AB50,288115Section 2881. 601.25 of the statutes is created to read: AB50,1392,1916601.25 Office of the public intervenor. (1) The office of the public 17intervenor shall assist individuals with insurance claims, policies, appeals, and 18other legal actions to pursue insurance coverage for medical procedures, 19prescription medications, and other health care services. AB50,1392,2420(2) The office of the public intervenor may levy an assessment on each insurer 21that is authorized to engage in the business of insurance in this state. The 22assessment levied under this subsection shall be based on the insurer’s premium 23volume for disability insurance policies, as defined in s. 632.895 (1) (a), written in 24this state. AB50,1393,2
1(3) The commissioner may provide by rule for the governance, duties, and 2administration of the office of the public intervenor. AB50,28823Section 2882. 601.31 (1) (mv) of the statutes is created to read: AB50,1393,64601.31 (1) (mv) For initial issuance or renewal of a license as a pharmacy 5benefit management broker or consultant under s. 628.495, amounts set by the 6commissioner by rule. AB50,28837Section 2883. 601.31 (1) (nv) of the statutes is created to read: AB50,1393,98601.31 (1) (nv) For issuing or renewing a license as a pharmaceutical 9representative under s. 632.863, an amount to be set by the commissioner by rule. AB50,288410Section 2884. 601.31 (1) (nw) of the statutes is created to read: AB50,1393,1311601.31 (1) (nw) For issuing or renewing a license as a pharmacy services 12administrative organization under s. 632.864, an amount to be set by the 13commissioner by rule. AB50,288514Section 2885. 601.41 (14) of the statutes is created to read: AB50,1393,2015601.41 (14) Value-based diabetes medication pilot project. The 16commissioner shall develop a pilot project to direct a pharmacy benefit manager, as 17defined in s. 632.865 (1) (c), and a pharmaceutical manufacturer to create a value-18based, sole-source arrangement to reduce the costs of prescription medication used 19to treat diabetes. The commissioner may promulgate rules to implement this 20subsection. AB50,288621Section 2886. 601.45 (1) of the statutes is amended to read: AB50,1394,622601.45 (1) Costs to be paid by examinees. The reasonable costs of 23examinations and audits under ss. 601.43, 601.44, 601.455, and 601.83 (5) (f) shall 24be paid by examinees except as provided in sub. (4), either on the basis of a system
1of billing for actual salaries and expenses of examiners and other apportionable 2expenses, including office overhead, or by a system of regular annual billings to 3cover the costs relating to a group of companies, or a combination of such systems, 4as the commissioner may by rule prescribe. Additional funding, if any, shall be 5governed by s. 601.32. The commissioner shall schedule annual hearings under s. 6601.41 (5) to review current problems in the area of examinations. AB50,28877Section 2887. 601.455 of the statutes is created to read: AB50,1394,98601.455 Fair claims processing, health insurance transparency, and 9claim denial rate audits. (1) Definitions. In this section: AB50,1394,1510(a) “Claim denial” means the refusal by an insurer to provide payment under 11a disability insurance policy for a service, treatment, or medication recommended 12by a health care provider. “Claim denial” includes the prospective refusal to pay for 13a service, treatment, or medication when a disability insurance policy requires 14advance approval before a prescribed medical service, treatment, or medication is 15provided. AB50,1394,1616(b) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a). AB50,1394,1717(c) “Health care provider” has the meaning given in s. 146.81 (1) (a) to (p). AB50,1394,2018(2) Claims processing. (a) Insurers shall process each claim for a disability 19insurance policy within a time frame that is reasonable and prevents an undue 20delay in an insured’s care, taking into account the medical urgency of the claim. AB50,1394,2421(b) If an insurer determines additional information is needed to process a 22claim for a disability insurance policy, the insurer shall request the information 23from the insured within 5 business days of making the determination and shall 24provide at least 15 days for the insured to respond. AB50,1395,1
1(c) All claim denials shall include all of the following: AB50,1395,321. A specific and detailed explanation of the reason for the denial that cites 3the exact medical or policy basis for the denial. AB50,1395,642. A copy of or a publicly accessible link to any policy, coverage rules, clinical 5guidelines, or medical evidence relied upon in making the denial decision, with 6specific citation to the provision justifying the denial. AB50,1395,973. Additional documentation, medical rationale, or criteria that must be met 8or provided for approval of the claim, including alternative options available under 9the policy. AB50,1395,1210(d) If an insurer uses artificial intelligence or algorithmic decision-making in 11processing a claim for a disability insurance policy, the insurer must notify the 12insured in writing of that fact. The notice shall include all of the following: AB50,1395,15131. A disclosure that artificial intelligence or algorithmic decision-making was 14used at any stage in reviewing the claim, even if a human later reviewed the 15outcome. AB50,1395,18162. A detailed explanation of how the artificial intelligence or algorithmic 17decision-making reached its decision, including any factors the artificial 18intelligence or algorithmic decision-making weighed. AB50,1395,20193. A contact point for requesting a human review of the claim if the claim was 20denied. AB50,1395,2321(3) Independent review of denials. In addition to an insured’s right to an 22independent review under s. 632.835, as applicable, insureds have the right to 23request a review by the office of the public intervenor of any claim denial. AB50,1396,2
