Democratic Assemblywoman Ellen Spiegel presented two bills on Friday that would allow patients to apply cash payments on drugs and the costs of out-of-network emergency bills to their insurance plan deductibles or annual out-of-pocket maximums.

The two bills aim to reduce the financial burden of meeting high deductibles and annual out-of-pocket maximums, which have become increasingly common in recent years, by allowing patients to contribute payments made outside the scope of his or her insurance plan to them. But health insurers, at a hearing on the bills during a meeting of the Assembly Commerce and Labor Committee on Friday, expressed concerns that the requirements as written could be technically difficult to accomplish and overly burdensome.

One of the bills Spiegel presented, AB185, would allow patients who choose to pay the cash price of a drug at the pharmacy counter to apply the payment to their insurance plan’s prescription drug deductible or overall deductible and annual out-of-pocket maximum. Spiegel argued that the change would save money both for patients, who may be able to get a cheaper cash price for the drug than they would with their insurance plan, and insurance companies, which wouldn’t be responsible for paying any share of those cash price prescriptions.

Spiegel showed lawmakers one example where a prescription for the drug levothyroxine, used to treat hypothyroidism, would cost patients a $15 co-pay and the insurers another $20.99 at one pharmacy, while the cash price for patients at another pharmacy would be only $10 with no additional payment required by the insurance company.

“Here the patient is saving money, the insurance company is saving money, and what this bill does is simply asks the insurance company to give the patient some credit for the money they’ve spent and the savings that they’ve accrued for the insurance company, and that credit comes in the form of just being something that counts toward their deductible,” Spiegel said. “It’s not asking for cash. It’s just saying give the patient credit for what they’re spending on their own.”

Heidi Englund, a patient with multiple sclerosis and a retired state employee, detailed for lawmakers the cost of her treatment: $23,000 per month for her main disease-modifying treatment, along with two other drugs that cost her $1,000 and $200 each month.

“I need to have insurance coverage regardless of my MS diagnosis, but secondly, I cannot afford to pay higher deductibles, premiums and copays,” Englund said. “It is necessary that any cost incurred to me out of pocket be credited back to me understanding the high cost of these drugs.”

But some patient advocates expressed concern that the bill doesn’t go far enough by not banning copay accumulators or accumulator adjustors, a practice where insurance companies don’t apply assistance patients receive from drug manufacturers or foundations to help cover drug costs to out-of-pocket maximums and deductibles.

“While AB185 is a good start for addressing some of the out-of-pocket costs patients face it is really barely scratching the surface of our medication affordability barriers that we are concerned about,” said Betsy VanDeusen, executive director of the Nevada Chapter of the National Hemophilia Foundation. “It is my hope that with a few edits the bill could be very effective at protecting patients’ abilities to afford their medications.”

VanDeusen told lawmakers that copay accumulators are not yet widespread in Nevada but that the practice essentially negates charitable resources provided to patients by drug manufacturers and foundations to meet their deductibles and out-of-pocket maximums and would require patients to come up with thousands of dollars personally.

But Spiegel said that allowing patients to apply financial assistance to their deductibles and out-of-pocket maximums could end up driving up insurance premiums in the long run.

“What happens is they’ll work through the deductible faster and then the insurance company will have more financial exposure in a quicker time period and that winds up having the ability to drive up premiums,” Spiegel said. “I feel for the patients who are going through this and really do need the relief, they do need the assistance, I’m not discounting that at all. But I was trying to come up with a methodology in a way that would provide some relief to consumers and patients without unduly burdening the insurance companies.”

Health insurers expressed support for the overall intent of the bill but raised concerns that some of the provisions sound simple but would be difficult to achieve in practice, such as a requirement that insurance companies manually process claims submitted by patients for each cash prescription paid.

“That in of itself seems simple but within the insurance industry mechanically how do we accomplish that particular goal?” said Tom Clark, lobbyist for the Nevada Association of Health Plans. “Educating the insured that if they do submit a claim with receipts for the cash that they’ve paid and want that applied to the deductible, it will only be applied to the deductible and that they are not going to receive that cash reimbursement.”

In response to some concerns raised by insurers during the hearing about allowing patients to apply the value of manufacturer coupons on drugs toward their deductibles and out-of-pocket maximums, Spiegel clarified that the credit toward the deductible would only be applied based on what the patient is actually paying and would not include any discounts.

Spiegel also outlined an amendment to the bill that would make the requirement that insurers apply the value patients pay for cash prescriptions to deductibles or out-of-pocket maximums optional for public insurers, including counties, school districts, local governments, and the state government. The Public Employee Benefits Program, which oversees health insurance for state employees, and other local government agencies submitted fiscal notes expressing concern that the legislation would drive up costs.

“To remove the fiscal notes, I want to change the ‘shall’ to a ‘may’ for those entities and then as they realize they will be saving money and it is better for their patients and better for their bottom line that they they will still be able to take advantage of it,” Spiegel told lawmakers.

A second bill Spiegel presented to the committee on Friday, AB225, would require insurers to apply the costs of out-of-network emergency room bills to patients’ annual out-of-pocket maximums. But the Health Services Coalition, which represents several self-funded employers and union health trust funds, expressed concerns during the hearing that the legislation would be overly burdensome on top of requirements already put in place by the Affordable Care Act.

“The ACA already mandates that all plans cover true emergencies out of network as in-network cost share,” said Health Services Coalition lobbyist Chelsea Capurro. “This bill is trying to do something else, which is including any out-of-network payments in annual maximums patients must pay. This isn’t part of the ACA, so we have a little bit of heartburn when we’re adding additional mandates on what we already have to comply with on the ACA.”

Insurers also raised other concerns with the legislation related to its provisions prohibiting them from retroactively denying claims for payments when they provided prior authorization for the service, requiring them to grant prior authorizations of services for a year and barring them from obtaining clawback payments made to providers for services provided more than a year ago. The insurers said that they plan to work further with Spiegel on the legislation.