What This Bill Does
This bill limits how much people with private health insurance must pay for insulin medications. It also creates a program where the federal government reimburses health care providers and pharmacies that give discounted insulin to people without insurance.
##
Who It Affects
- People with private health insurance coverage (group plans and individual plans)
- People without any health insurance
- Health care providers and pharmacies
- Health insurance companies
- Employers offering health plans
- The federal government
##
Key Provisions
- Health insurance plans must limit insulin cost-sharing to the lower of $35 or 25 percent of the negotiated price per 30-day supply, and cannot charge a deductible for selected insulin products starting January 1, 2024 (Sec. 2)
- Plans must cover at least one type of insulin in each dosage form (vial, pump, inhaler) and each category (rapid-acting, short-acting, intermediate-acting, long-acting, ultra long-acting, and premixed) when available (Sec. 2)
- The federal government will reimburse qualifying health care providers and pharmacies for the difference between what an uninsured person pays out-of-pocket and $35 per 30-day supply of insulin, starting January 1, 2024 (Sec. 3)
- Payments made by patients toward insulin cost-sharing count toward their yearly deductible and out-of-pocket maximum limits (Sec. 2)
- Plans can charge higher costs for insulin from providers outside their network and can impose normal costs on non-selected insulin products (Sec. 2)
##
What Changes
Insurance companies must provide affordable insulin access starting January 1, 2024. People with private insurance will pay no more than $35 per 30-day supply of selected insulin products. Health care providers and pharmacies can participate in a new federal program to help uninsured people afford insulin at $35 per 30-day supply.
##
Important Definitions
- **Selected insulin products:** At least one of each type and dosage form of insulin available that the health plan or insurance company chooses to cover
- **Insulin:** Medication that is licensed under federal law and continues to be sold in the United States
- **Uninsured individual:** A person who does not have insurance coverage for a particular insulin product (or a similar one in the same category)
- **Qualifying entity:** A health care provider or pharmacy that agrees not to charge uninsured patients any amount for insulin covered under this program and meets other requirements set by the Secretary
##
Effective Date
January 1, 2024
II
118TH CONGRESS
1ST SESSION
S. 954
To provide for appropriate cost-sharing for insulin products covered under
private health plans, and to establish a program to support health care
providers and pharmacies in providing discounted insulin products to
uninsured individuals.
IN THE SENATE OF THE UNITED STATES
MARCH 23, 2023
Mr. WARNOCK (for himself and Mr. KENNEDY) introduced the following bill;
which was read twice and referred to the Committee on Health, Edu-
cation, Labor, and Pensions
A BILL
To provide for appropriate cost-sharing for insulin products
covered under private health plans, and to establish a
program to support health care providers and pharmacies
in providing discounted insulin products to uninsured
individuals.
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 ‘‘Affordable Insulin Now
4
Act of 2023’’.
5
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•S 954 IS
SEC. 2. APPROPRIATE COST-SHARING FOR INSULIN PROD-
1
UCTS COVERED UNDER PRIVATE HEALTH
2
PLANS.
3
(a) IN GENERAL.—Part D of title XXVII of the Pub-
4
lic Health Service Act (42 U.S.C. 300gg–111 et seq.) is
5
amended by adding at the end the following:
6
‘‘SEC. 2799A–11. REQUIREMENTS WITH RESPECT TO COST-
7
SHARING FOR CERTAIN INSULIN PRODUCTS.
8
‘‘(a) IN GENERAL.—For plan years beginning on or
9
after January 1, 2024, a group health plan or health in-
10
surance issuer offering group or individual health insur-
11
ance coverage shall provide coverage of selected insulin
12
products, and with respect to such products, shall not—
13
‘‘(1) apply any deductible; or
14
‘‘(2) impose any cost-sharing in excess of the
15
lesser of, per 30-day supply—
16
‘‘(A) $35; or
17
‘‘(B) the amount equal to 25 percent of
18
the negotiated price of the selected insulin prod-
19
uct net of all price concessions received by or on
20
behalf of the plan or coverage, including price
21
concessions received by or on behalf of third-
22
party entities providing services to the plan or
23
coverage, such as pharmacy benefit manage-
24
ment services.
