HB 1604: Cost sharing; out-of-pocket expense credit.

Official summary

Abstract published by the legislature (via Open States). Text as published by the legislature; reproduced verbatim.

Requires an insurer, an administrator, and a pharmacy benefit manager to apply the annual limitation on cost sharing set forth in the federal Patient Protection and Affordable Care Act under 42 U.S.C. 18022(c)(1) to prescription drugs that: (1) are covered under a health plan; (2) are life-saving or intended to manage chronic pain; and (3) do not have an approved generic version. Provides that an insurer, an administrator, and a pharmacy benefit manager may not directly or indirectly set, alter, implement, or condition the terms of health insurance coverage based in part or entirely on information about the availability or amount of financial or product assistance available for a prescription drug. Requires, before December 31 of each year, each insurer and administrator to certify to the insurance commissioner that the insurer or administrator has fully and completely complied with the cost sharing requirements during the previous calendar year. Requires a health plan to credit toward a covered individual's deductible and annual maximum out-of-pocket expenses any amount the covered individual pays directly to any health care provider for a medically necessary covered health care service if a claim for the health care service is not submitted to the health plan and the amount paid by the covered individual to the health care provider is less than the average discounted rate for the health care service paid to a health care provider in the health plan's network. Requires a health plan to: (1) establish a procedure by which a covered individual may claim a credit; and (2) identify documentation necessary to support a claim for a credit.

Sponsors

Sponsors by party (alphabetical): Democratic 6 · Republican 8

“Support” is shown only as formal sponsorship recorded by the legislature. Roll-call votes are available on the official bill page.

Recent official actions

1. May 6, 2025Public Law 237
2. May 6, 2025Signed by the Governor
3. April 29, 2025Signed by the President of the Senate
4. April 24, 2025Signed by the President Pro Tempore
5. April 23, 2025Conference Committee Report 1: adopted by the Senate; Roll Call 493: yeas 45, nays 2
6. April 23, 2025Rules Suspended. Conference Committee Report 1: adopted by the House; Roll Call 521: yeas 91, nays 0
7. April 23, 2025Signed by the Speaker
8. April 22, 2025CCR # 1 filed in the House
9. April 22, 2025CCR # 1 filed in the Senate
10. April 17, 2025Senate conferees appointed: Carrasco and Qaddoura
11. April 17, 2025Senate advisors appointed: Randolph Lonnie M and Walker K
12. April 15, 2025House dissented from Senate amendments

Showing 12 most recent of 36 actions. Full history