Legislature(2017 - 2018)HOUSE FINANCE 519

04/18/2017 09:45 AM FINANCE

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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
-- Continued from 4/17/17 --
Heard & Held
Moved CSSB 88(RES) Out of Committee
+ Bills Previously Heard/Scheduled TELECONFERENCED
HOUSE BILL NO. 25                                                                                                             
     "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                                                                    
9:53:39 AM                                                                                                                    
Co-Chair Foster OPENED Public Testimony.                                                                                        
9:54:17 AM                                                                                                                    
ROBIN  STEVENS, SELF,  JUNEAU, supported  HB 25.  She shared                                                                    
that she  took birth control pills  for 22 years due  to her                                                                    
inability  to  find  a  doctor who  would  perform  a  tubal                                                                    
ligation. She explained that her  insurance only allowed her                                                                    
3  days  to refill  her  birth  control prescription  before                                                                    
beginning  the next  month's dosage.  She believed  that the                                                                    
women most  in need of  birth control had the  most barriers                                                                    
to access  due to  lack of  transportation, or  inability to                                                                    
take  leave  from work.  She  felt  that avoiding  pregnancy                                                                    
should not  be difficult.  She urged  members to  remove the                                                                    
barriers to  birth control. She  stated that a  year's worth                                                                    
of birth control was much  less expensive and safer than the                                                                    
cost of  childbirth. She  did not  "subscribe to  the theory                                                                    
that  it  took  two  to   tango  and  would  never  put  her                                                                    
reproductive future in the hands of her sexual partner."                                                                        
Representative Guttenberg  asked whether  she could  not get                                                                    
her  prescription  refilled  until  she  was  out  of  birth                                                                    
control.  Ms.  Stevens  replied   in  the  affirmative.  Ms.                                                                    
Stevens reported that birth control  prescriptions were on a                                                                    
28-day   cycle.  Her   insurance   through  the   Affordable                                                                    
Healthcare Act (ACA or Obama  Care) specified that she could                                                                    
only obtain a refill every 25 days.                                                                                             
Vice-Chair Gara  asked how long  her prescription  lasted or                                                                    
whether  she  periodically  had to  coordinate  through  her                                                                    
doctor and  the pharmacy. Ms. Stevens  stated that typically                                                                    
a prescription was written for a period of 15 months.                                                                           
9:58:42 AM                                                                                                                    
Representative Wilson  asked about her insurance  policy and                                                                    
whether it  was private or  a federal program.  She wondered                                                                    
whether  she  was subject  to  a  private insurers  rule  or                                                                    
federal law.  Ms. Stevens  had been  able to  access private                                                                    
insurance  due  to  the  ACA.  Representative  Wilson  asked                                                                    
whether  the  25-day rule  was  the  insurers or  a  federal                                                                    
guideline.  Ms.  Stevens  indicated  that  her  health  care                                                                    
provider  had mentioned  that  the  insurer established  the                                                                    
rule.  Representative Wilson  asked why  the tubal  ligation                                                                    
procedure was not authorized. Ms.  Stevens answered that she                                                                    
was  not  able to  find  a  doctor  to perform  the  surgery                                                                    
because she might change her mind.                                                                                              
10:00:12 AM                                                                                                                   
LISA EIGAN  LAGERQUIST, SELF, DOUGLAS,  spoke in  support of                                                                    
HB 25.  She provided information  about her personal  use of                                                                    
birth control. She thought it  was very important that other                                                                    
contraceptive options  were covered besides "The  Pill." She                                                                    
spoke about  the inconvenience  of having  to get  a monthly                                                                    
prescription refilled. She thought  that anything that could                                                                    
be  done to  help people  choose "intended  pregnancies" was                                                                    
imperative.  She emphasized  that anyone  that wanted  birth                                                                    
control should have access to  it. She urged support for the                                                                    
10:02:58 AM                                                                                                                   
BARRY    CHRISTENSEN,   ALASKA    PHARMACISTS   ASSOCIATION,                                                                    
KETCHIKAN  (via  teleconference),  spoke  in  favor  of  the                                                                    
