Priority for homeless children
The bill creates a two-year pilot program that gives priority to homeless
children and their families, as defined under federal law, on the waiting list that
WHEDA, or a public housing agency or other entity that contracts with WHEDA,
maintains under the federal Housing Choice Voucher Program. Under the bill,
WHEDA is required to develop policies and procedures for the pilot program.
Report on homeless children and youths
The bill requires DPI to annually submit a report to the legislature on the
number of homeless children and youths in the public schools of this state. Under
the bill, “homeless children and youths” is defined by reference to federal law
providing homeless assistance.
Rental assistance grants for homeless veterans
The bill requires DOA to award grants to each continuum of care organization
in Wisconsin for the purpose of providing tenant-based rental assistance to homeless
veterans. A continuum of care organization is an organization designated by the
federal Department of Housing and Urban Development that provides funding and
services to alleviate homelessness.
Eliminating employment grants program
Under current law, DOA may award grants of up to $75,000 to counties, cities,
villages, or towns to be used to connect homeless individuals with permanent
employment. The bill eliminates that grant program.
Landlord-tenant
Notification of building code violations
Under current law, before entering into a lease with or accepting any earnest
money or a security deposit from a prospective tenant, a landlord must disclose to the
prospective tenant any building code or housing code violations of which the landlord
has actual knowledge if the violation presents a significant threat to the prospective
tenant's health or safety. The bill eliminates the condition that the landlord have
actual knowledge of such a violation and that the threat to the prospective tenant's
health or safety be “significant”; under the bill, the landlord must disclose to a
prospective tenant a building code or housing code violation, regardless of whether
the landlord has actual knowledge of the violation, if the violation presents a threat
to the prospective tenant's health or safety.
Terminating a tenancy on the basis of criminal activity
Current law allows a landlord, upon providing notice to a tenant, to terminate
the tenant's tenancy, without an opportunity to cure the tenant's default, if the
tenant, a member of the tenant's household, or a guest of the tenant 1) engages in any
criminal activity that threatens the health or safety of other tenants, persons
residing in the immediate vicinity of the premises, or the landlord; 2) engages in any
criminal activity that threatens the right to peaceful enjoyment of the premises by
other tenants or persons residing in the immediate vicinity of the premises; or 3)
engages in any drug-related criminal activity on or near the premises. The bill
eliminates these provisions.
General housing
Low income housing tax credit
Under current law, WHEDA may certify a person to claim, for a period of up to
six years, a state tax credit if the person has an ownership interest in a low-income
housing project in Wisconsin and qualifies for the federal low-income housing tax
credit program. Current law limits the amount of credits WHEDA may annually
authorize to $42,000,000. The bill increases the period for which the credit may be
claimed to 10 years and increases the amount of credits that WHEDA may annually
authorize to $100,000,000. The bill also requires that the project be allocated the
federal credit and be financed with tax-exempt bonds that are not subject to the
federal credit's volume cap, as opposed to any tax-exempt bonds as required under
current law, and allows WHEDA to waive these requirements to the extent that
WHEDA anticipates that sufficient tax-exempt private activity bond volume cap
under federal law will not be available to finance low-income housing projects in any
year.
Housing quality standards grants
The bill requires DOA to award grants to owners of rental housing units in
Wisconsin for purposes of satisfying applicable housing quality standards.
Affordable housing grants
The bill requires DOA to award grants to municipalities for the purpose of
increasing the availability of affordable workforce housing within the
municipalities.
Water utility assistance program for low-income households
The bill creates a water utility assistance program for low-income households
that is administered by DOA. Under the program, low-income households may
apply for assistance from the state to help pay the cost of their water utility bills.
