drug to its formulary.
(2) Removing a prescription drug from its formulary if the drug manufacturer has removed the drug for sale in the United States.
5. 4. Enforcement. The commissioner may take any enforcement action under the commissioner’s authority to enforce compliance with this section.
Sec.
2. APPLICABILITY. This Act applies to a health benefit plan that is delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2024. 2025.