HB 17-CONTRACEPTIVES COVERAGE:INSURE;MED ASSIST  3:03:40 PM CHAIR PRAX announced that the first order of business would be HOUSE BILL NO. 17, "An Act relating to insurance coverage for contraceptives and related services; relating to medical assistance coverage for contraceptives and related services; and providing for an effective date." 3:04:32 PM REPRESENTATIVE ASHLEY CARRICK, Alaska State Legislator, as prime sponsor, presented HB 17. She stated that since the mid-'90s, 28 states have required health insurance plans regulated by the state to provide coverage of prescription drugs and devices, including contraceptives. Under a provision of the Affordable Care Act of 2010 (ACA), these state policies were expanded in several ways. She said ACA's contraceptive coverage guarantee extends from Section 13 of the Public Health Service Act, which requires non-grandfathered health insurance coverage and employer-sponsored group health plans to cover preventive services without cost-sharing. She said Section 27.13 required coverage of women's preventive services, as defined by the Health Resources and Service Administration (HRSA). She said HRSA asked the then Institute of Medicine to recommend that women's preventative services be covered, and based on this recommendation, HRSA defined women's preventative services to include all contraceptives approved by the U.S. Food and Drug Administration (FDA) and patient education and counseling for "women of reproductive capacity," as prescribed by a health care provider, collectively referred to as "contraceptive services." The final preventative services rules required insurers and group health plans to cover all such contraceptive services. REPRESENTATIVE CARRICK said more recently some states have amended and expanded their own requirements to match the federal guarantee. She offered examples. She said HB 17 would put into statute language consistent with the federal standards. It would also mandate dispensing coverage of contraceptives up to 12 months at a time. She noted that Alaskans often face numerous challenges when trying to access contraceptives, especially in rural areas where it is not feasible to travel multiple times to a pharmacy in a larger community. Additionally, some women work in high demand jobs that take them away from access to pharmacies, such as working on the North Slope, on fishing vessels, or in the mining industry. She argued that a one-year supply of contraceptives could assist many women to balance their health with their professional work. She cited research in the Journal of Obstetrics and Gynecology [hard copy included in the committee packet] as showing that women who are dispensed a 12-month supply of contraceptives have a 30 percent drop in unplanned pregnancy and a 46 percent drop in "the likelihood of abortion" compared to women dispensed a 1- to 3-month supply. Representative Carrick stated that HB 17 would also save money for the state. Based on prior, similar legislation, the former Department of Health and Social Services estimated a $1.35 million savings annually due to a reduction in unplanned pregnancies. She pointed out that HB 17 has zero fiscal impact. She expressed her knowledge that improved access to contraceptives means improved health for women and families. She said providers are still able to make decisions in consultation with their patients; the proposed legislation would take "insurance coverage away as a barrier to access." 3:08:46 PM REPRESENTATIVE CARRICK stated that HB 17 would offer the additional benefit of protecting victims of domestic violence. She noted that in the past few years there has been an increased awareness of domestic violence and sexual assault. She talked about contraceptive coercion as being a form of domestic or interpersonal violence by which abusers "dictate when and how contraceptives can or cannot be accessed as a means of being in power or control." She stated, "Contraceptive services have long been recognized by both government and a wide range of private sector experts as a vital and effective component of preventative and public health care." She talked about the benefits of contraceptive use in preventing unintended pregnancy and improving "birth spacing." She noted that there had been letters of support for previous versions of this legislation from organizations such as the Alaska Network of Domestic Violence and Sexual Assault (ANDVSA), the Alaska Public Health Association, and the League of Women Voters; and there are updated letters and resolutions from entities in support of HB 17. Representative Carrick concluded by stating that HB 17 makes sense for Alaska women and families. She introduced her staff to provide the sectional analysis. 