RSA 415-A:7 · Establishing Excess Cost Sharing

415-A:7 Establishing Excess Cost Sharing. –

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I.

In this section:

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(a)

"Insurer" means an entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a policy of insurance, health service corporation, health maintenance organization, preferred provider agreement, or any other entity providing accident and health insurance.

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(b)

"Rebate" means:

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(1)

Negotiated price concessions including, but not limited to, base rebates and reasonable estimates of any price protection rebates and performance-based rebates that may accrue directly or indirectly to the insurer during the coverage year from a manufacturer, dispensing pharmacy, or other party to the transaction; and

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(2)

Reasonable estimates of any fees and other administrative costs that are passed through to the health carrier and serve to reduce the insurer's prescription drug liabilities for the coverage year.

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II.

All rebates remitted by or on behalf of a pharmaceutical manufacturer, developer or labeler, directly or indirectly, to an insurer, or to a pharmacy benefits manager under contract with an insurer, related to its prescription drug benefits shall be remitted in one or both of the following ways:

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(a)

Remitted directly to the covered person at the point of sale to reduce the out-of-pocket cost to the covered person associated with a particular prescription drug;

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(b)

Remitted to, and retained by, the insurer. Rebates remitted to the insurer shall be applied by the insurer in its plan design and in future plan years to offset the premium for covered persons.

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III.

Beginning March 1, 2025, and annually thereafter, an insurer shall file with the commissioner a report in the manner and form determined by the commissioner demonstrating the manner in which the insurer and/or its contracted entity for pharmacy benefit services has complied with this section. The report shall include at least the following:

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(a)

An actuarial certification attesting:

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(1)

All discounts and rebates received by health insurers were used to reduce costs for policyholders in compliance with paragraph II.

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(2)

How rebates were remitted in the individual, small, and large group market.

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(3)

If applied pursuant to subparagraph II(b), an explanation of how remittance was applied to both plan design, based on estimated rebates, and in future plan years to offset premium.

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(4)

A description of the methodology employed to calculate the estimated rebate amount, for the purpose of applying to plan design.

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(b)

Methodology for determining estimated rebate amount:

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(1)

Insurers shall employ actuarial and analytical methodologies to estimate the total rebate amount expected to be received from drug manufacturers over a defined period.

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(2)

The determination of the estimated rebate amount shall account for factors such as historical rebate data, anticipated changes in drug utilization, formulary modifications, and other pertinent variables.

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(3)

The calculated estimated rebate amount shall adhere to generally accepted actuarial principles and industry best practices to ensure precision and dependability.

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(4)

The calculation shall be documented and made available for review by the insurance commissioner, upon request. III-a. This section shall not apply to Medicaid, the Medicaid Care Management Program, the Ryan White HIV/AIDS Program administered by the department of health and human services, or self-funded plans such as the state employee health benefit plan.

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IV.

Any insurer that violates any provision of this section may, at the discretion of the commissioner, be subject to subparagraph (a) or (b), or both:

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(a)

Its certificate of authority may be indefinitely suspended or revoked.

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(b)

A civil fine not to exceed $2,500 may be imposed for each violation. Repeated violations of the same provision shall constitute separate civil offenses.

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V.

In making the disclosures required under this section, an insurer shall not be required by the department to publish or otherwise reveal information regarding the amount of rebates it receives, including, but not limited to, information regarding the amount of rebates it receives on a product-, manufacturer-, or pharmacy-specific basis. Such information is protected as a trade secret, is not a public record subject to disclosure under RSA 91-A:1, and shall not be disclosed directly or indirectly. An insurer shall impose the confidentiality provision of this section on any vendor or third party that performs health care or administrative services on behalf of the insurer that may receive or have access to rebate information. Source. 2020, 15:1, eff. Sept. 15, 2020. 2024, 305:2, eff. June 30, 2024.

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