1(4) Prohibited practices. An insurer may not do any of the following with 2respect to a disability insurance policy: AB50,1396,33(a) Use vague or misleading policy terms to justify a claim denial. AB50,1396,44(b) Fail to provide a specific and comprehensible reason for a claim denial. AB50,1396,65(c) Cancel coverage under the policy after a claim is submitted due to alleged 6misstatements on the policy application. AB50,1396,87(d) Deny a claim based on hidden or ambiguous exclusions in a disability 8insurance policy. AB50,1396,99(e) Stall review of a claim to avoid timely payment. AB50,1396,1110(f) Reject a claim without reviewing all relevant medical records or consulting 11qualified experts. AB50,1396,1312(g) Fail to properly review or respond to an insured’s appeal in a timely 13manner. AB50,1396,1514(h) Allow non-physician personnel to determine whether care is medically 15necessary. AB50,1396,1716(i) Apply different medical necessity criteria based on financial interests 17rather than patient needs. AB50,1396,1918(j) Disregard a treating health care provider’s medical assessment without a 19valid clinical reason. AB50,1396,2120(k) Mandate prior approval for routine or urgent procedures in a manner that 21causes harmful delays. AB50,1396,2422(L) For a disability insurance policy that provides coverage of emergency 23medical services, refuse to cover emergency medical services provided by out-of-24network providers. AB50,1397,2
1(m) List a health care provider as in-network on a provider directory and then 2deny a claim by stating the health care provider is out-of-network. AB50,1397,43(n) Deny coverage based on age, gender, disability, or a chronic condition 4rather than medical necessity. AB50,1397,65(o) Apply stricter standards in reviewing claims related to mental health 6conditions than claims related to physical health conditions. AB50,1397,87(p) Perform a blanket denial of claims for high-cost conditions without an 8individualized review of each claim. AB50,1397,99(r) Reclassify a claim to a lower-cost treatment to reduce insurer payout. AB50,1397,1110(s) Require an insured to fail a cheaper treatment before approving coverage 11for necessary care. AB50,1397,1212(t) Manipulate cost-sharing rules to shift higher costs to insureds. AB50,1397,1713(5) Transparency and reporting. (a) Beginning on January 1, 2027, an 14insurer shall annually publish a report detailing the insurer’s claim denial rates, 15reasons for claim denials, and the outcome of any appeal of a claim denial for the 16previous year for all disability insurance policies under which the insurer provides 17coverage. AB50,1397,1918(b) The commissioner shall maintain a public database of insurers’ claim 19denial rates and the outcomes of independent reviews under s. 632.835. AB50,1397,2320(c) Beginning on January 1, 2027, an insurer that uses artificial intelligence 21or algorithmic decision-making in claims processing shall annually publish a report 22detailing all of the following for the previous year for all disability insurance policies 23under which the insurer provides coverage: AB50,1398,2
11. The percentage of claims submitted to the insurer that were reviewed by 2artificial intelligence or algorithmic decision-making. AB50,1398,532. The claim denial rate of claims reviewed by artificial intelligence or 4algorithmic decision-making compared to the claim denial rate of claims reviewed 5by humans. AB50,1398,763. The steps the insurer takes to ensure fairness and accuracy in decisions 7made by artificial intelligence or algorithmic decision-making. AB50,1398,118(6) Claim denial rate audits. (a) The commissioner may conduct an audit 9of an insurer if the insurer’s claim denials are of such frequency as to indicate a 10general business practice. This paragraph is supplemental to and does not limit 11any other powers or duties of the commissioner. AB50,1398,1312(b) The commissioner may collect any relevant information from an insurer 13that is necessary to conduct an audit under par. (a). AB50,1398,1514(c) The commissioner may contract with a 3rd party to conduct an audit under 15par. (a). AB50,1398,2016(d) The commissioner may, based on the findings of an audit under par. (a), 17order the insurer who is the subject of the audit to comply with a corrective action 18plan approved by the commissioner. The commissioner shall specify in any 19corrective action plan under this paragraph the deadline by which an insurer must 20be in compliance with the corrective action plan. AB50,1398,2221(e) An insurer who is the subject of an audit under par. (a) shall provide a 22written response to any adverse findings of the audit. AB50,1399,223(f) If an insurer fails to comply with a corrective action plan under par. (d) by
