HOUSE . . . . . . . . No. 4492
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The Commonwealth of Massachusetts
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HOUSE OF REPRESENTATIVES, September 18, 2025.
The committee on Financial Services, to whom was referred the petition (accompanied by bill, House, No. 1133) of Marjorie C. Decker relative to insurance coverage out-of-pocket limits for prescription drugs, reports recommending that the accompanying bill (House, No. 4492) ought to pass.
For the committee,
JAMES M. MURPHY.
FILED ON: 9/8/2025
HOUSE . . . . . . . . . . . . . . . No. 4492
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The Commonwealth of Massachusetts
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In the One Hundred and Ninety-Fourth General Court
(2025-2026)
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An Act relative to patient financial protection.
Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:
SECTION 1. Chapter 175 of the General Laws is hereby amended by inserting before section 47CCC the following section:-
Section 47AAA. Any policy, contract, agreement, plan or certificate of insurance issued, delivered or renewed within the commonwealth that provides coverage for prescription drugs shall establish a separate out-of-pocket limit for prescription drugs, which shall include specialty drugs. The out-of-pocket limit shall not exceed the dollar amount set as the minimum annual deductible for a high deductible health plan under section 223 of the federal Internal Revenue Code of 1986, 26 U.S.C. §223 (c)(2)(A)(i), for self-only and family coverage, respectively. For the purposes of this section the term “out-of-pocket limit” shall include expenses that: (1) are a cost-sharing expenditure under section 1302 of the federal Patient Protection and Affordable Care Act, 42 U.S.C. §18022 (c)(3); and (2) relate to prescription drug coverage.
SECTION 2. Chapter 176A of the General Laws is hereby amended by inserting after section 8DDD the following section:-
Section 8EEE. Any contract between a subscriber and the corporation under an individual or group hospital service plan which is delivered, issued, or renewed within the commonwealth that provides coverage for prescription drugs shall establish a separate out-of-pocket limit for prescription drugs, which shall include specialty drugs. The out out-of-pocket limit shall not exceed the dollar amount set as the minimum annual deductible for a high deductible health plan under section 223 of the federal Internal Revenue Code of 1986, 26 U.S.C. §223 (c)(2)(A)(i), for self-only and family coverage, respectively. For the purposes of this section the term “out-of-pocket limit” shall include expenses that: (1) are a cost-sharing expenditure under section 1302 of the federal Patient Protection and Affordable Care Act, 42 U.S.C. §18022 (c)(3); and (2) relate to prescription drug coverage.
SECTION 3. Chapter 176B of the General Laws is hereby amended by inserting after section 4DDD the following section:-
Section 4EEE. Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth that provides coverage for prescription drugs shall establish a separate out-of-pocket limit for prescription drugs, which shall include specialty drugs. The out-of-pocket limit shall not exceed the dollar amount set as the minimum annual deductible for a high deductible health plan under section 223 of the federal Internal Revenue Code of 1986, 26 U.S.C. §223 (c)(2)(A)(i), for self-only and family coverage, respectively. For the purposes of this section the term “out-of-pocket limit” shall include expenses that: (1) are a cost-sharing expenditure under section 1302 of the federal Patient Protection and Affordable Care Act, 42 U.S.C. §18022 (c)(3); and (2) relate to prescription drug coverage.
SECTION 4. Chapter 176G of the General Laws is hereby amended by inserting after section 4VV the following section:-
Section 4WW. Any individual or group health maintenance organization that provides coverage for prescription drugs shall establish a separate out-of-pocket limit for prescription drugs, which shall include specialty drugs. The out-of-pocket limit shall not exceed the dollar amount set as the minimum annual deductible for a high deductible health plan under section 223 of the federal Internal Revenue Code of 1986, 26 U.S.C. §223 (c)(2)(A)(i), for self-only and family coverage, respectively. For the purposes of this section the term “out-of-pocket limit” shall include expenses that: (1) are a cost-sharing expenditure under section 1302 of the federal Patient Protection and Affordable Care Act, 42 U.S.C. §18022 (c)(3); and (2) relate to prescription drug coverage.
SECTION 5. This act shall apply to all policies, contracts and certificates of health insurance subject to section 47AAA of chapter 175, section 8EEE of chapter 176A, section 4EEE of chapter 176B and section 4WW of chapter 176G of the General Laws delivered, issued or renewed on or after January 1, 2026.