Texans who need insulin soon could be paying less out of pocket
The legislation heads next to Gov. Greg Abbott’s desk
TEXAS (KSLA) — A proposal to cap out-of-pocket costs for insulin has made its way to Texas Gov. Greg Abbott’s desk.
Senate Bill 827, if signed into law by the governor, would cap co-pays for insured diabetics at $25 per 30-day supply of insulin.
The average cash price per unit of insulin rose by 47% from 2014-19, according to GoodRx.
“It’s like a mortgage payment for us to keep our kids alive monthly,” Sarah Wilson said.
The executive director of the Tyler Type One Diabetes Foundation said she has four children who live with diabetes every day.
“We have worked extra jobs to be able to afford their supplies,” Wilson said.
Many people put their health at risk due to the high costs of insulin.
“There are many in the Type 1 community who ration their insulin because it’s so expensive and who died because of that.”
Critics of the bill worry that it leaves out uninsured people who have diabetes.
However, Wilson said, many people with insurance often “fall through the cracks” while those who are uninsured or underinsured can take advantage of programs to help them.
The governor has 20 days to sign or veto Senate Bill 827. If he signs the measure, it would take effect Sept. 1.
Below is the text and analysis of Senate Bill 827:
|By: Kolkhorst, et al.||S.B. No. 827|
|(Lucio III, et al.)|
|Substitute the following for S.B. No. 827: No.|
|relating to health benefit plan cost-sharing requirements for|
|BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:|
|SECTION 1. Chapter 1358, Insurance Code, is amended by|
|adding Subchapter C to read as follows:|
|SUBCHAPTER C. COST-SHARING LIMIT|
|Sec. 1358.101. APPLICABILITY OF SUBCHAPTER. (a) This|
|subchapter applies only to a health benefit plan that provides|
|benefits for medical or surgical expenses incurred as a result of a|
|health condition, accident, or sickness, including an individual,|
|group, blanket, or franchise insurance policy or insurance|
|agreement, a group hospital service contract, or a small or large|
|employer group contract or similar coverage document that is|
|(1) an insurance company;|
|(2) a group hospital service corporation operating|
|under Chapter 842;|
|(3) a fraternal benefit society operating under|
|(4) a stipulated premium company operating under|
|(5) a reciprocal exchange operating under Chapter 942;|
|(6) a health maintenance organization operating under|
|(7) a multiple employer welfare arrangement that holds|
|a certificate of authority under Chapter 846; or|
|(8) an approved nonprofit health corporation that|
|holds a certificate of authority under Chapter 844.|
|(b) This subchapter applies to group health coverage made|
|available by a school district in accordance with Section 22.004,|
|(c) Notwithstanding any provision in Chapter 1551, 1575,|
|1579, or 1601 or any other law, this subchapter applies to:|
|(1) a basic coverage plan under Chapter 1551;|
|(2) a basic plan under Chapter 1575;|
|(3) a primary care coverage plan under Chapter 1579;|
|(4) basic coverage under Chapter 1601.|
|(d) Notwithstanding any other law, this subchapter applies|
|to coverage under:|
|(1) the child health plan program under Chapter 62,|
|Health and Safety Code, or the health benefits plan for children|
|under Chapter 63, Health and Safety Code; and|
|(2) the medical assistance program under Chapter 32,|
|Human Resources Code.|
|Sec. 1358.102. EXCEPTION. This subchapter does not apply|
|(1) a health benefit plan that provides coverage:|
|(A) only for a specified disease or for another|
|(B) only for accidental death or dismemberment;|
|(C) for wages or payments in lieu of wages for a|
|period during which an employee is absent from work because of|
|sickness or injury;|
|(D) as a supplement to a liability insurance|
|(E) for credit insurance;|
|(F) only for dental or vision care;|
|(G) only for hospital expenses; or|
|(H) only for indemnity for hospital confinement;|
|(2) a Medicare supplemental policy as defined by|
|Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);|
|(3) medical payment insurance coverage provided under|
|a motor vehicle insurance policy;|
|(4) a long-term care insurance policy, including a|
|nursing home fixed indemnity policy, unless the commissioner|
|determines that the policy provides benefit coverage so|
|comprehensive that the policy is a health benefit plan as described|
|by Section 1358.101;|
|(5) health and accident coverage provided by a risk|
|pool created under Chapter 172, Local Government Code; or|
|(6) a workers' compensation insurance policy.|
|Sec. 1358.103. LIMIT ON COST-SHARING REQUIREMENT. (a) In|
|this section, "insulin" means a prescription drug that contains|
|insulin and is used to treat diabetes. The term does not include an|
|insulin drug that is administered to a patient intravenously.|
|(b) A health benefit plan may not impose a cost-sharing|
|provision for insulin that is included in the health benefit plan's|
|formulary if the total amount the enrollee is required to pay|
|exceeds $25 per prescription for a 30-day supply, regardless of the|
|amount or type of insulin needed to fill the enrollee's|
|Sec. 1358.104. FORMULARY REQUIREMENT. A health benefit|
|plan must include at least one insulin from each therapeutic class|
|in the plan's formulary.|
|SECTION 2. The changes in law made by this Act apply only to|
|a health benefit plan that is delivered, issued for delivery, or|
|renewed on or after January 1, 2022. A health benefit plan|
|delivered, issued for delivery, or renewed before January 1, 2022,|
|is governed by the law as it existed immediately before the|
|effective date of this Act, and that law is continued in effect for|
|SECTION 3. This Act takes effect September 1, 2021.|
Committee Report (Substituted)
BACKGROUND AND PURPOSE
Texas has an above average rate of adults who have been diagnosed with diabetes. Studies have shown that medical expenses for those with diabetes are more than twice the average cost for� those who are not diabetic. In the past 15 years, the price of insulin has nearly tripled, which has led to increased cost-sharing requirements. Due to price increases, insulin rationing has become more common. This is a dangerous practice that jeopardizes the health and safety of the patient. C.S.S.B. 827 seeks to address this issue and allow consumers to be able to effectively budget for the costs associated with their insulin by capping cost-sharing for prescription insulin at $25 per prescription for a 30-day supply.
CRIMINAL JUSTICE IMPACT
It is the committee's opinion that this bill does not expressly create a criminal offense, increase the punishment for an existing criminal offense or category of offenses, or change the eligibility of a person for community supervision, parole, or mandatory supervision.
It is the committee's opinion that this bill does not expressly grant any additional rulemaking authority to a state officer, department, agency, or institution.
C.S.S.B. 827 amends the Insurance Code to cap the out-of-pocket costs that may be imposed under a health benefit plan's cost-sharing provision for prescription insulin that is included in the plan's formulary, other than an insulin drug administered intravenously, at $25 per prescription for a 30-day supply, regardless of the amount or type of insulin needed to fill the enrollee's prescription. A health benefit plan must include at least one insulin from each therapeutic class in its formulary. The bill establishes, and provides certain exceptions to, the applicability of its provisions. The bill applies only to a health benefit plan delivered, issued for delivery, or renewed on or after January 1, 2022.
September 1, 2021.
COMPARISON OF SENATE ENGROSSED AND SUBSTITUTE
While C.S.S.B. 827 may differ from the engrossed in minor or nonsubstantive ways, the following summarizes the substantial differences between the engrossed and committee substitute versions of the bill.
The original set the cost-sharing cap for prescription insulin at $50 for a 30-day supply, whereas the substitute sets the cap at $25 per prescription for a 30-day supply.
The substitute includes a requirement absent from the engrossed for a health benefit plan to include at least one insulin from each therapeutic class in its formulary.
Copyright 2021 KSLA. All rights reserved.