25
‘‘(b) DEFINITIONS.—In this section:
26
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•S 954 IS
‘‘(1) SELECTED INSULIN PRODUCTS.—The term
1
‘selected insulin products’ means at least one of each
2
dosage form (such as vial, pump, or inhaler dosage
3
forms) of each different type (such as rapid-acting,
4
short-acting, intermediate-acting, long-acting, ultra
5
long-acting, and premixed) of insulin (as defined
6
below), when available, as selected by the group
7
health plan or health insurance issuer.
8
‘‘(2) INSULIN
DEFINED.—The term ‘insulin’
9
means insulin that is licensed under subsection (a)
10
or (k) of section 351 and continues to be marketed
11
under such section.
12
‘‘(c) OUT-OF-NETWORK
PROVIDERS.—Nothing in
13
this section requires a plan or issuer that has a network
14
of providers to provide benefits for selected insulin prod-
15
ucts described in this section that are delivered by an out-
16
of-network provider, or precludes a plan or issuer that has
17
a network of providers from imposing higher cost-sharing
18
than the levels specified in subsection (a) for selected insu-
19
lin products described in this section that are delivered
20
by an out-of-network provider.
21
‘‘(d) RULE OF CONSTRUCTION.—Subsection (a) shall
22
not be construed to require coverage of, or prevent a group
23
health plan or health insurance coverage from imposing
24
cost-sharing other than the levels specified in subsection
25
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•S 954 IS
(a) on, insulin products that are not selected insulin prod-
1
ucts, to the extent that such coverage is not otherwise re-
2
quired and such cost-sharing is otherwise permitted under
3
Federal and applicable State law.
4
‘‘(e) APPLICATION
OF
COST-SHARING
TOWARDS
5
DEDUCTIBLES
AND OUT-OF-POCKET MAXIMUMS.—Any
6
cost-sharing payments made pursuant to subsection (a)(2)
7
shall be counted toward any deductible or out-of-pocket
8
maximum that applies under the plan or coverage.’’.
9
(b) NO EFFECT ON OTHER COST-SHARING.—Section
10
1302(d)(2) of the Patient Protection and Affordable Care
11
Act (42 U.S.C. 18022(d)(2)) is amended by adding at the
12
end the following new subparagraph:
13
‘‘(D) SPECIAL RULE RELATING TO INSU-
14
LIN COVERAGE.—The exemption of coverage of
15
selected insulin products (as defined in section
16
2799A–11(b) of the Public Health Service Act)
17
from the application of any deductible pursuant
18
to section 2799A–11(a)(1) of such Act, section
19
726(a)(1) of the Employee Retirement Income
20
Security Act of 1974, or section 9826(a)(1) of
21
the Internal Revenue Code of 1986 shall not be
22
considered when determining the actuarial value
23
of a qualified health plan under this sub-
24
section.’’.
25
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•S 954 IS
(c) COVERAGE
OF CERTAIN INSULIN PRODUCTS
1
UNDER CATASTROPHIC PLANS.—Section 1302(e) of the
2
Patient Protection and Affordable Care Act (42 U.S.C.
3
18022(e)) is amended by adding at the end the following:
4
‘‘(4) COVERAGE
OF
CERTAIN
INSULIN
PROD-
5
UCTS.—
6
‘‘(A) IN GENERAL.—Notwithstanding para-
7
graph (1)(B)(i), a health plan described in
8
paragraph (1) shall provide coverage of selected
9
insulin products, in accordance with section
10
2799A–11 of the Public Health Service Act, be-
11
fore an enrolled individual has incurred, during
12
the plan year, cost-sharing expenses in an
13
amount equal to the annual limitation in effect
14
under subsection (c)(1) for the plan year.
