SB 970 — Creates provisions relating to cost-sharing under health benefit plans

SECOND5021S03.07S REGULAR SESSION SENATE COMMITTEEAMENDMENT SUBSTITUTENO. FOR SENATE BILLNO.

970___ 103RDOffered GENERALASSEMBLY 5021S.02C KRISTINAMARTIN, Secretary ANACT To amend chapter 376, RSMo, by addingOf theretoAmend oneSS/SCS/Senate newBill sectionNo. relating to cost-sharing under health benefit plans.

Be970 it, enactedPage by3 the, GeneralSection Assembly376.488 of, theLine State59 , By inserting after all of Missouri,said asline follows:the following:

Section"8. A.

ChapterThe 376,provisions RSMo,of isthis amendedsection byshall addingapply theretoto oneany newhealth section,care plans issued to beemployees knownand astheir sectiondependents 376.448,under the Missouri consolidated health care plan established pursuant to readchapter as103 follows:that are delivered, issued for delivery, continued, or renewed in this state on or after August 28, 2026.

376.448.The terms "employees" and "health care plans" shall have the same meaning ascribed to them in section 103.003.";

1.and Further renumber the remaining subsections accordingly.

As used in this section, the following terms mean:

(1) "Cost-sharing", any co-payment, coinsurance, deductible, amount paid by an enrollee for health care services in excess of a coverage limitation, or similar charge required by or on behalf of an enrollee in order to receive a specific health care service covered by a health benefit plan, whether covered under medical benefits or pharmacy benefits.

The term "cost-sharing" shall include cost-sharing as defined in 42 U.S.C.

Section 18022(c);

(2) "Enrollee", the same meaning given to the term in section 376.1350;

(3) "Generic drug", the same meaning given to the term in 42 CFR 423.4;

(4) "Health benefit plan", the same meaning given to the term in section 376.1350;

SCS SB 970 2 (5) "Health care service", the same meaning given to the term in section 376.1350;

(6) "Health carrier", the same meaning given to the term in section 376.1350;

(7) "Pharmacy benefits manager", the same meaning given to the term in section 376.388.

2.

When calculating an enrollee's overall contribution to any out-of-pocket maximum or any cost-sharing requirement under a health benefit plan, a health carrier or pharmacy benefits manager shall include any amounts paid by the enrollee or paid on behalf of the enrollee for any medication where a generic drug substitute for such medication is not available.

3.

A health carrier or pharmacy benefits manager shall not vary an enrollee's out-of-pocket maximum or any cost- sharing requirement based on, or otherwise design benefits in a manner that takes into account, the availability of any cost-sharing assistance program for any medication where a generic drug substitute for such medication is not available.

4.

If, under federal law, application of the requirement under subsection 2 of this section would result in health savings account ineligibility under Section 223 of the Internal Revenue Code of 1986, as amended, the requirement under subsection 2 of this section shall apply to health savings account-qualified high deductible health plans with respect to any cost-sharing of such a plan after the enrollee has satisfied the minimum deductible under Section 223, except with respect to items or services that are preventive care under Section 223(c)(2)(C) of the Internal Revenue Code of 1986, as amended, in which case the requirement of subsection 2 of this section shall apply SCS SB 970 3 regardless of whether the minimum deductible under Section 223 has been satisfied.

5.

Nothing in this section shall prohibit a health carrier or health benefit plan from utilizing step therapy in accordance with section 376.2034.

6.

The provisions of this section shall not apply to health benefit plans that are covered under the Labor Management Relations Act of 1947, 29 U.S.C.

Section 141, et seq., as amended.

7.

The provisions of this section shall apply to health benefit plans entered into, amended, extended, or renewed on or after August 28, 2026.

8.

No changes to the provisions of the Employee Retirement Income Security Act of 1974 as codified in 29 U.S.C.

Chapter 18 and in effect on January 1, 2026, shall alter or in any way weaken the exemption in subsection 6 of this section.

9.

As specified in subsection 3 of this section, the provisions of this section shall only apply to the instances where a generic drug substitute for the medication is not available.