legislation on  behalf of the organization.  The association                                                                    
believed that the bill was  good public policy. He explained                                                                    
that  insurance plans  typically restrict  all prescriptions                                                                    
to 30 or 90 days.  He indicated that vacation overrides were                                                                    
only available on some plans  and were "fairly problematic."                                                                    
The insurers required very  specific information about dates                                                                    
of travel  and limited the  supply to the length  of travel.                                                                    
Additionally, ferry workers  whose job time on  the boat was                                                                    
extended were  denied overrides if the  pharmacist mentioned                                                                    
the refill  was necessary  for work and  not a  vacation. He                                                                    
referenced previous testimony  regarding "refill parameters"                                                                    
and delineated  that typically 75 percent  of a prescription                                                                    
had to be  used before refills were allowed  but some plans'                                                                    
parameters were more restrictive.                                                                                               
10:05:26 AM                                                                                                                   
Representative Guttenberg  mentioned that  prior discussions                                                                    
focused  on who  mandated quantities  of prescriptions;  the                                                                    
federal  government  or  private   insurers.  He  asked  Mr.                                                                    
Christiansen  to speak  to  prescription  drug managers  and                                                                    
their  role.  Mr.  Christiansen  explained  that  pharmacies                                                                    
contracted with prescription benefit  managers (PBM) and the                                                                    
PBM's  contracted  with  the group  or  individual  insurer.                                                                    
Every prescription  at the  "point of  sale" was  based upon                                                                    
the insurance  plans' parameters. He indicated  that all the                                                                    
pharmacists'  conversations   regarding  prescriptions  were                                                                    
with  the PBMs.  Representative  Guttenberg  asked how  much                                                                    
control the  PBMs had over  the actions of  the pharmacists.                                                                    
He  remarked  that  the  PBMs   were  determining  what  the                                                                    
pharmacists  could  do.  MR. Christiansen  agreed  with  the                                                                    
statement.   He   related    that   except   for   self-paid                                                                    
prescriptions,  which were  rare,  every decision  regarding                                                                    
prescriptions  was "dictated"  by  the  PBM's. Everyday  his                                                                    
staff spent "numerous, numerous hours"  on the phone and the                                                                    
computer with PBM's trying to  get people their medications.                                                                    
He characterized the situation as "challenging."                                                                                
10:09:05 AM                                                                                                                   
Representative Ortiz  thanked Mr.  Christiansen for  all his                                                                    
contributions to  the field. He asked  whether birth control                                                                    
refill  prescriptions  typically required  doctor's  visits.                                                                    
Mr.   Christiansen   responded  that   typically   providers                                                                    
authorized  refills for  11 months  after  the initial  one-                                                                    
month  prescription  and  shorter  prescriptions  were  most                                                                    
often easily refilled. He deduced  that if HB 25 passed, the                                                                    
pharmacists would  likely have to inform  the providers that                                                                    
12-month prescriptions were  allowable. Representative Ortiz                                                                    
asked  whether  in  Mr.  Christiansen's  experience,  issues                                                                    
around  access to  birth control  were  more problematic  in                                                                    
rural areas rather  than urban areas, and if HB  25 was more                                                                    
beneficial  for rural  residents. Mr.  Christiansen answered                                                                    
in  the affirmative.  He relayed  that  his pharmacy  served                                                                    
outlying rural  areas and he  could see how  the legislation                                                                    
would help residents in rural areas.                                                                                            
Co-Chair  Foster asked  Mr. Christiansen  to  expand on  his                                                                    
answer regarding  the difficulties with  prescription access                                                                    
in  rural villages.  He  spoke to  the  challenges in  small                                                                    
villages  regarding   healthcare  delivery  and   access  to                                                                    
prescriptions.  He  wondered  whether  there  was  a  higher                                                                    
number of  pregnancies in  rural villages due  to a  lack of                                                                    
services  and if  he knew  of  any attempts  to address  the                                                                    
challenges. Mr. Christiansen responded  that he did not have                                                                    
information  or  insight  specific to  the  representative's                                                                    
district but  offered to  ask pharmacists  from his  area to                                                                    
address the  questions. He related  that in the  rural areas                                                                    
he  served  around Ketchikan  the  difficulty  was in  rural                                                                    
residents receiving  medications in  general and  that birth                                                                    
control  was  typically  prescribed for  longer  periods  of                                                                    
time. He  understood that other  parts of Alaska  might face                                                                    
some unique challenges that he was unable to address.                                                                           
10:14:37 AM                                                                                                                   
ROBIN SMITH, SELF, ANCHORAGE  (via teleconference), spoke in                                                                    
favor  of  HB 25.  She  spoke  of the  higher  out-of-pocket                                                                    
medical  costs  that women  encountered  versus  men due  to                                                                    
contraceptive  coverage.  She  relayed  that  birth  control                                                                    
coverage  was  expanded   and  co-payments  were  eliminated                                                                    
through the  ACA. She was concerned  about potential changes                                                                    
in  the   Affordable  Care   Act  which   currently  covered                                                                    
contraception   due  to   the  current   administration  and                                                                    
Congress in  Washington. She  advocated providing  a variety                                                                    
of birth  control including vasectomy. She  thought that the                                                                    
ability  to  choose  pregnancy  empowered  women  and  their                                                                    
families and provided  the best outcomes for  the child. She                                                                    
voiced  that  increased  access to  contraceptives  was  the                                                                    
"key"  to reducing  the number  of  unwanted pregnancies  in                                                                    
Alaska. She  spoke to the  high number of spousal  and child                                                                    
abuse in  the state. She  argued that one  avoided pregnancy                                                                    
would help to pay for  a significant amount of birth control                                                                    
for  many  others.  She   relayed  her  personal  experience                                                                    
regarding the  inconvenience of attaining her  birth control                                                                    
prescriptions.  She  responded  to  Representative  Wilson's                                                                    
questions regarding  the impact  of HB  25. She  agreed that                                                                    
one "key limitation"  of state plans was  their inability to                                                                    
affect  nationwide or  self-insured scope  of coverage.  She                                                                    
suggested that  if enough states adopted  changes the action                                                                    
would potentially set off a  ripple effect across the entire                                                                    
insurance industry. She urged members to support HB 25.                                                                         
10:20:27 AM                                                                                                                   
SARA CLARK,  SELF, ANCHORAGE (via teleconference),  spoke in                                                                    
support of  HB 25. She  thought it was important  to support                                                                    
women  having  control  of their  reproductive  health.  She                                                                    
asked members to vote in favor of HB 25.                                                                                        
10:21:42 AM                                                                                                                   
Co-Chair Foster CLOSED Public Testimony.                                                                                        
Representative  Wilson  asked   whether  the  Department  of                                                                    
Health  and Social  Services (DHSS)  had  found anything  in                                                                    
statute that prevented Medicaid  from filling 12-month birth                                                                    
control prescriptions.                                                                                                          
10:22:05 AM                                                                                                                   
MARGARET   BRODIE,  DIRECTOR,   DIVISION   OF  HEALTH   CARE                                                                    
SERVICES,   DEPARTMENT  OF   HEALTH  AND   SOCIAL  SERVICES,                                                                    
responded  in the  affirmative and  noted that  AS 47.47.065                                                                    
outlined  the regulation.  She read  the following  language                                                                    
from the statute:                                                                                                               
     ? by regulations adopted by the commissioner in                                                                            
     conformity with applicable federal regulations.                                                                            
Representative  Wilson   asked  if  there  were   any  state                                                                    
regulations  that  prevented  a 12-month  prescription  from                                                                    
being written through Medicaid.  Ms. Brodie responded in the                                                                    
negative. Representative  Wilson referred  to Page  5, lines                                                                    
28 through 29:                                                                                                                  
     (13) a group health insurance policy covering                                                                              
     employees of a participating governmental unit is                                                                          
     subject to the requirements of AS 21.42.427.                                                                               
Representative Wilson inquired  whether the University's and                                                                    
the  largest  state union's  plans  were  covered under  the                                                                    
provision. Ms. Brodie was unable to answer the question.                                                                        
Representative Wilson  reiterated the question  and wondered                                                                    
whether the  following bill  language from  page 6,  lines 6                                                                    
through 8 also applied:                                                                                                         
     A self-insured group medical plan covering active                                                                          
     state employees provided under this section is subject                                                                     
     to the requirements of AS 21.42.427.                                                                                       
REPRESENTATIVE MATT  CLAMAN, SPONSOR, responded that  he was                                                                    
unfamiliar with the various health  plans for the University                                                                    
and was  unable to  provide the answer.  He offered  that if                                                                    
the plan  was a union  trust type of health  insurance plan,                                                                    
the federal Employee Retirement  Income Security Act (ERISA)                                                                    
exempted union  trusts from state regulations  and therefore                                                                    
state   law  could   not  impact   a   union  health   trust                                                                    
administered plan.                                                                                                              
10:26:07 AM                                                                                                                   
Representative Wilson  deduced that  the general  union plan                                                                    
[General Government Unit (GGU)]  was most likely exempt from                                                                    
the legislation.  She remarked that  the state paid  for the                                                                    
plan, but  did not manage  it. She believed that  the fiscal                                                                    
note  should be  updated because  according to  Ms. Brodie's                                                                    
testimony the state could  administer 12 month contraceptive                                                                    
prescriptions  for Medicaid.  She asked  Ms. Brodie  for the                                                                    
reasons why the state had  not done so, especially since the                                                                    
fiscal  note  identified  savings in  the  Medicaid  program                                                                    
under  the bill.  Representative Claman  offered to  provide                                                                    
the additional information.                                                                                                     
Co-Chair Seaton  suggested that  the legislature  could only                                                                    
act through  statute. However, the legislature  could advise                                                                    
the administration  through a  resolution. He  remarked that                                                                    
the  only way  the legislature  could override  a regulation                                                                    
was through statute.                                                                                                            
Representative  Wilson   pointed  out  that  there   was  no                                                                    
statute. She  confirmed with  Ms. Brodie  that DHSS  had not                                                                    
written  a  regulation  either.   She  declared  that  under                                                                    
current  regulation  or  statute   there  was  nothing  that                                                                    
prevented  12 month  prescriptions  under  Medicaid and  the                                                                    
Alaska Care plans with or without the bill.                                                                                     
Representative  Guttenberg  asked  that in  the  absence  of                                                                    
state   statute,   regulations,   or   a   plan   directive,                                                                    
prescription  parameters  were  left  up  to  the  PBM's  to                                                                    
contain  insurer's  costs.  Ms. Brodie  confirmed  that  the                                                                    
reason the  limit was in  place for most plans  and Medicaid                                                                    
was   cost   containment.   She  commented   that   Medicaid                                                                    
recipients revolved in and out  of the program and the state                                                                    
did not want to pay for ineligible prescriptions.                                                                               
10:30:37 AM                                                                                                                   
Vice-Chair Gara wanted  to ensure that the  bill remained in                                                                    
statute  for  as long  as  possible.  He mentioned  a  prior                                                                    
discussion that the bill would  only remain effective if the                                                                    
ACA remained  intact. He asked whether  the provisions would                                                                    
remain  in  statute  regardless   of  changes  to  the  ACA.                                                                    
Representative  Claman   cited  page  3,  lines   5  and  6,                                                                    
Subsection (1)  and noted that  the bill referenced  the ACA                                                                    
as amended. He  thought if the ACA  was completely repealed,                                                                    
Alaska statute  could possibly be  affected. He did  not see                                                                    
any likelihood  of repeal  of the ACA.  He thought  that the                                                                    
language  in the  bill "was  more than  adequate" to  ensure                                                                    
that HB 25 would continue  in the state. Vice-Chair Gara did                                                                    
not want  to "play  Vegas odds with  the bill."  He wondered                                                                    
whether  the  contraceptive  provisions in  the  bill  would                                                                    
remain  if Congress  removed  the  ACA provisions  regarding                                                                    
contraceptive  care. Representative  Claman did  not believe                                                                    
that the bill was "dependent  upon" the ACA and informed the                                                                    
committee that the ACA references  in the bill were specific                                                                    
to  religious exemptions.  He believed  that the  bill would                                                                    
continue  to be  applied even  if the  ACA was  repealed. He                                                                    
discerned that  the ACA religious  exemptions were  so broad                                                                    
that  creating religious  exemptions  in  state statute  may                                                                    
cause  problems, especially  if the  exemption was  narrower                                                                    
than the ACA's. He felt  that the endeavor to craft statutes                                                                    
based on  what possibly  could happen  with the  ACA created                                                                    
10:34:57 AM                                                                                                                   
Vice-Chair  Gara  asked  whether  the  12-month  requirement                                                                    
would remain  regardless of  the ACA.  Representative Claman                                                                    
answered in the affirmative. He  clarified that the 12 month                                                                    
requirement only  applied if the  provider wrote a  12 month                                                                    
prescription.  Vice-Chair Gara  understood the  "hazards" if                                                                    
the  state   developed  its  own  religious   exemption.  He                                                                    
reported  that relying  on the  current religious  exemption                                                                    
under ACA  would disappear in  state stature if the  ACA was                                                                    
repealed. He wondered why the  bill did not specify that the                                                                    
provisions  were  relying  on   the  current  ACA  religious                                                                    
exemption in 2017. He suggested  inserting language such as:                                                                    
"under the ACA religious exemption  as written as of January                                                                    
1,  2017." Representative  Claman  would not  object to  the                                                                    
amendment. Vice-Chair Gara asked  whether the language would                                                                    
be  added on  page 3,  line  6 of  the bill.  Representative                                                                    
Claman  recommended that  the  language  broadly applied  to                                                                    
Subsection (g) on page 2, lines 31 through page 3, line 10.                                                                     
10:37:22 AM                                                                                                                   
Representative Wilson interpreted the  bill language on page                                                                    
2,  line  3 that  the  bill  did  not  prohibit a  15  month                                                                    
prescription from being filled.                                                                                                 
LIZZIE KUBITZ, STAFF,  REPRESENTATIVE MATT CLAMAN, responded                                                                    
that  there was  a  federal  law limiting  the  period of  a                                                                    
prescription  to 12  months. Representative  Wilson was  not                                                                    
concerned  about  the federal  law  and  was only  concerned                                                                    
about  the  interpretation  of  the  bill's  provision.  Ms.                                                                    
Kubitz  responded  that   she  was  correct.  Representative                                                                    
Wilson read page 1, lines 6 through 8 of the bill:                                                                              
     Sec.  21.42.427.  Coverage  for contraceptives.  (a)  A                                                                    
     health care  insurer that offers, issues  for delivery,                                                                    
     delivers,  or  renews  in  the   state  a  health  care                                                                    
     insurance  plan  in  the  group  or  individual  market                                                                    
Representative  Wilson noted  the use  of the  word "shall."                                                                    
She asked whether  the bill only applied as  listed above to                                                                    
entities  that provided  contraceptive coverage.  Ms. Kubitz                                                                    
responded affirmatively.                                                                                                        
HB  25  was   HEARD  and  HELD  in   committee  for  further                                                                    

Document Name Date/Time Subjects
SB 88 - Opposition Document 4.18.2017.pdf HFIN 4/18/2017 9:45:00 AM
SB 88