What happened: The House Industry, Business and Labor Committee approved a further-amended version of House Bill 1216 that, in its amended form, (1) prevents contributions from cost‑sharing assistance programs from being counted toward an enrollee’s deductible or maximum out‑of‑pocket, (2) allows copay assistance to be applied at the pharmacy counter to reduce the patient’s out‑of‑pocket cost at point of sale, and (3) requires the enrollee to notify the health benefit plan of any cost‑sharing assistance used to reduce copayments. The committee then voted to give the bill a due pass in committee.

Why it matters: Sponsors and patient advocates described cases in which patients receiving manufacturer or foundation assistance for high-cost specialty drugs were later billed by insurers that treated the third‑party assistance as the patient’s payment and clawed it back. The amendment is a compromise intended to preserve patient access to assistance programs while limiting how insurers may use that third‑party assistance to alter deductibles and maximum out‑of‑pocket calculations.

Key points of the amendment: Representative Kent Koppelman, who explained the amendment, said it would (a) change certain drafting terms (for example, using “individual” instead of “person” to make clear human patients are meant), (b) add language that ‘‘contributions made by a cost sharing assistance program are not calculated as part of the enrollee’s deductible or maximum out of pocket,’’ and (c) require notification from enrollees to plans about use of cost‑sharing assistance. The amendment retains a provision allowing copay assistance to offset the point‑of‑sale copayment for the drug but not to be counted toward the patient’s deductible.

Sponsor and committee discussion: Representative Carls, the bill sponsor, said the amendment “pretty much negates the bill” from his original intent (which had aimed to require third‑party assistance be counted toward deductibles). Carls emphasized patients ‘‘navigate years of misdiagnosis…only to have the therapies co payment deductible become a barrier to access’’ and noted 19 states have adopted bans on accumulator practices. Representative Koppelman and others said the amendment is a compromise between patient access and insurer actuarial concerns. Representative Casper urged additional PBM transparency bills as a separate step.

Vote and outcome: Representative Shower (Shower) moved a due pass on House Bill 1216 as amended; Representative Casper seconded. The committee recorded a roll-call vote in which the clerk read members’ names; the roll-call as recorded in the transcript shows a majority in favor. The clerk then assigned the bill a carrier in the House.

Implementation notes and exemptions: Committee members confirmed the amendment exempts grandfathered plans. Members also noted the amendment will require a fiscal note. Representative Koppelman and others said details about how insurers or plans will operationalize enrollee notification and tracking of cost‑sharing assistance may be resolved after the bill advances.

Ending: Committee voted to give the further-amended HB1216 a due pass; sponsor and committee members said the amendment was a compromise and that additional PBM‑transparency work remains to be done.

Quotes (selected):
“Representative Kent Koppelman, on the goal of the amendment: ‘We’re saying…they can use copayment assistance…at the same time we not apply that to the deductible of the insured.’”

“Representative Thomas Carls, bill sponsor: ‘This bill is for the patient…Plans often require higher co pays for specialty and rare medicines… I don’t think this amendment accomplishes [the original goal]. It pretty much negates the bill.’”