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HB 5483

Relating to financial assistance available for a prescription drug

2026 Regular Session Introduced by Matthew Rohrbach

HB 5483 requires counting drug-assistance toward patient cost-sharing, extends the annual limit to all WV plans, and bans terms tied to the availability of such assistance.

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Bill Summary · HB 5483

HB 5483 (West Virginia, 2026 Session)
Summary of Purpose, Provisions, Impacts, and Timelines

Purpose
- To ensure that financial or product assistance for prescription drugs is treated as part of an insured’s cost-sharing calculations, apply an annual cost-sharing limit to all health plans offered in the state, and prevent insurers, pharmacy benefits managers (PBMs), and third-party administrators from altering coverage terms based on the availability or amount of drug-assistance. The bill aims to protect insured consumers from being disadvantaged when receiving prescription drugs whose costs are partially offset by assistance programs.

Key Provisions
- Cost-sharing calculation (multiple articles: WV Code sections 33-15-4t; 33-16-3ee; 33-24-7t; 33-25-8q; 33-25A-8t)
- Defines cost sharing as copays, coinsurance, or deductibles for covered health care items/services.
- Requires insurers and PBMs to include any cost-sharing amounts paid by the insured or on the insured’s behalf by another person when calculating the insured’s contribution to cost sharing.
- Applies this inclusive approach to the annual cost-sharing limit under federal law (42 U.S.C. 18022(c)) and related HSA considerations (42 U.S.C. 300gg-6(b)).
- Applies to all health care services covered under any health plan offered or issued by an insurer in West Virginia.

  • Annual cost-sharing limit

    • The annual limit on cost sharing under 42 U.S.C. § 18022(c)(1) shall apply to all health care services covered under any health plan in the state (not limited to specific plan types).

  • Prohibition on coverage terms based on assistance

    • Insurers, PBMs, and third-party administrators may not directly or indirectly set, alter, implement, or condition coverage terms or benefit design based on information about the availability or amount of financial or product assistance for prescription drugs.

  • Authority and implementation

    • The Insurance Commissioner may propose rules to implement the provisions (subject to legislative approval).

  • Effective dates

    • Provisions in existing sections are effective for policies/plans beginning on or after January 1, 2020.
    • Amendments made in 2026 become effective for policies/plans beginning on or after January 1, 2027.
    • Applicable to policies/plans delivered, executed, issued, amended, adjusted, or renewed in the state on or after the effective date (and per section, with an eventual 2027 effective horizon for 2026 amendments).

  • Penalties and restitution

    • Violations may incur civil penalties up to $10,000 per violation, with penalties imposed by the state Insurance Commissioner after a notice-and-hearing process.
    • The Commissioner’s order may require restitution to aggrieved persons.

Affected Parties and Impact
- Insurers, health plans, and PBMs operating in West Virginia.
- Third-party administrators handling coverage and cost-sharing for health plans.
- Enrollees/insured individuals who receive prescription drugs with financial/product assistance (e.g., manufacturer coupons, patient assistance programs).
- The bill seeks to prevent discriminatory or retroactive changes to coverage terms due to the presence or absence of drug-assistance programs, promoting consistency in cost-sharing obligations.

Notes on Implementation
- The bill contains parallel sections across multiple kinds of health plan entities (accident and sickness insurance, group plans, hospital/medical service organizations, health care corporations, and health maintenance organizations) to standardize treatment of cost sharing.
- Language references to federal cost-sharing limits (e.g., MAP/Liz types) align WV law with federal standards while extending applicability to all plans issued in the state.

Overall, HB 5483 aims to harmonize cost-sharing calculations by counting assistance toward patient obligations, extend federal cost-sharing limits to all WV health plans, and bar terms that hinge coverage on external financial assistance, with enforcement and clear effective dates.

Compiled from official sources — confirm details with the bill’s official record.

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