Amendment SSA1-AB68

AB68-SSA1,1349,10 632.7495 (4) (c) The coverage term aggregated with all consecutive periods of the insurer's coverage of the insured by individual health benefit plan coverage not required to be renewed under this subsection does not exceed 18 6 months. For purposes of this paragraph, coverage periods are consecutive if there are no more than 63 days between the coverage periods.

AB68-SSA1,2989 Section 2989 . 632.7496 of the statutes is created to read:

AB68-SSA1,1349,14 632.7496 Coverage requirements for short-term plans. (1) Definition. In this section, “short-term, limited duration plan” means an individual health benefit plan described in s. 632.7495 (4) that an insurer is not required to renew.

AB68-SSA1,1349,17 (2) Guaranteed issue. Every short-term, limited duration plan shall accept every individual in this state who applies for coverage whether or not any individual has a preexisting condition.

AB68-SSA1,1349,22 (3) Prohibiting discrimination based on health status. (a) A short-term, limited duration plan may not establish rules for the eligibility of any individual to enroll, or for the continued eligibility of any individual to remain enrolled, under the plan based on any of the following health status-related factors in relation to the individual or a dependent of the individual:

AB68-SSA1,1349,23 1. Health status.

AB68-SSA1,1349,24 2. Medical condition, including both physical and mental illnesses.

AB68-SSA1,1349,25 3. Claims experience.

AB68-SSA1,1350,1 4. Receipt of health care.

AB68-SSA1,1350,2 5. Medical history.

AB68-SSA1,1350,3 6. Genetic information.

AB68-SSA1,1350,5 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

AB68-SSA1,1350,6 8. Disability.

AB68-SSA1,1350,13 (b) A short-term, limited duration plan may not require any individual, as a condition of enrollment or continued enrollment under the plan, to pay, on the basis of any health status-related factor under par. (a) with respect to the individual or a dependent of the individual, a premium or contribution or a deductible, copayment, or coinsurance amount that is greater than the premium or contribution or deductible, copayment, or coinsurance amount respectively for a similarly situated individual enrolled under the plan.

AB68-SSA1,1350,15 (4) Premium rate variation. A short-term, limited duration plan may vary premium rates for a specific plan based only on the following considerations:

AB68-SSA1,1350,16 (a) Whether the policy or plan covers an individual or a family.

AB68-SSA1,1350,17 (b) Rating area in the state, as established by the commissioner.

AB68-SSA1,1350,20 (c) Age, except that the rate may not vary by more than 3 to 1 for adults over the age groups and the age bands shall be consistent with recommendations of the National Association of Insurance Commissioners.

AB68-SSA1,1350,21 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

AB68-SSA1,1350,23 (5) Annual and lifetime limits. A short-term, limited duration plan may not establish any of the following:

AB68-SSA1,1350,25 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB68-SSA1,1351,2 (b) Limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan for the initial or cumulative duration of the plan.

AB68-SSA1,2990 Section 2990. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to read:

AB68-SSA1,1351,12 632.76 (2) (a) No claim for loss incurred or disability commencing after 2 years from the date of issue of the policy may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of loss. This paragraph does not apply to a group health benefit plan, as defined in s. 632.745 (9), which is subject to s. 632.746 , a disability insurance policy, as defined in s. 632.895 (1) (a), or a self-insured health plan, as defined in s. 632.85 (1) (c).

AB68-SSA1,1351,18 (ac) 1. Notwithstanding par. (a), no No claim or loss incurred or disability commencing after 12 months from the date of issue of under an individual disability insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of the loss.

AB68-SSA1,1351,25 2. Except as provided in subd. 3., an An individual disability insurance policy, as defined in s. 632.895 (1) (a), other than a short-term policy subject to s. 632.7495 (4) and (5), may not define a preexisting condition more restrictively than a condition that was present before the date of enrollment for the coverage, whether physical or mental, regardless of the cause of the condition, for which and regardless of whether medical advice, diagnosis, care, or treatment was recommended or received within 12 months before the effective date of coverage.

AB68-SSA1,2991 Section 2991. 632.76 (2) (ac) 3. (intro.) of the statutes is amended to read:

AB68-SSA1,1352,4 632.76 (2) (ac) 3. (intro.) Except as the commissioner provides by rule under s. 632.7495 (5), all of the following apply to an individual disability insurance policy that is a short-term, limited duration policy subject to s. 632.7495 (4) and (5):

AB68-SSA1,2992 Section 2992. 632.76 (2) (ac) 3. b. of the statutes is amended to read:

AB68-SSA1,1352,11 632.76 (2) (ac) 3. b. The policy shall reduce the length of time during which a may not impose any preexisting condition exclusion may be imposed by the aggregate of the insured's consecutive periods of coverage under the insurer's individual disability insurance policies that are short-term policies subject to s. 632.7495 (4) and (5). For purposes of this subd. 3. b., coverage periods are consecutive if there are no more than 63 days between the coverage periods.