15
‘‘(B) TERMINOLOGY.—For purposes of
16
subparagraph (A)—
17
‘‘(i) the term ‘selected insulin prod-
18
ucts’ has the meaning given such term in
19
section 2799A–11(b) of the Public Health
20
Service Act; and
21
‘‘(ii) the requirements of section
22
2799A–11 of such Act shall be applied by
23
deeming each reference in such section to
24
‘individual health insurance coverage’ to be
25
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6
•S 954 IS
a reference to a plan described in para-
1
graph (1).’’.
2
(d) ERISA.—
3
(1) IN GENERAL.—Subpart B of part 7 of sub-
4
title B of title I of the Employee Retirement Income
5
Security Act of 1974 (29 U.S.C. 1185 et seq.) is
6
amended by adding at the end the following:
7
‘‘SEC. 726. REQUIREMENTS WITH RESPECT TO COST-SHAR-
8
ING FOR CERTAIN INSULIN PRODUCTS.
9
‘‘(a) IN GENERAL.—For plan years beginning on or
10
after January 1, 2024, a group health plan or health in-
11
surance issuer offering group health insurance coverage
12
shall provide coverage of selected insulin products, and
13
with respect to such products, shall not—
14
‘‘(1) apply any deductible; or
15
‘‘(2) impose any cost-sharing in excess of the
16
lesser of, per 30-day supply—
17
‘‘(A) $35; or
18
‘‘(B) the amount equal to 25 percent of
19
the negotiated price of the selected insulin prod-
20
uct net of all price concessions received by or on
21
behalf of the plan or coverage, including price
22
concessions received by or on behalf of third-
23
party entities providing services to the plan or
24
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•S 954 IS
coverage, such as pharmacy benefit manage-
1
ment services.
2
‘‘(b) DEFINITIONS.—In this section:
3
‘‘(1) SELECTED INSULIN PRODUCTS.—The term
4
‘selected insulin products’ means at least one of each
5
dosage form (such as vial, pump, or inhaler dosage
6
forms) of each different type (such as rapid-acting,
7
short-acting, intermediate-acting, long-acting, ultra
8
long-acting, and premixed) of insulin (as defined
9
below), when available, as selected by the group
10
health plan or health insurance issuer.
11
‘‘(2) INSULIN
DEFINED.—The term ‘insulin’
12
means insulin that is licensed under subsection (a)
13
or (k) of section 351 of the Public Health Service
14
Act (42 U.S.C. 262) and continues to be marketed
15
under such section.
16
‘‘(c) OUT-OF-NETWORK
PROVIDERS.—Nothing in
17
this section requires a plan or issuer that has a network
18
of providers to provide benefits for selected insulin prod-
19
ucts described in this section that are delivered by an out-
20
of-network provider, or precludes a plan or issuer that has
21
a network of providers from imposing higher cost-sharing
22
than the levels specified in subsection (a) for selected insu-
23
lin products described in this section that are delivered
24
by an out-of-network provider.
25
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•S 954 IS
‘‘(d) RULE OF CONSTRUCTION.—Subsection (a) shall
1
not be construed to require coverage of, or prevent a group
2
health plan or health insurance coverage from imposing
3
cost-sharing other than the levels specified in subsection
4
(a) on, insulin products that are not selected insulin prod-
5
ucts, to the extent that such coverage is not otherwise re-
6
quired and such cost-sharing is otherwise permitted under
7
Federal and applicable State law.
8
‘‘(e) APPLICATION
OF
COST-SHARING
TOWARDS
9
DEDUCTIBLES
AND OUT-OF-POCKET MAXIMUMS.—Any
10
cost-sharing payments made pursuant to subsection (a)(2)
11
shall be counted toward any deductible or out-of-pocket
12
maximum that applies under the plan or coverage.’’.
13
(2) CLERICAL AMENDMENT.—The table of con-
14
tents in section 1 of the Employee Retirement In-
15
come Security Act of 1974 (29 U.S.C. 1001 et seq.)
16
is amended by inserting after the item relating to
17
section 725 the following:
18
‘‘Sec. 726. Requirements with respect to cost-sharing for certain insulin prod-
ucts.’’.
