H4333 — An Act relative to consumer deductibles

Summary

An Act relative to consumer deductibles

Bill Text

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The bill adds a new section to Chapter 176O, establishing requirements for health insurance cost sharing calculations and definitions relevant to enrollees and insurers.

• Chapter 176O

  Section 31. (a) In this Section, the following terms shall have the following meanings: “Insurer” means any health insurance issuer that is subject to state law regulating insurance and offers health insurance coverage, as defined in 42 U.S.C. § 300gg-91, or any state or local governmental employer plan. “Cost sharing requirement” means any copayment, coinsurance, deductible, or annual limitation on cost sharing (including but not limited to a limitation subject to 42 U.S.C. §§ 18022(c) and 300gg-6(b)), required by or on behalf of an enrollee in order to receive a specific health care service, including a prescription drug, covered by a health plan. “Enrollee” means any individual entitled to health care services from an insurer. “Health plan” means a policy, contract, certification, or agreement offered or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. “Health care service” means an item or service furnished to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury or physical disability. “Person” means a natural person, corporation, mutual company, unincorporated association, partnership, joint venture, limited liability company, trust, estate, foundation, not-for-profit corporation, unincorporated organization, government or governmental subdivision or agency. (b) When calculating an enrollee’s contribution to any applicable cost sharing requirement, an insurer shall include any cost sharing amounts paid by the enrollee or on behalf of the enrollee by another person. Any cost sharing or reductions made for an enrollee’s benefit or towards an enrollee’s applicable cost sharing requirement shall be applied in full at the time it is rendered and wholly towards the enrollee’s out-of-pocket costs, deductible, cost sharing or similar enrollee obligation. If under Federal law, application of this requirement would result in health savings account ineligibility under section 223 of the Federal Internal Revenue Code, this requirement shall apply for health savings account-qualified high-deductible health plans with respect to the deductible of such a plan after the covered individual has satisfied the minimum deductible under section 223 of the Federal Internal Revenue Code, except for with respect to items or services that are preventive care pursuant to section 223(c)(2)(C) of the Federal Internal Revenue Code, in which case the requirements of this paragraph shall apply regardless of whether the minimum deductible under section 223 has been satisfied. (c) When calculating an enrollee’s contribution to the annual limitation on cost sharing set forth in 42 U.S.C. §§ 18022(c) and 300gg-6(b), an insurer shall include expenditures for any health care service covered by the enrollee’s health plan and included within a category of essential health benefits as described in 42 U.S.C. § 18022(b)(1). This section shall apply with respect to health plans that are entered into, amended, extended, or renewed on or after January 1, 2026. The Commission may promulgate such rules and regulations as it may deem necessary to implement this section.

  This new section defines key terms and outlines how insurers must calculate enrollee cost-sharing contributions, including the inclusion of assistance from other persons and specifying applications for health plans starting from January 1, 2026.

Sponsors

• Joint Committee on Financial Services · Primary

Subjects