Senate Bill S8257

                                 
BILL NUMBER: S8257A

SPONSOR: SUTTON
 
TITLE OF BILL:

An act directing the department of health to establish an alternative
payment methodology (APM) for federally qualified health centers to
preserve and improve patient access to fertility care

 
PURPOSE:

Requires the department of health to develop a supplemental Medicaid
payment to federally qualified health centers for reimbursement for
certain uncovered fertility drugs.

 
SUMMARY OF SPECIFIC PROVISIONS:

Section 1: Requires the Department of Health to establish a new Medicaid
alternative payment methodology that results in a supplemental payment
to Federally Qualified Health Centers in addition to other rates they
receive. This alternative payment methodology would be an amount equal
to the difference between (a) the aggregate amount the health center
              

paid to acquire eligible injectable fertility drugs for Medicaid
patients under Section 340B of the Federal Public Health Services Act
between January 1-December 31, 2024, and (b) the aggregate amount the
health center would have paid to acquire those drugs based on average
wholesale acquisition cost for such drugs during the same period. Eligi-
ble injectable fertility drugs are limited to Gonadotropin, GNRH Antag-
onists, and GNRH Agonists.

Section 2: Effective date.

 
JUSTIFICATION:

In 2017, New York State became the first state to provide Medicaid
coverage for some services related to fertility, including coverage for
some forms of ovulation enhancing drugs. CMS approved a State Plan
Amendment for this coverage, submitted by New York State, which included
a 90-10% federal-state match. While approval at that time limited cover-
age to office visits, ultrasounds, and other services, it also included
limited coverage of prescription drugs that promote fertility. Unfortu-
nately, the list of drugs only included four types of oral ovulation
enhancing drugs. Since that time, more effective drugs have become
available, including injectable ovulation enhancing drugs to treat
fertility issues.

Several federally qualified health centers currently provide fertility
services to their patients, including those enrolled in Medicaid. While
commercial insurers generally cover the full range of fertility treat-
ments, including injectable ovulation enhancing drugs, Medicaid only
covers the less effective, oral drugs. This coverage imbalance results
in Medicaid patients having to pay "out-of-pocket" for these more effec-
tive drugs, while those with commercial insurance have these drugs
covered by their insurance. To address this imbalance, some FQHCs assist
their Medicaid patients in covering the out-of-pocket costs for these
more effective injectable drugs but are significantly limited in the
number of patients they can assist because of constrained financial
resources.

This bill will help address this coverage imbalance by providing FQHCs
with a dedicated funding stream to offer the full range of fertility
services to their patients enrolled in Medicaid.

 
PRIOR LEGISLATIVE HISTORY:

2025: Passed Senate

 
FISCAL IMPLICATIONS:

None. Any supplemental payment is part of the already approved state
plan amendment that the State allocated the funds in previous years as
part of a 90-10% federal state match.

 
EFFECTIVE DATE:
This act shall take effect immediately.