AB68-SSA1,2993 Section 2993. 632.795 (4) (a) of the statutes is amended to read:

AB68-SSA1,1352,24 632.795 (4) (a) An insurer subject to sub. (2) shall provide coverage under the same policy form and for the same premium as it originally offered in the most recent enrollment period, subject only to the medical underwriting used in that enrollment period. Unless otherwise prescribed by rule, the insurer may apply deductibles, preexisting condition limitations, waiting periods , or other limits only to the extent that they would have been applicable had coverage been extended at the time of the most recent enrollment period and with credit for the satisfaction or partial satisfaction of similar provisions under the liquidated insurer's policy or plan. The insurer may exclude coverage of claims that are payable by a solvent insurer under insolvency coverage required by the commissioner or by the insurance regulator of another jurisdiction. Coverage shall be effective on the date that the liquidated insurer's coverage terminates.

AB68-SSA1,2994 Section 2994. 632.796 of the statutes is created to read:

AB68-SSA1,1353,2 632.796 Drug cost report. (1) Definition. In this section, “disability insurance policy” has the meaning given in s. 632.895 (1) (a).

AB68-SSA1,1353,8 (2) Report required. Annually, at the time the insurer files its rate request with the commissioner, each insurer that offers a disability insurance policy that covers prescription drugs shall submit to the commissioner a report that identifies the 25 prescription drugs that are the highest cost to the insurer and the 25 prescription drugs that have the highest cost increases over the 12 months before the submission of the report.

AB68-SSA1,2995 Section 2995. 632.862 of the statutes is created to read:

AB68-SSA1,1353,11 632.862 Application of prescription drug payments. (1) Definitions. In this section:

AB68-SSA1,1353,12 (a) “Brand name” has the meaning given in s. 450.12 (1) (a).

AB68-SSA1,1353,13 (b) “Brand name drug” means any of the following:

AB68-SSA1,1353,15 1. A prescription drug that contains a brand name and that has no generic equivalent.

AB68-SSA1,1353,19 2. A prescription drug that contains a brand name and has a generic equivalent but for which the enrollee has received prior authorization from the insurer offering the disability insurance policy or the self-insured health plan or authorization from a physician to obtain the prescription drug under the policy or plan.

AB68-SSA1,1353,20 (c) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

AB68-SSA1,1353,21 (d) “Prescription drug” has the meaning given in s. 450.01 (20)

AB68-SSA1,1353,22 (e) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB68-SSA1,1354,3 (2) Application of discounts. A disability insurance policy that offers a prescription drug benefit or a self-insured health plan shall apply to any calculation of an out-of-pocket maximum and to any deductible of the policy or plan for an enrollee the amount that any discount provided by the manufacturer of a brand name drug reduces the cost sharing amount charged to an enrollee for that brand name drug.

AB68-SSA1,2996 Section 2996. 632.863 of the statutes is created to read:

AB68-SSA1,1354,5 632.863 Pharmaceutical representatives. (1) Definitions. In this section:

AB68-SSA1,1354,8 (a) “Health care professional” means a physician or other health care practitioner who is licensed to provide health care services or to prescribe pharmaceutical or biologic products.

AB68-SSA1,1354,10 (b) “Pharmaceutical” means a medication that may legally be dispensed only with a valid prescription from a health care professional.

AB68-SSA1,1354,13 (c) “Pharmaceutical representative” means an individual who markets or promotes pharmaceuticals to health care professionals on behalf of a pharmaceutical manufacturer for compensation.

AB68-SSA1,1354,17 (d) “Wholesale acquisition cost” means the most recently reported manufacturer list or catalog price for a brand-name drug or generic drug available to wholesalers or direct purchasers in the United States, before application of discounts, rebates, or reductions in price.

AB68-SSA1,1354,23 (2) Licensure. (a) No individual may act as a pharmaceutical representative in this state without obtaining a pharmaceutical representative license. In order to obtain a license, an individual shall apply to the commissioner, on a form prescribed by the commissioner. A license issued under this paragraph shall be renewed on an annual basis. The application to obtain or renew a license shall include all of the following information:

AB68-SSA1,1354,25 1. The applicant's full name, residence address and telephone number, and business address and telephone number.

AB68-SSA1,1355,1 2. A description of the type of work in which the applicant will engage.

AB68-SSA1,1355,2 3. The fee under s. 601.31 (1) (nv).

AB68-SSA1,1355,4 4. An attestation that the applicant meets the professional education requirements under sub. (3).

AB68-SSA1,1355,5 5. Proof that the applicant has paid any assessed penalties and fees.

AB68-SSA1,1355,6 6. Any other information required by the commissioner.

AB68-SSA1,1355,11 (b) The pharmaceutical representative shall report, in writing, to the commissioner any change to the information submitted on the application under par. (a) or any material change to the pharmaceutical representative's business operations or to any information provided under this section. The report shall be made no later than 4 business days after the change or material change occurs.

AB68-SSA1,1355,13 (c) A pharmaceutical representative shall display his or her license during each visit with a health care professional.

