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AB50,291018Section 2910. 609.825 of the statutes is created to read:
AB50,1430,2019609.825 Coverage of emergency ambulance services. (1) In this
20section:
AB50,1430,2121(a) Ambulance service provider has the meaning given in s. 256.01 (3).
AB50,1431,222(b) Self-insured governmental plan means a self-insured health plan of the
23state or a county, city, village, town, or school district that has a network of

1participating providers and imposes on enrollees in the self-insured health plan
2different requirements for using providers that are not participating providers.
AB50,1431,73(2) A defined network plan, preferred provider plan, or self-insured
4governmental plan that provides coverage of emergency medical services shall
5cover emergency ambulance services provided by an ambulance service provider
6that is not a participating provider at a rate that is not lower than the greatest rate
7that is any of the following:
AB50,1431,98(a) A rate that is set or approved by a local governmental entity in the
9jurisdiction in which the emergency ambulance services originated.
AB50,1431,1510(b) A rate that is 400 percent of the current published rate for the provided
11emergency ambulance services established by the federal centers for medicare and
12medicaid services under title XVIII of the federal Social Security Act, 42 USC 1395
13et seq., in the same geographic area or a rate that is equivalent to the rate billed by
14the ambulance service provider for emergency ambulance services provided,
15whichever is less.
AB50,1431,1816(c) The contracted rate at which the defined network plan, preferred provider
17plan, or self-insured governmental plan would reimburse a participating
18ambulance service provider for the same emergency ambulance services.
AB50,1432,219(3) No defined network plan, preferred provider plan, or self-insured
20governmental plan may impose a cost-sharing amount on an enrollee for emergency
21ambulance services provided by an ambulance service provider that is not a
22participating provider at a rate that is greater than the requirements that would

1apply if the emergency ambulance services were provided by a participating
2ambulance service provider.
AB50,1432,63(4) No ambulance service provider that receives reimbursement under this
4section may bill an enrollee for any additional amount for emergency ambulance
5services except for any copayment, coinsurance, deductible, or other cost-sharing
6responsibilities required to be paid by the enrollee.
AB50,1432,87(5) For purposes of this section, emergency ambulance services does not
8include air ambulance services.
AB50,29119Section 2911. 609.83 of the statutes is amended to read:
AB50,1432,1310609.83 Coverage of drugs and devices; application of payments.
11Limited service health organizations, preferred provider plans, and defined
12network plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (6) (b),
13(16t), and (16v).
AB50,291214Section 2912. 609.847 of the statutes is created to read:
AB50,1432,1715609.847 Preexisting condition discrimination and certain benefit
16limits prohibited. Limited service health organizations, preferred provider
17plans, and defined network plans are subject to s. 632.728.
AB50,291318Section 2913. 611.11 (4) (a) of the statutes is amended to read:
AB50,1432,2019611.11 (4) (a) In this subsection, municipality has the meaning given in s.
20345.05 (1) (c), but also includes any transit authority created under s. 66.1039.
AB50,291421Section 2914. 625.12 (1) (a) of the statutes is amended to read:
AB50,1432,2322625.12 (1) (a) Past and prospective loss and expense experience within and
23outside of this state, except as provided in s. 632.728.
AB50,291524Section 2915. 625.12 (1) (e) of the statutes is amended to read:
AB50,1433,2
1625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors,
2including the judgment of technical personnel.
AB50,29163Section 2916. 625.12 (2) of the statutes is amended to read:
AB50,1433,124625.12 (2) Classification. Except as provided in s. ss. 632.728 and 632.729,
5risks may be classified in any reasonable way for the establishment of rates and
6minimum premiums, except that no classifications may be based on race, color,
7creed or national origin, and classifications in automobile insurance may not be
8based on physical condition or developmental disability as defined in s. 51.01 (5).
9Subject to ss. 632.365, 632.728, and 632.729, rates thus produced may be modified
10for individual risks in accordance with rating plans or schedules that establish
11reasonable standards for measuring probable variations in hazards, expenses, or
12both. Rates may also be modified for individual risks under s. 625.13 (2).
AB50,291713Section 2917. 625.15 (1) of the statutes is amended to read:
AB50,1433,2114625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may
15itself establish rates and supplementary rate information for one or more market
16segments based on the factors in s. 625.12 and, if the rates are for motor vehicle
17liability insurance, subject to s. 632.365, or the insurer may use rates and
18supplementary rate information prepared by a rate service organization, with
19average expense factors determined by the rate service organization or with such
20modification for its own expense and loss experience as the credibility of that
21experience allows.
AB50,291822Section 2918. 628.34 (3) (a) of the statutes is amended to read:
AB50,1434,723628.34 (3) (a) No insurer may unfairly discriminate among policyholders by

