AB43: Bill Text

AB43,,8684 1. Health status.

AB43,,8685 2. Medical condition, including both physical and mental illnesses.

AB43,,8686 3. Claims experience.

AB43,,8687 4. Receipt of health care.

AB43,,8688 5. Medical history.

AB43,,8689 6. Genetic information.

AB43,,8690 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

AB43,,8691 8. Disability.

AB43,,8692 (b) An insurer that offers a short-term, limited duration plan may not require any individual, as a condition of enrollment or continued enrollment under the short-term, limited duration plan, to pay, on the basis of any health status-related factor described 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 short-term, limited duration plan.

AB43,,8693 (4) Premium rate variation. An insurer that offers a short-term, limited duration plan may vary premium rates for a specific short-term, limited duration plan based only on the following considerations:

AB43,,8694 (a) Whether the short-term, limited duration plan covers an individual or a family.

AB43,,8695 (b) Rating area in the state, as established by the commissioner.

AB43,,8696 (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.

AB43,,8697 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

AB43,,8698 (5) Annual and lifetime limits. A short-term, limited duration plan may not establish any of the following:

AB43,,8699 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the short-term, limited duration plan.

AB43,,8700 (b) Limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the short-term, limited duration plan for a term of coverage or for the aggregate duration of the short-term, limited duration plan.

AB43,3082 Section 3082. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to read:

AB43,,8702 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).

AB43,,8703 (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.

AB43,,8704 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.

AB43,3083 Section 3083. 632.76 (2) (ac) 3. (intro.) of the statutes is amended to read:

AB43,,8706 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 policy, limited duration plan subject to s. 632.7495 (4) and (5):

AB43,3084 Section 3084. 632.76 (2) (ac) 3. b. of the statutes is amended to read:

AB43,,8708 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.

AB43,3085 Section 3085. 632.795 (4) (a) of the statutes is amended to read:

AB43,,8710 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.

AB43,3086 Section 3086. 632.862 of the statutes is created to read:

AB43,,8712 632.862 Application of prescription drug payments. (1) Definitions. In this section:

AB43,,8713 (a) “Brand name” has the meaning given in s. 450.12 (1) (a).

AB43,,8714 (b) “Brand name drug” means any of the following:

AB43,,8715 1. A prescription drug that contains a brand name and that has no generic equivalent.

AB43,,8716 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 self-insured health plan or authorization from a physician to obtain the prescription drug under the disability insurance policy or self-insured health plan.

AB43,,8717 (c) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

AB43,,8718 (d) “Prescription drug” has the meaning given in s. 450.01 (20).

AB43,,8719 (e) “Self-insured health plan” means a self-insured health plan of the state or a county, city, village, town, or school district.

AB43,,8720 (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 amount and to any deductible of the disability insurance policy or self-insured health 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 the enrollee for that brand name drug.

AB43,3087 Section 3087. 632.863 of the statutes is created to read:

AB43,,8722 632.863 Pharmaceutical representatives. (1) Definitions. In this section:

AB43,,8723 (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.

AB43,,8724 (b) “Pharmaceutical” means a medication that may legally be dispensed only with a valid prescription from a health care professional.

AB43,,8725 (c) “Pharmaceutical representative” means an individual who markets or promotes pharmaceuticals to health care professionals on behalf of a pharmaceutical manufacturer for compensation.

AB43,,8726 (2) Licensure. Beginning on the first day of the 12th month beginning after the effective date of this subsection .... [LRB inserts date], no individual may act as a pharmaceutical representative in this state without being licensed by the commissioner as a pharmaceutical representative under this section. In order to obtain a license, the individual shall apply to the commissioner in the form and manner prescribed by the commissioner. The term of a license issued under this subsection is one year and is renewable.

AB43,,8727 (3) Display of license. A pharmaceutical representative licensed under sub. (2) shall display the pharmaceutical representative’s license during each visit with a health care professional.

AB43,,8728 (4) Enforcement. (a) Any individual who violates this section shall be fined not less than $1,000 nor more than $3,000 for each offense. Each day of continued violation constitutes a separate offense.

AB43,,8729 (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 the pharmaceutical representative remedies all violations related to the suspension or revocation and pays all assessed penalties and fees.

AB43,,8730 (5) Rules. The commissioner shall promulgate rules to implement this section, including rules that require pharmaceutical representatives to complete continuing educational coursework as a condition of licensure.

AB43,3088 Section 3088. 632.864 of the statutes is created to read:

AB43,,8732 632.864 Pharmacy services administrative organizations. (1) Definitions. In this section:

AB43,,8733 (a) “Administrative service” means any of the following:

AB43,,8734 1. Assisting with claims.