Although the program is administered by DOA, DOA may contract with a county
department, another local governmental agency, or a private nonprofit organization
for processing applications and making assistance payments. DOA must establish
a payments schedule for the program. If the number of household applicants exceeds
the number anticipated to apply, payments to households may be reduced and DOA
may suspend additional applications for assistance. Under the bill, a household
eligible for water utility assistance may also be eligible for a crisis assistance
payment if the household is experiencing or at risk of experiencing a water
utility–related emergency, as defined by DOA.
insurance
Pharmacy benefit manager and prescription drug benefit regulation
The bill generally requires pharmacy benefit managers to be licensed with the
commissioner of insurance or to have an employee benefit plan administrator license
under current law. The bill also establishes certain requirements on pharmacy
benefit managers and certain health plans regarding their interactions with
pharmacies and pharmacists. Under the bill, a pharmacy benefit manager is an
entity that contracts to administer or manage prescription drug benefits on behalf
of an insurer, a cooperative, or another entity that provides prescription drug
benefits to Wisconsin residents.
The bill requires a pharmacy benefit manager to be licensed either as a
pharmacy benefit manager or as an employee benefit plan administrator, which is
an existing license under current law, in order to perform the activities of a pharmacy
benefit manager. The bill specifies that an entity that is both an employee benefit
plan administrator and a pharmacy benefit manager need only have a single license
as an administrator. To obtain a license, the pharmacy benefit manager must pay
the applicable fee; supply a bond; provide its federal employer identification number;
and show to the commissioner that the pharmacy benefit manager intends to act in
good faith in compliance with applicable laws, rules, and commissioner's orders
through certain competent and trustworthy individuals, to designate an individual
to directly administer the prescription drug benefits, and, if not organized in
Wisconsin, to agree to be subject to the jurisdiction of the commissioner and
Wisconsin courts. Under the bill, pharmacy benefit manager licenses may be
limited, suspended, or revoked for the same reasons as for employee benefit plan
administrator licenses, which include that the pharmacy benefit manager is
unqualified; repeatedly or knowingly violates laws, rules, or commissioner's orders;
endangers enrollees or the public; or has inadequate financial resources. After a
pharmacy benefit manager's license is ordered suspended or revoked, the
commissioner may allow the pharmacy benefit manager to continue to provide
services for the purpose of providing continuity of care to existing enrollees. In
addition to powers the commissioner has, generally, to implement and enforce
insurance-related laws, the bill allows the commissioner to examine, audit, or accept
an audit of a pharmacy benefit manager in the same manner as employee benefit
plan administrators and insurers and to promulgate any rules to implement
licensure of pharmacy benefit managers.
Unless federal law requires otherwise, a pharmacy benefit manager is
prohibited in the bill from retroactively denying a pharmacist's or pharmacy's claim
unless the original claim was fraudulent, the payment of the original claim was
incorrect, the pharmacy services were not rendered by the pharmacist or pharmacy,
the pharmacist or pharmacy violated state or federal law, or the reduction is
permitted by contract and is related to a quality program. The bill limits recovery
for an incorrect payment to the amount that exceeds the allowable claim. The bill
requires every pharmacy benefit manager to submit annual transparency reports
containing information specified in the bill to the commissioner. The bill sets
requirements on a pharmacy benefit manager; insurer; defined network plan, such
as a health maintenance organization; or a self-insured governmental health plan
that is conducting an audit of a pharmacist or pharmacy.
Certain health plans, or pharmacy benefit managers on behalf of health plans,
may require a pharmacy to fulfill certification or accreditation requirements in order
to participate in the plan's network of providers. The bill requires a pharmacy benefit
manager or a representative of a pharmacy benefit manager to provide to a
pharmacy, within 30 days of receipt of a written request from the pharmacy, written
notice of the certification or accreditation requirements as a determinant of network
participation. The bill prohibits a pharmacy benefit manager or representative from
changing its accreditation requirements more frequently than once every 12 months.
Current law requires pharmacy benefit managers to agree in their contracts to
make certain disclosures regarding prescription drug reimbursement, including
updating maximum allowable cost pricing information for prescribed drugs or
devices at least every seven business days, reimbursing pharmacies or pharmacists
subject to the updated maximum allowable cost pricing, and modifying information
in the maximum allowable cost information in a timely fashion. Pharmacy benefit
managers currently must also include in each contract with a pharmacy a process
to appeal, investigate, and resolve pricing disputes in accordance with the specifics
in current law. These current law requirements are unchanged by the bill.
