What This Bill Does
This bill requires private health insurance plans and Medicaid to limit what people 26 years old and younger have to pay out of pocket for insulin (a medication used to treat diabetes). The bill caps monthly insulin costs and eliminates upfront deductibles (the amount people must pay before insurance kicks in) for young people on these plans.
##
Who It Affects
- People 26 years old and younger with private health insurance coverage
- People 26 years old and younger enrolled in Medicaid
- Health insurance companies offering group and individual plans
- Medicaid state programs
- Self-insured group health plans (employer-sponsored plans that pay claims directly rather than buying insurance)
##
Key Provisions
- Insurance plans must cover at least one type of each different form of insulin (such as vials, pumps, or inhalers) and each different action type (such as rapid-acting or long-acting) when available (Sec. 2(a))
- Young people 26 and under pay no upfront deductible for selected insulin products (Sec. 2(a))
- Cost-sharing for selected insulin products cannot exceed either $35 per 30-day supply or 25 percent of the negotiated price, whichever is lower (Sec. 2(a))
- Plans can charge higher costs if insulin is delivered by an out-of-network provider (a healthcare provider not in the plan's network) (Sec. 2(a))
- Amounts young people pay for insulin count toward their annual deductible and out-of-pocket maximum (the most they have to pay in a year) (Sec. 2(a))
##
What Changes
If this bill becomes law, starting January 1, 2024, young people 26 and under will no longer face an upfront deductible for insulin covered by private health plans or Medicaid. Their monthly insulin costs will be capped at the lower of $35 or 25 percent of the actual negotiated price. These changes only apply to "selected insulin products" that plans choose to cover, not to all insulin products.
##
Important Definitions
- **Selected insulin products**: At least one of each form (vial, pump, inhaler) of each type (rapid-acting, short-acting, intermediate-acting, long-acting, ultra long-acting, premixed) of insulin that the insurance plan or Medicaid program chooses to cover when available
- **Insulin**: Insulin that is licensed by the federal government and continues to be sold in the United States
- **Negotiated price**: The price agreed upon between the insurance plan and insulin manufacturers, including all discounts and rebates the plan receives
- **Cost-sharing**: Out-of-pocket payments people make for healthcare, such as copays (flat fees) or coinsurance (percentage of costs)
##
Effective Date
January 1, 2024 for private health plans and Medicaid (Sec. 2(a))
I
118TH CONGRESS
1ST SESSION H. R. 1587
To provide for appropriate cost-sharing for individuals 26 years of age or
younger for insulin products covered under private health plans and Medicaid.
IN THE HOUSE OF REPRESENTATIVES
MARCH 14, 2023
Mr. LANDSMAN introduced the following bill; which was referred to the Com-
mittee on Energy and Commerce, and in addition to the Committees on
Ways and Means, and Education and the Workforce, for a period to be
subsequently determined by the Speaker, in each case for consideration
of such provisions as fall within the jurisdiction of the committee con-
cerned
A BILL
To provide for appropriate cost-sharing for individuals 26
years of age or younger for insulin products covered
under private health plans and Medicaid.
Be it enacted by the Senate and House of Representa-
1
tives of the United States of America in Congress assembled,
2
SECTION 1. SHORT TITLE.
3
This Act may be cited as the ‘‘Making Insulin Afford-
4
able for All Children Act’’.
5
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SEC. 2. APPROPRIATE COST-SHARING FOR INDIVIDUALS 26
1
YEARS OF AGE OR YOUNGER FOR INSULIN
2
PRODUCTS
COVERED
UNDER
PRIVATE
3
HEALTH PLANS AND MEDICAID.
4
(a) PRIVATE HEALTH PLANS.—
5
(1) IN GENERAL.—Part D of title XXVII of the
6
Public Health Service Act (42 U.S.C. 300gg–111 et
7
seq.) is amended by adding at the end the following:
8
‘‘SEC. 2799A–11. REQUIREMENTS WITH RESPECT TO COST-
9
SHARING FOR CERTAIN INSULIN PRODUCTS.
10
‘‘(a) IN GENERAL.—For plan years beginning on or
11
after January 1, 2024, a group health plan or health in-
12
surance issuer offering group or individual health insur-
13
ance coverage shall, with respect to enrolled individuals
14
26 years of age or younger, provide coverage of selected
15
insulin products, and with respect to such products, shall
16
not—
17
‘‘(1) apply any deductible; or
18
‘‘(2) impose any cost-sharing in excess of the
19
lesser of, per 30-day supply—
20
‘‘(A) $35; or
21
‘‘(B) the amount equal to 25 percent of
22
the negotiated price of the selected insulin prod-
23
uct net of all price concessions received by or on
24
behalf of the plan or coverage, including price
25
concessions received by or on behalf of third-
26
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•HR 1587 IH
party entities providing services to the plan or
1
coverage, such as pharmacy benefit manage-
2
ment services.
3
‘‘(b) DEFINITIONS.—In this section:
4
‘‘(1) SELECTED INSULIN PRODUCTS.—The term
5
‘selected insulin products’ means at least one of each
6
dosage form (such as vial, pump, or inhaler dosage
7
forms) of each different type (such as rapid-acting,
8
short-acting, intermediate-acting, long-acting, ultra
9
long-acting, and premixed) of insulin (as defined
10
below), when available, as selected by the group
11
health plan or health insurance issuer.
12
‘‘(2) INSULIN
DEFINED.—The term ‘insulin’
13
means insulin that is licensed under subsection (a)
14
or (k) of section 351 and continues to be marketed
15
under such section, including any insulin product
16
that has been deemed to be licensed under section
17
351(a) pursuant to section 7002(e)(4) of the Bio-
18
logics Price Competition and Innovation Act of 2009
19
and continues to be marketed pursuant to such li-
20
censure.
21
‘‘(c) OUT-OF-NETWORK
PROVIDERS.—Nothing in
22
this section requires a plan or issuer that has a network
23
of providers to provide benefits for selected insulin prod-
24
ucts described in this section that are delivered by an out-
25
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•HR 1587 IH
of-network provider, or precludes a plan or issuer that has
1
a network of providers from imposing higher cost-sharing
2
than the levels specified in subsection (a) for selected insu-
3
lin products described in this section that are delivered
4
by an out-of-network provider.
5
‘‘(d) RULE OF CONSTRUCTION.—Subsection (a) shall
6
not be construed to require coverage of, or prevent a group
7
health plan or health insurance coverage from imposing
8
cost-sharing other than the levels specified in subsection
9
(a) on, insulin products that are not selected insulin prod-
10
ucts or insulin products for an individual not described
11
in subsection (a), to the extent that such coverage is not
12
otherwise required and such cost-sharing is otherwise per-
13
mitted under Federal and applicable State law.
14
‘‘(e) APPLICATION
OF
COST-SHARING
TOWARDS
15
DEDUCTIBLES
AND OUT-OF-POCKET MAXIMUMS.—Any
16
cost-sharing payments made pursuant to subsection (a)(2)
17
shall be counted toward any deductible or out-of-pocket
18
maximum that applies under the plan or coverage.’’.
19
(2) NO EFFECT ON OTHER COST-SHARING.—
20
Section 1302(d)(2) of the Patient Protection and Af-
21
fordable Care Act (42 U.S.C. 18022(d)(2)) is
22
amended by adding at the end the following new
23
subparagraph:
24
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•HR 1587 IH
‘‘(D) SPECIAL RULE RELATING TO INSU-
1
LIN COVERAGE.—The exemption of coverage of
2
selected insulin products (as defined in section
3
2799A–11(b) of the Public Health Service Act)
4
from the application of any deductible pursuant
5
to section 2799A–11(a)(1) of such Act, section
6
726(a)(1) of the Employee Retirement Income
7
Security Act of 1974, or section 9826(a)(1) of
8
the Internal Revenue Code of 1986 shall not be
9
considered when determining the actuarial value
10
of a qualified health plan under this sub-
11
section.’’.
12
(3) COVERAGE OF CERTAIN INSULIN PRODUCTS
13
UNDER CATASTROPHIC PLANS.—Section 1302(e) of
14
the Patient Protection and Affordable Care Act (42
15
U.S.C. 18022(e)) is amended by adding at the end
16
the following:
17
‘‘(4) COVERAGE
OF
CERTAIN
INSULIN
PROD-
18
UCTS.—
19
‘‘(A) IN GENERAL.—Notwithstanding para-
20
graph (1)(B)(i), a health plan described in
21
paragraph (1) shall provide coverage of selected
22
insulin products, with respect to an enrolled in-
23
dividual who is 26 years of age or younger, in
24
accordance with section 2799A–11 of the Public
25
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•HR 1587 IH
Health Service Act, before the enrolled indi-
1
vidual has incurred, during the plan year, cost-
2
sharing expenses in an amount equal to the an-
3
nual limitation in effect under subsection (c)(1)
4
for the plan year.
5
‘‘(B) TERMINOLOGY.—For purposes of
6
subparagraph (A)—
7
‘‘(i) the term ‘selected insulin prod-
8
ucts’ has the meaning given such term in
9
section 2799A–11(b) of the Public Health
10
Service Act; and
11
‘‘(ii) the requirements of section
12
2799A–11 of such Act shall be applied by
13
deeming each reference in such section to
14
‘individual health insurance coverage’ to be
15
a reference to a plan described in para-
16
graph (1).’’.
17
(4) ERISA.—
18
(A) IN GENERAL.—Subpart B of part 7 of
19
subtitle B of title I of the Employee Retirement
20
Income Security Act of 1974 (29 U.S.C. 1185
21
et seq.) is amended by adding at the end the
22
following:
23
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•HR 1587 IH
‘‘SEC. 726. REQUIREMENTS WITH RESPECT TO COST-SHAR-
1
ING FOR CERTAIN INSULIN PRODUCTS.
2
‘‘(a) IN GENERAL.—For plan years beginning on or
3
after January 1, 2024, a group health plan or health in-
4
surance issuer offering group health insurance coverage
5
shall, with respect to enrolled individuals 26 years of age
6
or younger, provide coverage of selected insulin products,
7
and with respect to such products, shall not—
8
‘‘(1) apply any deductible; or
9
‘‘(2) impose any cost-sharing in excess of the
10
lesser of, per 30-day supply—
11
‘‘(A) $35; or
12
‘‘(B) the amount equal to 25 percent of
13
the negotiated price of the selected insulin prod-
14
uct net of all price concessions received by or on
15
behalf of the plan or coverage, including price
16
concessions received by or on behalf of third-
17
party entities providing services to the plan or
18
coverage, such as pharmacy benefit manage-
19
ment services.
20
‘‘(b) DEFINITIONS.—In this section:
21
‘‘(1) SELECTED INSULIN PRODUCTS.—The term
22
‘selected insulin products’ means at least one of each
23
dosage form (such as vial, pump, or inhaler dosage
24
forms) of each different type (such as rapid-acting,
25
short-acting, intermediate-acting, long-acting, ultra
26
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•HR 1587 IH
long-acting, and premixed) of insulin (as defined
1
below), when available, as selected by the group
2
health plan or health insurance issuer.
3
‘‘(2) INSULIN
DEFINED.—The term ‘insulin’
4
means insulin that is licensed under subsection (a)
5
or (k) of section 351 of the Public Health Service
6
Act (42 U.S.C. 262) and continues to be marketed
7
under such section, including any insulin product
8
that has been deemed to be licensed under section
9
351(a) of such Act pursuant to section 7002(e)(4)
10
of the Biologics Price Competition and Innovation
11
Act of 2009 (Public Law 111–148) and continues to
12
be marketed pursuant to such licensure.
13
‘‘(c) OUT-OF-NETWORK
PROVIDERS.—Nothing in
14
this section requires a plan or issuer that has a network
15
of providers to provide benefits for selected insulin prod-
16
ucts described in this section that are delivered by an out-
17
of-network provider, or precludes a plan or issuer that has
18
a network of providers from imposing higher cost-sharing
19
than the levels specified in subsection (a) for selected insu-
20
lin products described in this section that are delivered
21
by an out-of-network provider.
22
‘‘(d) RULE OF CONSTRUCTION.—Subsection (a) shall
23
not be construed to require coverage of, or prevent a group
24
health plan or health insurance coverage from imposing
25
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•HR 1587 IH
cost-sharing other than the levels specified in subsection
1
(a) on, insulin products that are not selected insulin prod-
2
ucts or insulin products for an individual not described
3
in subsection (a), to the extent that such coverage is not
4
otherwise required and such cost-sharing is otherwise per-
5
mitted under Federal and applicable State law.
6
‘‘(e) APPLICATION
OF
COST-SHARING
TOWARDS
7
DEDUCTIBLES
AND OUT-OF-POCKET MAXIMUMS.—Any
8
cost-sharing payments made pursuant to subsection (a)(2)
9
shall be counted toward any deductible or out-of-pocket
10
maximum that applies under the plan or coverage.’’.
11
(B) CLERICAL AMENDMENT.—The table of
12
contents in section 1 of the Employee Retire-
13
ment Income Security Act of 1974 (29 U.S.C.
14
1001 et seq.) is amended by inserting after the
15
item relating to section 725 the following:
16
‘‘Sec. 726. Requirements with respect to cost-sharing for certain insulin prod-
ucts.’’.
(5) INTERNAL REVENUE CODE.—
17
(A) IN GENERAL.—Subchapter B of chap-
18
ter 100 of the Internal Revenue Code of 1986
19
is amended by adding at the end the following
20
new section:
21
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•HR 1587 IH
‘‘SEC. 9826. REQUIREMENTS WITH RESPECT TO COST-SHAR-
1
ING FOR CERTAIN INSULIN PRODUCTS.
2
‘‘(a) IN GENERAL.—For plan years beginning on or
3
after January 1, 2024, a group health plan shall, with re-
4
spect to enrolled individuals 26 years of age or younger,
5
provide coverage of selected insulin products, and with re-
6
spect to such products, shall not—
7
‘‘(1) apply any deductible; or
8
‘‘(2) impose any cost-sharing in excess of the
9
lesser of, per 30-day supply—
10
‘‘(A) $35; or
11
‘‘(B) the amount equal to 25 percent of
12
the negotiated price of the selected insulin prod-
13
uct net of all price concessions received by or on
14
behalf of the plan, including price concessions
15
received by or on behalf of third-party entities
16
providing services to the plan, such as phar-
17
macy benefit management services.
18
‘‘(b) DEFINITIONS.—In this section:
19
‘‘(1) SELECTED INSULIN PRODUCTS.—The term
20
‘selected insulin products’ means at least one of each
21
dosage form (such as vial, pump, or inhaler dosage
22
forms) of each different type (such as rapid-acting,
23
short-acting, intermediate-acting, long-acting, ultra
24
long-acting, and premixed) of insulin (as defined
25
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•HR 1587 IH
below), when available, as selected by the group
1
health plan.
2
‘‘(2) INSULIN
DEFINED.—The term ‘insulin’
3
means insulin that is licensed under subsection (a)
4
or (k) of section 351 of the Public Health Service
5
Act (42 U.S.C. 262) and continues to be marketed
6
under such section, including any insulin product
7
that has been deemed to be licensed under section
8
351(a) of such Act pursuant to section 7002(e)(4)
9
of the Biologics Price Competition and Innovation
10
Act of 2009 (Public Law 111–148) and continues to
11
be marketed pursuant to such licensure.
12
‘‘(c) OUT-OF-NETWORK
PROVIDERS.—Nothing in
13
this section requires a plan that has a network of providers
14
to provide benefits for selected insulin products described
15
in this section that are delivered by an out-of-network pro-
16
vider, or precludes a plan that has a network of providers
17
from imposing higher cost-sharing than the levels specified
18
in subsection (a) for selected insulin products described
19
in this section that are delivered by an out-of-network pro-
20
vider.
21
‘‘(d) RULE OF CONSTRUCTION.—Subsection (a) shall
22
not be construed to require coverage of, or prevent a group
23
health plan from imposing cost-sharing other than the lev-
24
els specified in subsection (a) on, insulin products that are
25
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•HR 1587 IH
not selected insulin products or insulin products fo
[Text truncated for display. Full text available on Congress.gov.]