ARC 8865C - Iowa Administrative Rules

Adopted and Filed

Timely payment of pharmacy claims, 59.3

Untitled document

ARC 8865C

INSURANCE DIVISION[191]

Adopted and Filed

Rulemaking related to timely payment of pharmacy claims

The Insurance Division hereby amends Chapter 59, “Pharmacy Benefits Managers,” Iowa Administrative Code.

Legal Authority for Rulemaking

This rulemaking is adopted under the authority provided in Iowa Code section 510B.11 and 2022 Iowa Acts, House File 2384, section 22.

State or Federal Law Implemented

This rulemaking implements, in whole or in part, Iowa Code chapter 510B.

Purpose and Summary

This amendment updates Chapter 59 to reflect changes necessary to conform with statutory provisions and reduce harm to public welfare by ensuring the timely payment of pharmacy claims.

Public Comment and Changes to Rulemaking

Notice of Intended Action for this rulemaking was published in the Iowa Administrative Bulletin on November 27, 2024, as ARC 8429C. A public hearing was held on the following date(s):

●December 19, 2024

This rulemaking was also Adopted and Filed Emergency and published in the Iowa Administrative Bulletin as ARC 8427C on the same date.

The public hearing was attended by members of the public; however, no public comments were received at the public hearing.

The Division received written comments from AlignRx, the Iowa Pharmacy Association (IPA), the National Association of Chain Drug Stores (NACDS), and the Pharmaceutical Care Management Association (PCMA). The comments support striking the “or increase” language.

No changes from the Notice have been made.

Adoption of Rulemaking

This rulemaking was adopted by Douglas Ommen, Iowa Insurance Commissioner, on January 14, 2025.

Fiscal Impact

This rulemaking has no fiscal impact to the State of Iowa.

Jobs Impact

After analysis and review of this rulemaking, no impact on jobs has been found.

Waivers

Any person who believes that the application of the discretionary provisions of this rulemaking would result in hardship or injustice to that person may petition the Division for a waiver of the discretionary provisions, if any, pursuant to 191—Chapter 4.

Review by Administrative Rules Review Committee

The Administrative Rules Review Committee, a bipartisan legislative committee which oversees rulemaking by executive branch agencies, may, on its own motion or on written request by any individual or group, review this rulemaking at its regular monthly meeting or at a special meeting. The Committee’s meetings are open to the public, and interested persons may be heard as provided in Iowa Code section 17A.8(6).

Effective Date

This rulemaking will become effective on March 12, 2025, at which time the Adopted and Filed Emergency rulemaking is hereby rescinded.

The following rulemaking action is adopted:

ITEM 1.Amend rule 191—59.3(510B) as follows:

191—59.3(510B) Timely payment of pharmacy claims.

59.3(1) All benefits payable under a pharmacy benefits management plan shall be paid as soon as feasible but within 20 days after receipt of a clean claim when the claim is submitted electronically and shall be paid within 30 days after receipt of a clean claim when the claim is submitted in paper format.

59.3(2) A payment to the pharmacy for a clean claim is considered to be overdue and not timely if not paid within 20 or 30 days, whichever is applicable. If a clean claim is not timely paid, the pharmacy benefits manager must pay the pharmacy interest at the rate of 10 percent per annum commencing the day after any claim payment or portion thereof was due until the claim is finally settled or adjudicated in full.

59.3(3) A pharmacy benefits manager may demonstrate the date a claim is paid by a mail record or a bank statement.

59.3(4) Pursuant to Iowa Code section 510B.4 and paragraph 59.4(1)“j,”510B.8C, a pharmacy benefits manager shall not retroactively reduce or increase reimbursement, through adjustment or reconciliation or any other means, of a clean claim paid to pharmacies.

[Filed 1/17/25, effective 3/12/25]

[Published 2/5/25]

EDITOR’S NOTE: For replacement pages for IAC, see IAC Supplement 2/5/25.