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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 insureds 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 insureds 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 providers 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 insurers 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 insurers 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 insureds 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 states wholesale
12distributor and fully after the prescription drug to be imported is in the possession
13of this states 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.
AB50,1402,2
15. The program is adequately financed to support administrative functions of
2the program while generating significant cost savings to residents of this state.
AB50,1402,436. The program does not put residents of this state at a higher risk than if the
4program did not exist.
AB50,1402,657. The program provides and is projected to continue to provide substantial
6cost savings to residents of this state.
AB50,1402,97(2) Anticompetitive behavior. The commissioner, in consultation with the
8attorney general, shall identify the potential for and monitor anticompetitive
9behavior in industries affected by a prescription drug importation program.
AB50,1402,1910(3) Approval of program design; certification. No later than the first day
11of the 7th month beginning after the effective date of this subsection .... [LRB
12inserts date], the commissioner shall submit to the joint committee on finance a
13report that includes the design of the prescription drug importation program in
14accordance with this section. The commissioner may not submit the proposed
15program to the federal department of health and human services unless the joint
16committee on finance approves the proposed program. Within 14 days of the date of
17approval by the joint committee on finance of the proposed program, the
18commissioner shall submit to the federal department of health and human services
19a request for certification of the approved program.
AB50,1403,420(4) Implementation of certified program. After the federal department of
21health and human services certifies the prescription drug importation program
22submitted under sub. (3), the commissioner shall begin implementation of the
23program, and the program shall be fully operational by 180 days after the date of

1certification by the federal department of health and human services. The
2commissioner shall do all of the following to implement the program to the extent
3the action is in accordance with other state laws and the certification by the federal
4department of health and human services:
AB50,1403,75(a) Become a licensed wholesale distributor, designate another state agency to
6become a licensed wholesale distributor, or contract with a licensed wholesale
7distributor.
AB50,1403,98(b) Contract with one or more Canadian suppliers that meet the criteria in
9sub. (1) (c) and (n).
AB50,1403,1210(c) Create an outreach and marketing plan to communicate with and provide
11information to health plans and health insurance policies, employers, pharmacies,
12health care providers, and residents of this state on participating in the program.
AB50,1403,1513(d) Develop and implement a registration process for health plans and health
14insurance policies, pharmacies, and health care providers interested in
15participating in the program.
AB50,1403,1716(e) Create a publicly accessible source for listing prices of prescription drugs
17imported under the program.
AB50,1403,2018(f) Create, publicize, and implement a method of communication to promptly
19answer questions from and address the needs of persons affected by the
20implementation of the program before the program is fully operational.
AB50,1403,2221(g) Establish the audit functions under sub. (1) (n) with a timeline to complete
22each audit function every 2 years.
AB50,1404,2
1(h) Conduct any other activities determined by the commissioner to be
2important to successful implementation of the program.
AB50,1404,43(5) Report. By January 1 and July 1 of each year, the commissioner shall
4submit to the joint committee on finance a report including all of the following:
AB50,1404,65(a) A list of prescription drugs included in the prescription drug importation
6program under this section.
AB50,1404,97(b) The number of pharmacies, health care providers, and health plans and
8health insurance policies participating in the prescription drug importation
9program under this section.
AB50,1404,1410(c) The estimated amount of savings to residents of this state, health plans
11and health insurance policies, and employers resulting from the implementation of
12the prescription drug importation program under this section reported from the
13date of the previous report under this subsection and from the date the program
14was fully operational.
AB50,1404,1615(d) Findings of any audit functions under sub. (1) (n) completed since the date
16of the previous report under this subsection.
AB50,1404,1817(6) Rule making. The commissioner may promulgate any rules necessary to
18implement this section.
AB50,288919Section 2889. 601.59 of the statutes is created to read:
AB50,1404,2020601.59 State-based exchange. (1) Definitions. In this section:
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