1the deadline specified by the commissioner, the commissioner may order the 2insurer to pay a forfeiture pursuant to s. 601.64 (3). AB50,1399,63(7) Forfeitures. A violation of this section that results in a harmful delay in 4an insured’s care or an adverse health outcome for an insured shall be subject to a 5civil forfeiture of $10,000 per occurrence, in addition to any other penalties provided 6in s. 601.64 (3) or other law. AB50,28887Section 2888. 601.575 of the statutes is created to read: AB50,1399,138601.575 Prescription drug importation program. (1) Importation 9program requirements. The commissioner, in consultation with persons 10interested in the sale and pricing of prescription drugs and appropriate officials 11and agencies of the federal government, shall design and implement a prescription 12drug importation program for the benefit of residents of this state, that generates 13savings for residents, and that satisfies all of the following: AB50,1399,1614(a) The commissioner shall designate a state agency to become a licensed 15wholesale distributor or to contract with a licensed wholesale distributor and shall 16seek federal certification and approval to import prescription drugs. AB50,1399,1817(b) The program shall comply with relevant requirements of 21 USC 384, 18including safety and cost savings requirements. AB50,1399,2019(c) The program shall import prescription drugs from Canadian suppliers 20regulated under any appropriate Canadian or provincial laws. AB50,1399,2221(d) The program shall have a process to sample the purity, chemical 22composition, and potency of imported prescription drugs. AB50,1400,223(e) The program shall import only those prescription drugs for which 24importation creates substantial savings for residents of this state and only those
1prescription drugs that are not brand-name drugs and that have fewer than 4 2competitor prescription drugs in the United States. AB50,1400,43(f) The commissioner shall ensure that prescription drugs imported under the 4program are not distributed, dispensed, or sold outside of this state. AB50,1400,55(g) The program shall ensure all of the following: AB50,1400,761. Participation by any pharmacy or health care provider in the program is 7voluntary. AB50,1400,982. Any pharmacy or health care provider participating in the program has the 9appropriate license or other credential in this state. AB50,1400,12103. Any pharmacy or health care provider participating in the program charges 11a consumer or health plan the actual acquisition cost of the imported prescription 12drug that is dispensed. AB50,1400,1613(h) The program shall ensure that a payment by a health plan or health 14insurance policy for a prescription drug imported under the program reimburses no 15more than the actual acquisition cost of the imported prescription drug that is 16dispensed. AB50,1400,1817(i) The program shall ensure that any health plan or health insurance policy 18participating in the program does all of the following: AB50,1400,20191. Maintains a formulary and claims payment system with current 20information on prescription drugs imported under the program. AB50,1400,23212. Bases cost-sharing amounts for participants or insureds under the plan or 22policy on no more than the actual acquisition cost of the prescription drug imported 23under the program that is dispensed to the participant or insured. AB50,1401,3
13. Demonstrates to the commissioner or a state agency designated by the 2commissioner how premiums under the plan or policy are affected by savings on 3prescription drugs imported under the program. AB50,1401,64(j) Any wholesale distributor importing prescription drugs under the program 5shall limit its profit margin to the amount established by the commissioner or a 6state agency designated by the commissioner. AB50,1401,87(k) The program may not import any generic prescription drug that would 8violate federal patent laws on branded products in the United States. AB50,1401,139(L) The program shall comply with tracking and tracing requirements of 21 10USC 360eee and 360eee-1, to the extent practical and feasible, before the 11prescription drug to be imported comes into the possession of this state’s wholesale 12distributor and fully after the prescription drug to be imported is in the possession 13of this state’s wholesale distributor. AB50,1401,1514(m) The program shall establish a fee or other mechanism to finance the 15program that does not jeopardize significant savings to residents of this state. AB50,1401,1616(n) The program shall have an audit function that ensures all of the following: AB50,1401,18171. The commissioner has a sound methodology to determine the most cost-18effective prescription drugs to include in the program. AB50,1401,20192. The commissioner has a process in place to select Canadian suppliers that 20are high quality, high performing, and in full compliance with Canadian laws. AB50,1401,22213. Prescription drugs imported under the program are pure, unadulterated, 22potent, and safe. AB50,1401,23234. The program is complying with the requirements of this subsection.
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