Under the bill, a health insurance policy or a governmental self-insured health
plan may not, and a policy or plan must ensure that a pharmacy benefit manager
does not, restrict a pharmacy from or penalize a pharmacy for informing an enrollee
under the policy or plan of any differential between the out-of-pocket cost of a drug
to the enrollee under the policy or plan and the cost an individual would pay for the
drug without using insurance. Health insurance policies are referred to in the bill
as disability insurance policies. The bill prohibits a policy, plan, or pharmacy benefit
manager from requiring an enrollee under the policy or plan to pay more for a covered
drug than either the cost-sharing amount for the prescription drug under the policy
or plan or the amount the enrollee would pay for the drug without using insurance,
whichever amount is lower.
The bill requires pharmacies to post a sign describing the pharmacist's ability
to substitute a less expensive drug product equivalent or interchangeable biological
product for the prescribed drug or biological product unless the consumer or the
prescribing practitioner indicates otherwise. Under current law, a pharmacist is
required to dispense either the prescribed drug or biological product or, if lower in
price, a drug product equivalent or interchangeable biological product. The
pharmacist is currently required to inform the consumer of the options available in
dispensing the prescription. The bill requires each pharmacy to have available for
the public a listing of the retail price, updated monthly or more often, of the 100 most
commonly prescribed prescription drugs available for purchase at the pharmacy.
The bill also requires pharmacies to make available for the public information on
how to access a list, created by the Pharmacy Examining Board, of the 100 most
commonly prescribed generic drugs with the corresponding brand name, and the
federal Food and Drug Administration's list of currently approved interchangeable
biological products, to which the Pharmacy Examining Board currently has to
provide a link on its website.
The bill requires a health insurance policy, governmental self-insured health
plan, or pharmacy benefit manager to provide advanced written notice to an enrollee
of a formulary change that either removes a prescription drug from the formulary or
reassigns a prescription drug to a higher benefit tier. A higher benefit tier is a tier
with a higher deductible, copayment, or coinsurance than the tier the prescription
drug had been assigned. The advanced notice required by the bill must be provided
no fewer than 30 days before the expected formulary change, must include
information on the procedure for the enrollee to request an exception to the
formulary change, and need only be provided to those enrollees who are using the
drug at the time the notification must be sent. A policy, plan, or pharmacy benefit
manager is not required to provide advanced written notice if the prescription drug
is no longer approved by the federal Food and Drug Administration; is the subject
of a notice, guidance, warning, announcement, or other statement from the FDA
relating to concerns about the safety of the drug; or is approved by the FDA for use
without a prescription. A policy, plan, or pharmacy benefit manager is also not
required to provide advanced written notice for the removal or reassignment of a
prescription drug if the policy, plan, or pharmacy benefit manager adds to the
formulary at the same or a lower benefit tier a generic prescription drug that is
approved by the FDA for use as an alternative to the prescription drug or a
prescription drug in the same pharmacologic class or with the same mechanism of
action. A lower benefit tier has a lower deductible, copayment, or coinsurance than
the prescription drug's current benefit tier.
The bill requires a pharmacist or pharmacy to notify an enrollee in a policy or
plan if a prescription drug for which an enrollee is filling or refilling a prescription
is removed from the formulary and the policy or plan or a pharmacy benefit manager
acting on behalf of a policy or plan adds to the formulary at the same or a lower
cost-sharing tier a generic prescription drug or a prescription drug in the same
pharmacologic class or with the same mechanism of action. If an enrollee has had
an adverse reaction to the prescription drug that is being substituted for an
originally prescribed drug, the bill allows the pharmacist or pharmacy to extend the
prescription order for the originally prescribed drug to fill one 30-day supply of the
originally prescribed drug for the cost-sharing amount that applies to the
prescription drug at the time of the substitution.
Fiduciary duty of pharmacy benefit managers
The bill imposes fiduciary and disclosure requirements on pharmacy benefit
managers. Specifically, the bill provides that a pharmacy benefit manager owes a
fiduciary duty to a plan sponsor and requires that a pharmacy benefit manager
annually disclose all of the following information to the plan sponsor:
1. The indirect profit received by the pharmacy benefit manager from owning
a pharmacy or service provider.