AB43,,8735 2. Assisting with audits.

AB43,,8736 3. Providing centralized payment.

AB43,,8737 4. Performing certification in a specialized care program.

AB43,,8738 5. Providing compliance support.

AB43,,8739 6. Setting flat fees for generic drugs.

AB43,,8740 7. Assisting with store layout.

AB43,,8741 8. Managing inventory.

AB43,,8742 9. Providing marketing support.

AB43,,8743 10. Providing management and analysis of payment and drug dispensing data.

AB43,,8744 11. Providing resources for retail cash cards.

AB43,,8745 (b) “Independent pharmacy” means a pharmacy operating in this state that is licensed under s. 450.06 or 450.065 and is under common ownership with no more than 2 other pharmacies.

AB43,,8746 (c) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).

AB43,,8747 (d) “Pharmacy services administrative organization” means an entity operating in this state that does all of the following:

AB43,,8748 1. Contracts with an independent pharmacy to conduct business on the independent pharmacy’s behalf with a 3rd-party payer.

AB43,,8749 2. Provides at least one administrative service to an independent pharmacy and negotiates and enters into a contract with a 3rd-party payer or pharmacy benefit manager on behalf of the independent pharmacy.

AB43,,8750 (e) “Third-party payer” means an entity, including a plan sponsor, health maintenance organization, or insurer, operating in this state that pays or insures health, medical, or prescription drug expenses on behalf of beneficiaries.

AB43,,8751 (2) Licensure. (a) Beginning on the first day of the 12th month beginning after the effective date of this paragraph .... [LRB inserts date], no person may operate as a pharmacy services administrative organization in this state without being licensed by the commissioner as a pharmacy services administrative organization under this section. In order to obtain a license, the person shall apply to the commissioner in the form and manner prescribed by the commissioner. The application shall include all of the following:

AB43,,8752 1. The name, address, telephone number, and federal employer identification number of the applicant.

AB43,,8753 2. The name, business address, and telephone number of a contact person for the applicant.

AB43,,8754 3. The fee under s. 601.31 (1) (nw).

AB43,,8755 4. Evidence of financial responsibility of at least $1,000,000.

AB43,,8756 5. Any other information required by the commissioner.

AB43,,8757 (b) The term of a license issued under par. (a) shall be 2 years from the date of issuance.

AB43,,8758 (3) Disclosure to the commissioner. (a) A pharmacy services administrative organization licensed under sub. (2) shall disclose to the commissioner the extent of any ownership or control of the pharmacy services administrative organization by an entity that does any of the following:

AB43,,8759 1. Provides pharmacy services.

AB43,,8760 2. Provides prescription drug or device services.

AB43,,8761 3. Manufactures, sells, or distributes prescription drugs, biologicals, or medical devices.

AB43,,8762 (b) A pharmacy services administrative organization licensed under sub. (2) shall notify the commissioner in writing within 5 days of any material change in its ownership or control relating to an entity described in par. (a).

AB43,,8763 (4) Rules. The commissioner may promulgate rules to implement this section.

AB43,3089 Section 3089. 632.865 (2m) of the statutes is created to read:

AB43,,8765 632.865 (2m) Fiduciary duty and disclosures to health benefit plan sponsors. (a) A pharmacy benefit manager owes a fiduciary duty to the health benefit plan sponsor to act according to the health benefit plan sponsor’s instructions and in the best interests of the health benefit plan sponsor.

AB43,,8766 (b) A pharmacy benefit manager shall annually provide, no later than the date and using the method prescribed by the commissioner by rule, the health benefit plan sponsor all of the following information from the previous calendar year:

AB43,,8767 1. The indirect profit received by the pharmacy benefit manager from owning any interest in a pharmacy or service provider.

AB43,,8768 2. Any payment made by the pharmacy benefit manager to a consultant or broker who works on behalf of the health benefit plan sponsor.

AB43,,8769 3. From the amounts received from all drug manufacturers, the amounts retained by the pharmacy benefit manager, and not passed through to the health benefit plan sponsor, that are related to the health benefit plan sponsor’s claims or bona fide service fees.

AB43,,8770 4. The amounts, including pharmacy access and audit recovery fees, received from all pharmacies that are in the pharmacy benefit manager’s network or have a contract to be in the network and, from these amounts, the amount retained by the pharmacy benefit manager and not passed through to the health benefit plan sponsor.

AB43,3090 Section 3090. 632.868 of the statutes is created to read:

AB43,,8772 632.868 Insulin safety net programs. (1) Definitions. In this section: