Legislative Initiatives to Cut Cost-Sharing: A Closer Look at Diabetes, Breast Cancer, and Infertility

Rising healthcare costs have been a topic of debate in state legislatures across the country for years, with a specific interest in addressing costs for consumers. Recently, lawmakers have targeted cost-sharing requirements for certain services and treatments that are often considered costly for patients. Cost-sharing requirements typically refer to patient out-of-pocket costs, such as copayments, coinsurance, and deductibles. 

Diabetes

Over the years state legislatures have targeted diabetes care costs with a specific focus on insulin expenses for patients. In 2019, Colorado became the first state to enact a limit of copayment on insulin, often called “copay cap.” Colorado’s law went into effect in 2020 and prohibited state-regulated insurers from imposing cost-sharing requirements greater than $100 for a 30-day supply of insulin. Now, half of the states have some sort of limit on insulin cost-sharing ranging from $25 to $100 for a 30-day supply. In addition, the federal Inflation Reduction Act of 2022 capped cost-sharing for insulin under Medicare at $35, which is emerging as a new standard among states. In March, Oregon Governor Kotek (D), signed legislation (OR SB 1508) reducing the state’s existing insulin copay cap from $75 to $35 for a 30-day supply. At least 11 other states are considering legislation to either create a $35 cap or lower an existing cap to $35. 

Breast Cancer

Lawmakers in several state legislatures are debating cost-sharing for breast cancer examinations this year. While screening mammograms are typically fully covered without cost-sharing under the federal Affordable Care Act, follow-up diagnostic or supplemental breast examinations that are necessary upon detecting abnormality or for individuals at high risk of breast cancer are not covered the same way. Legislation to limit or prohibit cost-sharing for such examinations has been gaining momentum in recent years with 10 states enacting legislation in 2023. This year, 21 additional states are considering such legislation. Notably, Kentucky (KY HB 115) and Mississippi MS SB 2858) recently enacted legislation to prohibit cost-sharing requirements for diagnostic or supplemental breast examinations. 

Infertility

There has been considerable attention around fertility treatments, such as in vitro fertilization (IVF), this year. Of note, state lawmakers have introduced over 60 bills across 25 states related to insurance coverage of fertility treatments. Nine of those states are considering legislation that include limits on cost-sharing for fertility treatments. Lawmakers in Pennsylvania introduced bills in both the House and Senate (PA HB 1383 and PA SB 602) to require insurers to waive cost-sharing requirements for infertility care, and in the House, members are debating a bill (PA HB 1493) to require insurers to waive cost-sharing requirements for fertility preservation care. In other states, lawmakers have included in bills establishing fertility treatment coverage requirements, provisions to specify that insurers cannot impose cost-sharing requirements on fertility treatments that are different or higher than requirements for either maternity coverage or other service benefits.  

Tracking State Health Care Legislation 

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