(e) INTERNAL REVENUE CODE.—
19
(1) IN
GENERAL.—Subchapter B of chapter
20
100 of the Internal Revenue Code of 1986 is amend-
21
ed by adding at the end the following new section:
22
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9
•S 954 IS
‘‘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 provide
4
coverage of selected insulin products, and with respect to
5
such products, shall not—
6
‘‘(1) apply any deductible; or
7
‘‘(2) impose any cost-sharing in excess of the
8
lesser of, per 30-day supply—
9
‘‘(A) $35; or
10
‘‘(B) the amount equal to 25 percent of
11
the negotiated price of the selected insulin prod-
12
uct net of all price concessions received by or on
13
behalf of the plan, including price concessions
14
received by or on behalf of third-party entities
15
providing services to the plan, such as phar-
16
macy benefit management services.
17
‘‘(b) DEFINITIONS.—In this section:
18
‘‘(1) SELECTED INSULIN PRODUCTS.—The term
19
‘selected insulin products’ means at least one of each
20
dosage form (such as vial, pump, or inhaler dosage
21
forms) of each different type (such as rapid-acting,
22
short-acting, intermediate-acting, long-acting, ultra
23
long-acting, and premixed) of insulin (as defined
24
below), when available, as selected by the group
25
health plan.
26
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10
•S 954 IS
‘‘(2) INSULIN
DEFINED.—The term ‘insulin’
1
means insulin that is licensed under subsection (a)
2
or (k) of section 351 of the Public Health Service
3
Act (42 U.S.C. 262) and continues to be marketed
4
under such section.
5
‘‘(c) OUT-OF-NETWORK
PROVIDERS.—Nothing in
6
this section requires a plan that has a network of providers
7
to provide benefits for selected insulin products described
8
in this section that are delivered by an out-of-network pro-
9
vider, or precludes a plan that has a network of providers
10
from imposing higher cost-sharing than the levels specified
11
in subsection (a) for selected insulin products described
12
in this section that are delivered by an out-of-network pro-
13
vider.
14
‘‘(d) RULE OF CONSTRUCTION.—Subsection (a) shall
15
not be construed to require coverage of, or prevent a group
16
health plan from imposing cost-sharing other than the lev-
17
els specified in subsection (a) on, insulin products that are
18
not selected insulin products, to the extent that such cov-
19
erage is not otherwise required and such cost-sharing is
20
otherwise permitted under Federal and applicable State
21
law.
22
‘‘(e) APPLICATION
OF
COST-SHARING
TOWARDS
23
DEDUCTIBLES
AND OUT-OF-POCKET MAXIMUMS.—Any
24
cost-sharing payments made pursuant to subsection (a)(2)
25
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11
•S 954 IS
shall be counted toward any deductible or out-of-pocket
1
maximum that applies under the plan.’’.
2
(2) CLERICAL AMENDMENT.—The table of sec-
3
tions for subchapter B of chapter 100 of such Code
4
is amended by adding at the end the following new
5
item:
6
‘‘Sec. 9826. Requirements with respect to cost-sharing for certain insulin prod-
ucts.’’.
(f) IMPLEMENTATION.—The Secretary of Health and
7
Human Services, the Secretary of Labor, and the Sec-
8
retary of the Treasury may implement the provisions of,
9
including the amendments made by, this subsection
10
through sub-regulatory guidance, program instruction or
11
otherwise.
12
SEC. 3. REIMBURSEMENT FOR INSULIN FURNISHED TO UN-
13
INSURED INDIVIDUALS.
14
(a) IN GENERAL.—The Secretary of Health and
15
Human Services (in this section referred to as the ‘‘Sec-
16
retary’’) shall establish a program under which the Sec-
17
retary enters into agreements with qualifying entities for
18
purposes of furnishing insulin products to uninsured indi-
19
viduals.
20
(b) PAYMENT.—The Secretary shall pay to each
21
qualifying entity with an agreement in effect under this
22
section, with respect to each 30-day supply of insulin prod-
23
ucts furnished to an uninsured individual by such entity
24
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[Text truncated for display. Full text available on Congress.gov.]