3:10:41 PM CHERIE BOWMAN, Staff, Representative Ashley Carrick, Alaska State Legislature, on behalf of Representative Carrick, prime sponsor of HB 17, provided the sectional analysis [included in the committee packet], which read as follows [original punctuation provided]: Section 1 AS 21.42.427. Coverage for contraceptives. Amends AS 21.42 by adding a new section which (1) requires a health care insurer to provide coverage for prescription contraceptives and medical services necessary for those products or devices (including over-the-counter emergency contraception that was obtained without a prescription); (2) requires reimbursement to a health care provider or dispensing entity for dispensing prescription contraceptives intended to last for a 12-month period for subsequent dispensing; (3) prevents an insurer from offsetting the costs of compliance; (4) prevents an insurer from restricting or delaying coverage for contraceptives; (5) if the provider recommends a particular service or FDA-approved item based on a determination of medical necessity, the plan or issuer must cover that service or item without cost sharing; and (6) exempts religious employers if certain criteria are met. Section 2 AS 29.10.200. Limitation of home rule powers. Amends AS 29.10.200 by adding a provision applying to home rule municipalities. Section 3 AS 29.20.420. Health insurance policies. Amends AS 29.20 by adding a new section clarifying that municipal health care insurance plans that are self-insured are subject to the requirements of sec. 1. Section 4 AS 39.30.090. Procurement of group insurance. Clarifies that a group health insurance policy covering employees of a participating governmental unit is subject to the requirements of sec. 1. Section 5 AS 39.30.091. Authorization for self-insurance and excess loss insurance. Clarifies that a self-insured group medical plan covering active state employees provided under this section is subject to the requirements of sec. 1. Section 6 AS 47.07.065. Payment for prescribed drugs. Requires the Department of Health and Social Services to pay for prescription contraceptives intended to last for a 12-month period for subsequent dispensing for eligible recipients of medical assistance, if prescribed to and requested by the recipient, as well as medical services necessary for Distributed by the Office of Representative Ashley Carrick 1.25.2023 2 those products or devices. The Department of Health and Social Services must also provide coverage for over-the-counter emergency contraception that was obtained without a prescription. Section 7 Uncodified law applicability Requires the Department of Health to immediately amend and submit for federal approval a state plan for medical assistance coverage consistent with sec. 6 of this Act. Section 8 Uncodified law applicability Makes sec. 6 of the Act conditional on the approval required under sec. 7 of the Act. Section 9 Uncodified law applicability If, under sec. 8 of this Act, sec. 6 of this Act takes effect, it takes effect on the day after the date the revisor of statutes receives notice from the commissioner of health and social services under sec. 8 of this Act. 3:15:10 PM REPRESENTATIVE MINA expressed appreciation to the bill sponsor and asked whether "the month-span for different types of contraceptives" is found in statute or regulations. 3:15:59 PM REPRESENTATIVE CARRICK offered her understanding that it is typically within a one- to three-month span depending on patient needs, in consultation with the provider. 3:16:31 PM REPRESENTATIVE SADDLER, seeking a baseline, asked about current limits to the duration of a prescription for any medication. REPRESENTATIVE CARRICK answered she is not sure and suggested Ms. Wing-Heier from the Division of Insurance could provide an answer. 3:17:46 PM REPRESENTATIVE RUFFRIDGE directed attention to language in HB 17, [Section 1, paragraph (2)], on page 2, lines 5-9, which read as follows: (2) reimburse a health care provider or dispensing entity for dispensing prescription contraceptives intended to last for a 12-month period for subsequent dispensings of the same prescription contraceptive to the insured regardless of whether the insured was enrolled in the health care insurance plan at the time of the first dispensing. REPRESENTATIVE RUFFRIDGE asked for more information regarding the part about enrollment. REPRESENTATIVE CARRICK offered her understanding that that potentially may allow for some type of reimbursement, but deferred again to Ms. Wing-Heier. REPRESENTATIVE RUFFRIDGE then directed attention to the repeated use of the term "emergency contraception" in HB 17, first seen on page 1, line 11, and he offered his understanding that emergency contraception is available over the counter (OTC). He asked whether the intent of the bill language was that a person would go get emergency contraception from wherever it is sold and expect to obtain it at no charge upfront. REPRESENTATIVE CARRICK answered that she thinks the language means that someone who has [insurance] coverage for "Plan B" [emergency contraception] and purchases it could submit for reimbursement. This would allow someone to get Plan B without having to first make an appointment with a medical provider to get a prescription, which can be a burden. She said she thinks it does not mean the person could get it at no cost upfront. REPRESENTATIVE RUFFRIDGE highlighted language on page 2, beginning on line 26: "cost containment measure does not unreasonably limit choice in access to coverage". He asked what would be considered unreasonable. REPRESENTATIVE CARRICK, in response, offered her understanding that that is not defined in statute, but the reason for this language is to ensure that people are incentivized "to go for generics as much as possible." In response to a follow-up question regarding restrictions in cost-containment measures related to prescriptions, and whether that may refer to mail order prescriptions, she related the key goal of HB 17 is to provide access to contraceptives. 3:24:24 PM REPRESENTATIVE SADDLER indicated concern that HB 17 may provide "special consideration for this particular kind of prescription." He also questioned whether there was such a thing as reasonable limitations of choice in terms of contraceptive prescriptions. REPRESENTATIVE CARRICK emphasized that emergency contraceptives are not the same thing as an abortifacient drug. She said she would like to find out more about the issue of what is reasonable. That said, she reiterated that the goal of HB 17 is "to direct toward generics in order to help with the cost containment." In response to a follow-up question, she highlighted the medical difference between emergency contraception and an abortifacient drug. REPRESENTATIVE SADDLER asked about the cost of HB 17 to the State of Alaska. 3:28:42 PM LORI WING-HEIER, Director, Anchorage Office, Division of Insurance Director, Department of Commerce, Community & Economic Development, addressed the previously asked questions regarding cost and what is reasonable. She confirmed that based on previous iterations of this legislation, insurance companies had determined the cost would be negligible. Contraceptives would still be covered; the difference would be in the cost-sharing, which is the person's deductible and co-pay, which she estimated would be about $3. She said HB 17 is asking those be waived in dispensing birth control. She said she could not think of an example of a contraceptive pill on the market today where there would be "an unreasonable expectation or an unreasonable limit for [the generic version] to be dispensed in the state of Alaska." The only exception she could think of, she said, would be in a case where an individual worked on the North Slope, for example, and had come to Fairbanks to pick up a prescription for a contraceptive, and the pharmacy was currently out of the generic brand. In this scenario, she opined, it would be unreasonable to send the person back to the North Slope without the prescription when a brand-name drug could be substituted. 3:31:20 PM REPRESENTATIVE RUFFRIDGE reiterated his question about cost- containment measures. He offered understanding about the Medicaid system using cost-management techniques, and he asked if "this bill would override those for Medicaid." He asked whether HB 17 could result in a slight increase in cost to Medicaid. MS. WING-HEIER responded that the division is not involved with Medicaid; therefore, she cannot speak to that issue. 3:32:44 PM REPRESENTATIVE SUMNER asked if there is any "strong reason" this should not be applied to all medications that do not have "an abuse potential." MS. WING-HEIER responded that a provider currently can prescribe a 12-month dose of whatever medication a patient needs, but the insurance plan may be the limiting factor by only paying for 3 months at a time. In response to a follow-up question, she confirmed that is what is trying to be addressed under HB 17. 3:33:48 PM REPRESENTATIVE CARRICK added that HB 17 could be more comprehensive and include other types of medication, but the reason she is carrying the proposed legislation is because many women have specifically asked for 12-month contraceptive prescriptions to be allowed. 3:34:53 PM REPRESENTATIVE SADDLER asked what the justification is to limit any other drug to a three-month prescription and whether there is a therapeutic benefit to doing so. 3:35:26 PM MS. WING-HEIER noted that often a physician gives a patient a drug on a trial basis and asked the patient to come back for blood work in three months to determine the efficacy of the drug. In response to a follow-up question, she said this may be beyond her expertise, but she supposed birth control is a drug that is not looked at as heavily as looking at lab work; rather it is a matter of determining effectiveness in preventing [conception]. 3:36:34 PM CHAIR PRAX announced that HB 17 was held over.