No. CS/CS/SB 1760
Filed under Healthcare.
Health Care Coverage; Establishing the Joint Legislative Committee on Medicaid Oversight for specified purposes; revising encounter data reporting requirements for prepaid Medicaid plans; requiring managed care plans to report to the agency and the Office of Insurance Regulation the existence of and specified details relating to certain affiliations by a specified date and annually thereafter; revising requirements for contracts between a pharmacy benefit manager and a participating pharmacy; revising and specifying additional practices pharmacy benefit managers are prohibited from engaging in, etc.
Plain English Summary
AI-GENERATEDPharmacies can now refuse to fill a prescription if a pharmacy benefit manager's reimbursement is below their cost to acquire the drug, and PBMs may not pay independent pharmacies less than they pay their own affiliated pharmacies.
Pharmacy benefit managers may no longer hold an ownership stake in, or share an investor with, a drug manufacturer -- a new wall between the companies that negotiate drug prices and the companies that make the drugs.
Medicaid managed care plans must now report their ownership ties and payments to affiliated companies to state regulators every year, and can no longer count above-market payments to affiliates as an allowable cost.
Plans must also refund a larger share of excess profit to the state -- 70% instead of 50% above a lower 3% threshold -- while a new legislative committee gains power to compel Medicaid records and testimony.
AIAbove a revenue threshold, the share of a managed care plan's profit that must be refunded to the state rises from 50% to 70%, and the threshold at which refunds start drops from 5% to 3% of revenue.
AIA ten-member Joint Legislative Committee on Medicaid Oversight is created with authority to access any relevant record held by a state agency or a Medicaid contractor and to compel state officials or employees to testify before it.
AIEach Medicaid managed care plan must report to the agency and the Office of Insurance Regulation, every year, any person or entity that controls, is controlled by, or is affiliated with the plan, and any business transaction with an affiliate over $25,000.
AIWhen calculating the achieved savings rebate a plan owes the state, a payment to an affiliated company that exceeds market rate can no longer be counted as an allowable expense, which raises the plan's apparent profit and its refund obligation.
AIA pharmacy benefit manager may not stop a pharmacy from declining to dispense a drug when the reimbursement rate offered for it is less than what the pharmacy paid to acquire it.
AIA pharmacy benefit manager may not reimburse an independent pharmacy at a lower rate than it pays a pharmacy it owns or is affiliated with for the same prescription.
AIA pharmacy benefit manager may not maintain an ownership or investment interest in a drug manufacturer, share common ownership with one, or share an investor with one.
AIThe ban on a pharmacy benefit manager clawing back money from a pharmacy now covers offsets and any amount recouped, not just designated fees, whenever the recoupment would cut what the pharmacy is paid.