summary
Introduced
01/21/2025
01/21/2025
In Committee
03/20/2025
03/20/2025
Crossed Over
02/18/2025
02/18/2025
Passed
03/26/2025
03/26/2025
Dead
Signed/Enacted/Adopted
05/06/2025
05/06/2025
Introduced Session
2025 Regular Session
Bill Summary
Cost sharing; out-of-pocket expense credit. 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.
AI Summary
This bill introduces comprehensive regulations for health insurance cost sharing and out-of-pocket expenses in Indiana, effective January 1, 2026. The legislation defines key terms like "cost sharing" (copayments, coinsurance, deductibles) and establishes new requirements for insurers, pharmacy benefit managers, and health plans. Specifically, the bill requires that the annual cost-sharing limitation from the Affordable Care Act be applied to life-saving or chronic pain prescription drugs without generic alternatives. It prohibits insurers and pharmacy benefit managers from setting health plan terms based on the availability of financial assistance for prescription drugs. The bill also mandates that health plans credit a covered individual's out-of-pocket expenses toward their deductible when they pay directly to a healthcare provider for a medically necessary service, provided the payment is less than the average discounted network rate. Additionally, health plans must create a procedure for individuals to claim such credits and publish information about the process. Insurers and administrators must annually certify their compliance with these requirements to the insurance commissioner, with the goal of making healthcare more affordable and transparent for Indiana residents.
Committee Categories
Business and Industry
Sponsors (14)
Julie McGuire (R)*,
Mike Bohacek (R),
Cynthia Carrasco (R),
J.D. Ford (D),
Aaron Freeman (R),
Andrea Hunley (D),
Joanna King (R),
Bob Morris (R),
Fady Qaddoura (D),
Lonnie Randolph (D),
Linda Rogers (R),
Robin Shackleford (D),
Kyle Walker (R),
Shelli Yoder (D),
Last Action
Public Law 237 (on 05/06/2025)
Official Document
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