1charging different premiums or by offering different terms of coverage except on the
2basis of classifications related to the nature and the degree of the risk covered or the
3expenses involved, subject to ss. 632.365, 632.728, 632.729, 632.746 and, 632.748,
4and 632.7496. Rates are not unfairly discriminatory if they are averaged broadly
5among persons insured under a group, blanket or franchise policy, and terms are
6not unfairly discriminatory merely because they are more favorable than in a
7similar individual policy.
AB50,29198Section 2919. 628.42 of the statutes is created to read:
AB50,1434,109628.42 Disclosure and review of prior authorization requirements.
10(1) In this section:
AB50,1434,1111(a) Health care plan has the meaning given in s. 628.36 (2) (a) 1.
AB50,1434,1412(b) 1. Prior authorization means the process by which a health care plan or
13a contracted utilization review organization determines the medical necessity and
14medical appropriateness of otherwise covered health care services.
AB50,1434,17152. Prior authorization includes any requirement that an enrollee or provider
16notify the health care plan or a contracted utilization review organization before, at
17the time of, or concurrent to providing a health care service.
AB50,1434,1818(b) Provider has the meaning given in s. 628.36 (2) (a) 2.
AB50,1434,2119(2) (a) A health care plan shall maintain a complete list of services for which
20prior authorization is required, including services where prior authorization is
21performed by an entity under contract with the health care plan.
AB50,1434,2422(b) A health care plan shall publish the list under par. (a) on its website. The
23list shall be accessible by members of the general public without requiring the
24creation of any of an account or the entry of any credentials or personal information.
AB50,1435,2
1(c) The list under par. (a) is not required to contain any clinical review criteria
2applicable to the services.
AB50,1435,103(3) (a) A health care plan shall make any current prior authorization
4requirements and restrictions along with the clinical review criteria applicable to
5those requirements or restrictions accessible and conspicuously posted on its
6website to enrollees and providers. Content published by a 3rd party and licensed
7for use by a health care plan or a contracted utilization review organization may
8satisfy this subsection if it is available to access through the website of the health
9care plan or the contracted utilization review organization as long as the website
10does not unreasonably restrict access.
AB50,1435,1311(b) The prior authorization requirements and restrictions under par. (a) shall
12be described in detail, and shall be written in easily understandable, plain
13language.
AB50,1435,1614(c) The prior authorization requirements and restrictions under par. (a) shall
15indicate all of the following for each service subject to the prior authorization
16requirements and restrictions:
AB50,1435,18171. When the requirement or restriction began for policies issued or delivered
18in this state, including effective dates and any termination dates.
AB50,1435,20192. The date that the requirement or restriction was listed on the website of the
20health care plan or a contracted utilization review organization.
AB50,1435,21213. The date that the requirement or restriction was removed in this state.
AB50,1435,23224. A method to access a standardized electronic prior authorization request
23transaction process.
AB50,1436,2
1(4) Any clinical review criteria on which a prior authorization requirement or
2restriction is based shall satisfy all of the following:
AB50,1436,43(a) The criteria are based on nationally recognized, generally accepted
4standards except where provided by law.
AB50,1436,65(b) The criteria are developed in accordance with the current standards of a
6national medical accreditation entity.
AB50,1436,87(c) The criteria ensure quality of care and access to needed health care
8services.
AB50,1436,99(d) The criteria are evidence-based.
AB50,1436,1110(e) The criteria are sufficiently flexible to allow deviations from current
11standards when justified.
AB50,1436,1312(f) The criteria are evaluated and updated when necessary and no less
13frequently than once every year.
AB50,1436,1614(5) No health care plan may deny a claim for failure to obtain prior
15authorization if the prior authorization requirement was not in effect on the date
16that the service was provided.
AB50,1436,2117(6) No health care plan nor any utilization review organization contracted
18with a health care plan may deem supplies or services as incidental or deny a claim
19for supplies or services if a provided health care service associated with the
20supplies or services receives prior authorization or if a provided health care service
21associated with the supplies or services does not require prior authorization.
AB50,1437,922(7) If a health care plan intends to impose a new prior authorization
23requirement or restriction or intends to amend a prior authorization requirement
24or restriction, the health care plan shall provide all providers contracted with the

1health care plan advanced written notice of the new or amended requirement or
2restriction no less than 60 days before the new or amended requirement or
3restriction is implemented. The advanced written notice may be provided in an
4electronic format if the provider has agreed in advance to receive the notices
5electronically. No health care plan may implement a new or amended prior
6authorization requirement or restriction unless the health care plan or a contracted
7utilization review organization has updated the post on its website required under
8sub. (3) to reflect the new or amended prior authorization requirement or
9restriction.
AB50,292010Section 2920. 628.495 of the statutes is created to read:
AB50,1437,1311628.495 Pharmacy benefit management broker and consultant
12licenses. (1) Definition. In this section, pharmacy benefit manager has the
13meaning given in s. 632.865 (1) (c).
AB50,1437,1814(2) License required. Beginning on the first day of the 12th month
15beginning after the effective date of this subsection .... [LRB inserts date], no
16individual may act as a pharmacy benefit management broker or consultant and no
17individual may act to procure the services of a pharmacy benefit manager on behalf
18of a client without being licensed by the commissioner under this section.
AB50,1437,2119(3) Rules. The commissioner may promulgate rules to establish criteria and
20procedures for initial licensure and renewal of licensure and to implement licensure
21under this section.
AB50,292122Section 2921. 632.35 of the statutes is amended to read:
AB50,1438,323632.35 Prohibited rejection, cancellation and nonrenewal. No insurer
24may cancel or refuse to issue or renew an automobile insurance policy wholly or