AB68-SSA1,1355,18 (3) Professional education requirements. (a) In order to become initially licensed under sub. (2) (a), a pharmaceutical representative shall complete a professional education course as determined by the commissioner. A pharmaceutical representative shall, upon request, provide the commissioner with proof of the coursework's completion.

AB68-SSA1,1355,22 (b) In order to renew a license under sub. (2) (a), a pharmaceutical representative shall complete a minimum of 5 hours of continuing professional education courses. A pharmaceutical representative shall, upon request, provide the commissioner with proof of the coursework's completion.

AB68-SSA1,1356,2 (c) The professional education coursework required under pars. (a) and (b) shall include training in ethical standards, whistleblower protections, laws and rules applicable to pharmaceutical marketing, and other areas that the commissioner may identify by rule.

AB68-SSA1,1356,4 (d) The commissioner shall regularly designate courses that fulfill the requirements under this subsection and publish a list of the designated courses.

AB68-SSA1,1356,9 (e) The professional education coursework required under this subsection may not be provided by the employer of a pharmaceutical representative or be funded, in any way, by the pharmaceutical industry or a 3rd party funded by the pharmaceutical industry. A provider of a course designated under par. (d) shall disclose any conflict of interest.

AB68-SSA1,1356,13 (4) Disclosure to commissioner. (a) No later than June 1 of each year, a pharmaceutical representative shall provide to the commissioner, in the manner prescribed by the commissioner, all of the following information from the previous calendar year:

AB68-SSA1,1356,16 1. The total number of times the pharmaceutical representative contacted health care professionals in this state and the specialties of the health care professionals contacted.

AB68-SSA1,1356,20 2. For each contact with a health care professional in this state, the location and duration of the contact, the pharmaceuticals for which the pharmaceutical representative provides information, and the value of any item, including a product sample, compensation, material, or gift, provided to the health care professional.

AB68-SSA1,1356,23 (b) The commissioner shall publish the information provided under par. (a) on the commissioner's Internet site in a manner in which individual health care professionals are not identifiable by name or other identifiers.

AB68-SSA1,1357,4 (5) Disclosure to health care professionals. During each contact with a health care professional, a pharmaceutical representative shall disclose the wholesale acquisition cost of any pharmaceutical for which the pharmaceutical representative provides information and the names of at least 3 generic prescription drugs from the same therapeutic class, or if 3 are not available, as many as are available for prescriptive use.

AB68-SSA1,1357,9 (6) Ethical standards. The commissioner shall promulgate a rule that contains ethical standards for pharmaceutical representatives and shall publish the ethical standards on the commissioner's Internet site. In addition to the ethical standards contained in the rule, a pharmaceutical representative may not do any of the following:

AB68-SSA1,1357,12 (a) Engage in deceptive or misleading marketing of a pharmaceutical, including the knowing concealment, suppression, omission, misleading representation, or misstatement of a material fact.

AB68-SSA1,1357,17 (b) Use a title or designation that could reasonably lead a licensed health care professional, or an employee or representative of a licensed health care professional, to believe that the pharmaceutical representative is licensed to practice medicine, nursing, dentistry, optometry, pharmacy, or other similar health occupation in this state unless the pharmaceutical representative holds a license to practice.

AB68-SSA1,1357,18 (c) Attend a patient examination without the patient's consent.

AB68-SSA1,1357,21 (7) Enforcement. (a) Any individual violating this section shall be fined not less than $1,000 nor more than $3,000 for each offense. Each day the violation continues shall constitute a separate offense.

AB68-SSA1,1358,2 (b) The commissioner may suspend or revoke the license of a pharmaceutical representative who violates this section. A suspended or revoked license may not be reinstated until all violations related to the suspension or revocation have been remedied and all assessed penalties and fees have been paid. An individual whose pharmaceutical representative license is revoked for any cause may not be issued a license under sub. (2) (a) until at least 2 years after the date of revocation.

AB68-SSA1,1358,6 (c) A health care professional who meets with a pharmaceutical representative who does not display his or her license or share the information required under sub. (5) may report the pharmaceutical representative to the commissioner for further action.

AB68-SSA1,1358,7 (8) Rules. The commissioner may promulgate rules to implement this section.

AB68-SSA1,2997 Section 2997. 632.864 of the statutes is created to read:

AB68-SSA1,1358,10 632.864 Pharmacy services administrative organizations. (1) Definitions. In this section:

AB68-SSA1,1358,11 (a) “Administrative service” means any of the following:

AB68-SSA1,1358,12 1. Assisting with claims.

AB68-SSA1,1358,13 2. Assisting with audits.

AB68-SSA1,1358,14 3. Providing centralized payment.

AB68-SSA1,1358,15 4. Performing certification in a specialized care program.

AB68-SSA1,1358,16 5. Providing compliance support.

AB68-SSA1,1358,17 6. Setting flat fees for generic drugs.

AB68-SSA1,1358,18 7. Assisting with store layout.

AB68-SSA1,1358,19 8. Managing inventory.