Washington State
House of Representatives
Office of Program Research
BILL
ANALYSIS
Health Care & Wellness Committee
SSB 5610
Brief Description: Requiring cost sharing for prescription drugs to be counted against an enrollee's obligation, regardless of source.
Sponsors: Senate Committee on Health & Long Term Care (originally sponsored by Senators Frockt, Cleveland, Conway, Dhingra, Hasegawa, Honeyford, Keiser, Kuderer, Liias, Lovelett, Lovick, Randall, Robinson, Salda?a, Salomon, Stanford, Van De Wege and Wilson, C.).
Brief Summary of Substitute Bill
  • Requires certain third-party payments to count towards an enrollee's cost-sharing obligation or out-of-pocket maximum for certain health plans.
Hearing Date: 2/17/22
Staff: Jim Morishima (786-7191).
Background:

Health plans may impose cost-sharing as part of the prescription drug benefit of a health plan.  This cost-sharing can vary depending on the health plan and the type of drug.  Generally, enrollee cost-sharing for prescription drugs counts against the enrollee's out-of-pocket maximum, which is the enrollee's maximum financial responsibility for the plan year.  However, federal law permits health carriers to restrict whether third-party payments count toward the out-of-pocket maximum.
Summary of Bill:

For non-grandfathered health plans (including health plans offered to state and school employees) issued or renewed on or after January 1, 2023, a health carrier or a health care benefit manager must include cost-sharing amounts paid on behalf of the enrollee for certain prescription drugs when calculating the enrollee's contribution to any applicable cost-sharing or out-of-pocket maximum.  The amounts must be applied toward the enrollee's applicable cost-sharing or out-of-pocket maximum in full at the time it is rendered.  
 
This requirement is applicable to drugs that either do not have a generic equivalent or drugs for which the enrollee obtained access via prior authorization, step therapy, or an exception process.  The requirement does not apply, however, to drugs not subject to a deductible.
 
The requirement does not apply to a qualifying health plan for a health savings account to the extent necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from a health savings account under Internal Revenue Service laws, regulations, and guidance. 
 
The Insurance Commissioner may adopt any rules necessary to implement these requirements.
Appropriation: None.
Fiscal Note: Available on original bill.  New fiscal note requested on February 8, 2022.
Effective Date: The bill takes effect 90 days after adjournment of the session in which the bill is passed.