1partially because of one or more of the following characteristics of any person: age,
2sex, residence, race, color, creed, religion, national origin, ancestry, marital status
3or, occupation, or status as a holder or nonholder of a license under s. 343.03 (3r).
AB50,29224Section 2922. 632.728 of the statutes is created to read:
AB50,1438,65632.728 Coverage of persons with preexisting conditions; guaranteed
6issue; benefit limits. (1) Definitions. In this section:
AB50,1438,87(a) Cost sharing includes deductibles, coinsurance, copayments, or similar
8charges.
AB50,1438,99(b) Health benefit plan has the meaning given in s. 632.745 (11).
AB50,1438,1010(c) Self-insured health plan has the meaning given in s. 632.85 (1) (c).
AB50,1438,1711(2) Guaranteed issue. (a) Every individual health benefit plan shall accept
12every individual in this state who, and every group health benefit plan shall accept
13every employer in this state that, applies for coverage, regardless of the sexual
14orientation, the gender identity, or any preexisting condition of any individual or
15employee who will be covered by the plan. A health benefit plan may restrict
16enrollment in coverage described in this paragraph to open or special enrollment
17periods.
AB50,1438,2118(b) The commissioner shall establish a statewide open enrollment period that
19is no shorter than 30 days, during which every individual health benefit plan shall
20allow individuals, including individuals who do not have coverage, to enroll in
21coverage.
AB50,1439,322(3) Prohibiting discrimination based on health status. (a) An
23individual health benefit plan or a self-insured health plan may not establish rules

1for the eligibility of any individual to enroll, or for the continued eligibility of any
2individual to remain enrolled, under the plan based on any of the following health
3status-related factors in relation to the individual or a dependent of the individual:
AB50,1439,441. Health status.
AB50,1439,552. Medical condition, including both physical and mental illnesses.
AB50,1439,663. Claims experience.
AB50,1439,774. Receipt of health care.
AB50,1439,885. Medical history.
AB50,1439,996. Genetic information.
AB50,1439,11107. Evidence of insurability, including conditions arising out of acts of domestic
11violence.
AB50,1439,12128. Disability.
AB50,1439,2013(b) An insurer offering an individual health benefit plan or a self-insured
14health plan may not require any individual, as a condition of enrollment or
15continued enrollment under the plan, to pay, on the basis of any health status-
16related factor under par. (a) with respect to the individual or a dependent of the
17individual, a premium or contribution or a deductible, copayment, or coinsurance
18amount that is greater than the premium or contribution or deductible, copayment,
19or coinsurance amount, respectively, for an otherwise similarly situated individual
20enrolled under the plan.
AB50,1440,221(c) Nothing in this subsection prevents an insurer offering an individual
22health benefit plan or a self-insured health plan from establishing premium

1discounts or rebates or modifying otherwise applicable cost sharing in return for
2adherence to programs of health promotion and disease prevention.
AB50,1440,53(4) Premium rate variation. A health benefit plan offered on the individual
4or small employer market or a self-insured health plan may vary premium rates for
5a specific plan based only on the following considerations:
AB50,1440,66(a) Whether the policy or plan covers an individual or a family.
AB50,1440,77(b) Rating area in the state, as established by the commissioner.
AB50,1440,108(c) Age, except that the rate may not vary by more than 3 to 1 for adults over
9the age groups and the age bands shall be consistent with recommendations of the
10National Association of Insurance Commissioners.
AB50,1440,1111(d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.
AB50,1440,1612(5) Statewide risk pool. An insurer offering a health benefit plan may not
13segregate enrollees into risk pools other than a single statewide risk pool for the
14individual market and a single statewide risk pool for the small employer market or
15a single statewide risk pool that combines the individual and small employer
16markets.
AB50,1440,1817(6) Annual and lifetime limits. An individual or group health benefit plan
18or a self-insured health plan may not establish any of the following:
AB50,1440,2019(a) Lifetime limits on the dollar value of benefits for an enrollee or a
20dependent of an enrollee under the plan.
AB50,1440,2221(b) Annual limits on the dollar value of benefits for an enrollee or a dependent
22of an enrollee under the plan.
AB50,1441,323(7) Cost sharing maximum. A health benefit plan offered on the individual

1or small employer market may not require an enrollee under the plan to pay more in
2cost sharing than the maximum amount calculated under 42 USC 18022 (c),
3including the annual indexing of the limits.
AB50,1441,64(8) Medical loss ratio. (a) In this subsection, medical loss ratio means
5the proportion, expressed as a percentage, of premium revenues spent by a health
6benefit plan on clinical services and quality improvement.
AB50,1441,87(b) A health benefit plan on the individual or small employer market shall
8have a medical loss ratio of at least 80 percent.
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