2. Any payments made to a consultant or broker who works on behalf of the plan
sponsor.
3. From the amounts received from drug manufacturers, the amounts retained
by the pharmacy benefit manager that are related to the plan sponsor's claims or
bona fide service fees.
4. The amounts received from network pharmacies and the amount retained
by the pharmacy benefit manager.
Application of manufacturer discounts
Health insurance policies and plans often apply deductibles and out-of-pocket
maximum amounts to the benefits covered by the policy. A deductible is an amount
that enrollees in the policy must pay out of pocket before attaining the full benefits
of the plan. An out-of-pocket maximum amount is a limit specified by the policy or
plan on the amount that enrollees have paid themselves, and once this limit is
reached, the policy or plan covers the benefit entirely. The bill requires health
insurance policies that offer prescription drug benefits and self-insured health plans
to apply the amount of discounts that a manufacturer of a brand name drug provides
to reduce the amount of cost-sharing that is charged to any enrollee for those brand
name drugs to this out-of-pocket maximum amount and deductible for the enrollee.
This requirement applies for brand name drugs that have no generic equivalent and
for brand name drugs that have a generic equivalent but that the enrollee has prior
authorization or physician approval to obtain. Health insurance policies are referred
to in the bill as disability insurance policies.
Reimbursement to federal drug pricing program participants
The bill prohibits any person from reimbursing certain entities that participate
in the federal drug pricing program, known as the 340B program, for a drug subject
to an agreement under the program at a rate lower than that paid for the same drug
to pharmacies that are similar in prescription volume. The bill also prohibits a
person from imposing any fee, charge back, or other adjustment on the basis of the
entity's participation in the 340B program. The entities covered by the prohibitions
under the bill are federally qualified health centers, critical access hospitals, and
grantees under the federal Ryan White HIV/AIDS program, as well as these entities'
pharmacies and any pharmacy with which any of the entities have contracted to
dispense drugs through the 340B program.
Drug margin data reporting by hospitals in the 340B program
The bill requires each hospital participating in the 340B program to report to
OCI the per unit margin for each drug covered under the 340B program dispensed
in the previous year, the total margin, and how the margin revenue was used. OCI
is required under the bill to publicly post the information submitted and publish a
report analyzing the data. The 340B program limits the pricing of prescription drugs
paid by entities that are covered by the program due to agreements between
prescription drug manufacturers and the federal government.
Prescription drug affordability review board
The bill creates a prescription drug affordability review board, whose purpose
is to protect Wisconsin residents and other stakeholders from the high costs of
prescription drugs. The board consists of the commissioner of insurance and the
following members, all of whom are appointed by the governor for four-year terms:
1. Two members who represent the pharmaceutical drug industry, at least one
of whom is a licensed pharmacist.
2. Two members who represent the health insurance industry.
3. Two members who represent the health care industry, at least one of whom
is a licensed practitioner.
4. Two members who represent the interests of the public.
The bill requires the board to meet in open session at least four times per year
to review prescription drug pricing information. The board must provide at least two
weeks' public notice of its meetings, make the meeting's materials publicly available
at least one week prior to meeting, and provide the opportunity for public comment.
The bill imposes conflict of interest requirements for the board relating to recusal
and public disclosure of certain conflicts. The bill directs the board to access and
assess drug pricing information, to the extent practicable, by accessing and assessing
information from other states, by assessing spending for the drug in Wisconsin, and
by accessing other available pricing information.
Under the bill, the board must conduct drug cost affordability reviews. The first
step in such reviews is for the board to identify prescription drugs whose increase in
wholesale acquisition cost exceeds specified thresholds and other prescription drugs
that may create affordability challenges for the health care system in Wisconsin. For
each identified prescription drug, the board must determine whether to conduct an
affordability review by seeking stakeholder input and considering the average
patient cost share for the drug. During an affordability review, the board must
determine whether use of the prescription drug that is fully consistent with the
labeling approved by the federal Food and Drug Administration or standard medical
practice has led or will lead to an affordability challenge for the health care system
in Wisconsin. In making this determination, the bill requires the board to consider
a variety of factors, which include the following:
1. The drug's wholesale acquisition cost.
2. The average monetary price concession, discount, or rebate the
manufacturer provides, or is expected to provide, for the drug to health plans.
3. The total amount of price concessions, discounts, and rebates the
manufacturer provides to each pharmacy benefit manager for the drug.
4. The price at which therapeutic alternatives have been sold and the average
monetary concession, discount, or rebate the manufacturer provides, or is expected
to provide, to health plan payors and pharmacy benefit managers for therapeutic
alternatives.
5. The costs to health plans based on patient access consistent with federal
labeled indications and recognized standard medical practice.
6. The impact on patient access resulting from the drug's cost relative to
insurance benefit design.
7. The current or expected dollar value of drug–specific patient access
programs that are supported by the manufacturer.
8. The relative financial impacts to health, medical, or social services costs that
can be quantified and compared to baseline effects of existing therapeutic
alternatives.
9. The average patient copay or other cost-sharing for the drug.
If the board determines that a prescription drug will lead to an affordability
challenge, the bill directs the board to establish an upper payment limit for that drug
that applies to all purchases and payor reimbursements of the drug dispensed or
administered to individuals in Wisconsin. In establishing the upper payment limit,
the board must consider the cost of administering the drug, the cost of delivering it
to consumers, and other relevant administrative costs. For certain drugs, the board
must solicit information from the manufacturer regarding the price increase and, if
the board determines that the price increase is not a result of the need for increased
manufacturing capacity or other effort to improve patient access during a public
health emergency, the board must establish an upper payment limit equal to the
drug's cost prior to the price increase.
Moneys from pharmacy benefit manager regulation used for general
program operations
The bill credits to the appropriation account for OCI's general program
operations all moneys received from the regulation of pharmacy benefit managers,
pharmacy benefit management brokers, pharmacy benefit management
consultants, pharmacy services administration organizations, and pharmaceutical
sales representatives.
Drug cost reporting
The bill generally requires certain prescription drug cost reporting by drug
manufacturers, pharmacy benefit managers, insurers, and pharmacy services
administrative organizations.
Under the bill, each insurer that offers a health insurance policy that covers
prescription drugs must submit to OCI an annual 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. Health insurance policies are referred to in the bill as disability
insurance policies.
The bill requires a drug manufacturer to notify OCI if it increases the wholesale
acquisition cost of a brand-name or generic drug on the market in Wisconsin by more
than an amount specified in the bill, or if it intends to introduce to market a
brand-name or generic drug that has an annual wholesale acquisition cost of more
than a specified amount. The manufacturer must include with the notice
justification for and documentation regarding the price increase. The bill requires
each manufacturer to provide OCI an annual description of each
manufacturer-sponsored patient assistance program in effect during the previous
year. Each manufacturer must also report to OCI the value of price concessions
provided to each pharmacy benefit manager for each drug sold.
The bill requires pharmacy benefit managers to report to OCI the amount
received from manufacturers as drug rebates and the value of price concessions
provided by manufacturers for each drug. OCI is required under the bill to publicly
post information submitted, analyze data collected, publish a report on emerging
trends in prescription prices and price increases, and annually conduct a public
hearing based on that analysis. OCI must also conduct a statistically valid survey
of pharmacies regarding whether the pharmacy agreed to not disclose that customer
drug benefit cost-sharing exceeds the cost of the dispensed drug.
The bill requires pharmacy services administrative organizations to annually
report to OCI the negotiated reimbursement rates of the 25 prescription drugs with
the highest reimbursement rates, the 25 prescription drugs with the largest
year-to-year change in reimbursement rate, and the schedule of fees charged to
pharmacies.
Licensure of pharmaceutical representatives
The bill requires a pharmaceutical representative to be licensed by OCI and to
display his or her license during each visit with a health care professional. The bill
defines “pharmaceutical representative” to mean an individual who markets or
promotes pharmaceuticals to health care professionals on behalf of a pharmaceutical
manufacturer for compensation.
Under the bill, the license must be annually renewed. The application to obtain
or renew a license must include the applicant's contact information, a description of
the type of work in which he or she will engage, an attestation that the professional
education requirements are met, the license fee, proof that any penalties and other
fees are paid, and any other information required by OCI. Under the bill, the license
fee is set by the commissioner. The bill requires the pharmaceutical representative
to report, within four business days, any change to the information provided on the
application or any material change to his or her business operations or other
information required to be reported under the bill.
The bill requires that a pharmaceutical representative complete a professional
education course prior to becoming licensed and to annually complete at least five
hours of continuing professional education. The coursework must include, at a
minimum, training in ethical standards, whistleblower protections, and the laws
and rules applicable to pharmaceutical marketing. The bill directs the commissioner
to regularly publish a list of courses that fulfill the education requirements. Under
the bill, a course provider must disclose any conflict of interest and the courses may
not be provided by an employer of a pharmaceutical representative or be funded by
the pharmaceutical industry or a third party funded by the industry.
The bill requires that, no later than June 1 of each year, a pharmaceutical
representative report to OCI his or her total number of contacts with health care
professionals in Wisconsin, the specialties of those health care professionals, the
location and duration of each contact, the pharmaceuticals discussed, and the value
of any item provided to a health care professional. The bill directs the commissioner
to publish the information on OCI's website, without identifying individual health
care professionals.
The bill requires that a pharmaceutical representative, during each contact
with a health care professional, disclose the wholesale acquisition cost of any
pharmaceuticals discussed and the names of at least three generic prescription
drugs from the same therapeutic class.
The bill directs the commissioner to promulgate ethical standards for
pharmaceutical representatives. Additionally, the bill prohibits a pharmaceutical
representative from engaging in deceptive or misleading marketing of a
pharmaceutical product; using a title or designation that could reasonably lead a
licensed health care professional, or an employee or representative of such a
professional, to believe that he or she is licensed to practice in a health occupation
unless he or she holds a license to practice; or attending an examination without the
patient's consent.
Under the bill, an individual violating any of these provisions is subject to a fine
and his or her license may be suspended or revoked. An individual whose license is
revoked must wait at least two years before applying for a new license.
Pharmacy benefit management broker and consultant licensing
The bill requires a person who is acting as a pharmacy benefit management
broker or consultant or any other person who procures the services of a pharmacy
benefit manager on behalf of a client to obtain a license. The bill allows OCI to
establish criteria, procedures, and fees for licensure by rule. Pharmacy benefit
managers, as defined under current law, are entities that contract to administer or
manage prescription drug benefits on behalf of an insurer or other entity that
provides prescription drug benefits.
Pharmacy services administrative organizations
The bill requires that pharmacy services administrative organizations
(PSAOs) be licensed by OCI. Under the bill, a PSAO is an entity operating in
Wisconsin that does all of the following:
1. Contracts with an independent pharmacy to conduct business on the
pharmacy's behalf with a third-party payer.
2. Provides at least one administrative service to an independent pharmacy
and negotiates and enters into a contract with a third-party payer or pharmacy
benefit manager on the pharmacy's behalf.
The bill defines “independent pharmacy" to mean a licensed pharmacy
operating in Wisconsin that is under common ownership with no more than two other
pharmacies. “Administrative service” is defined to mean assisting with claims or
audits, providing centralized payment, performing certification in a specialized care
program, providing compliance support, setting flat fees for generic drugs, assisting
with store layout, managing inventory, providing marketing support, providing
management and analysis of payment and drug dispensing data, or providing
resources for retail cash cards. The bill defines “third-party payer” to mean an entity
operating in Wisconsin that pays or insures health, medical, or prescription drug
expenses on behalf of beneficiaries.
To obtain the license required by the bill, a person must apply to OCI and
provide the contact information for the applicant and a contact person, evidence of
financial responsibility of at least $1,000,000, and any other information required by
the commissioner. Under the bill, the license fee is set by the commissioner and the
term of a license is two years.
The bill also requires that a PSAO disclose to OCI the extent of any ownership
or control by an entity that provides pharmacy services; provides prescription drug
or device services; or manufactures, sells, or distributes prescription drugs,
biologicals, or medical devices. The PSAO must notify OCI within five days of any
material change in its ownership or control related to such an entity.
Cost-sharing cap on insulin
