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SB-524 Health care coverage: patient steering.(2021-2022)

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Date Published: 04/13/2021 09:00 PM
SB524:v97#DOCUMENT

Amended  IN  Senate  April 13, 2021
Amended  IN  Senate  March 11, 2021

CALIFORNIA LEGISLATURE— 2021–2022 REGULAR SESSION

Senate Bill
No. 524


Introduced by Senator Skinner

February 17, 2021


An act to add Chapter 9.6 (commencing with Section 4450) to Division 2 of the Business and Professions Code, relating to health care coverage.


LEGISLATIVE COUNSEL'S DIGEST


SB 524, as amended, Skinner. Health care coverage: patient steering.
Existing law provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or health insurance policy that provides coverage for outpatient prescription drugs to cover medically necessary prescription drugs.
This bill would prohibit a health care service plan or a health insurer, including a self-insured employer plan, or the agent of a health care service plan or health insurer from engaging in patient steering. steering, as specified. The bill would define “patient steering” to mean communicating to an enrollee or insured that they are required to have a prescription dispensed at, or pharmacy services provided by, a particular pharmacy, as specified, or offering group health care coverage contracts or policies that include provisions that limit access to only pharmacy providers that are owned or operated by the health care service plan, health insurer, or plan’s or insurer’s agent. The bill would provide that these provisions do not apply to a “fully integrated delivery system,” and would also make related findings and declarations.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: NO   Local Program: NO  

The people of the State of California do enact as follows:


SECTION 1.

 The Legislature finds and declares all of the following:
(a) When a health care service plan, health insurer, or pharmacy benefit manager requires a patient to use a specific pharmacy provider for services that otherwise could be provided by any pharmacy in the provider network, it unjustifiably limits patient choice and may put the patient’s health at risk.
(b) Evidence shows that limiting access to pharmacy providers is designed to eliminate competition and can result in higher costs for the patient and for the health care system as a whole. It can result in patients losing connection with trusted providers and being unable to get the advice and consultation they need.
(c) Therefore, it is necessary to limit the practice of “patient steering,” used by some health care service plans and health insurers, and their contracted pharmacy benefit managers, to those situations when it is used for established clinical or logistical reasons, and not for financial benefit to the plan or insurer, or their agents.

SEC. 2.

 Chapter 9.6 (commencing with Section 4450) is added to Division 2 of the Business and Professions Code, to read:
CHAPTER  9.6. Patient Steering

4450.
 (a) A health care service plan or a health insurer, including a self-insured employer plan, or the agent of a health care service plan or health insurer shall not engage in patient steering.
(b) “Patient steering” means either of the following:
(1) Communicating to an enrollee or insured, verbally, electronically, or in writing, that they are required to have a prescription dispensed at, or pharmacy services provided by, a particular pharmacy or pharmacies if there are other pharmacies in the network that have the ability to dispense the medication or provide the services.
(2) Offering or including in contract or policy designs for purchasers of group health care coverage provisions that limit enrollees’ or insureds’ access to only those pharmacy providers that are owned or operated by the health care service plan, health insurer, or plan’s or insurer’s agent, or owned or operated by a corporate affiliate of the health care service plan, health insurer, or plan’s or insurer’s agent.
(c) “Patient steering” does not include directing an enrollee or insured to a specific pharmacy for a specific prescription due to the need for special handling or clinical requirements that cannot be performed by other pharmacies in the provider network of the health care service plan, health insurer, or plan’s or insurer’s agent.
(d) Nothing in this chapter shall prevent a health care service plan, or health insurer, including a self-insured employer plan, or the agent of a health care service plan or health insurer from offering enrollees or insureds financial incentives to use a particular pharmacy, including, but not limited to, reductions in copays or other financial incentives given to the enrollee or insured when the prescription is dispensed.
(e) This chapter does not apply to a health care service plan that is part of a fully integrated delivery system where enrollees, including enrollees in a self-insured employer plan administered by the health care service plan or its health insurer affiliate, primarily use pharmacies that are entirely owned and operated by the health care service plan, and the plan’s enrollees, including enrollees in a self-insured employer plan administered by the health care service plan or its health insurer affiliate, may use any pharmacy in the health care service plan’s network that has the ability to dispense the medication or provide the services.