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. AB50,1441,109(c) A group health benefit plan other than one described under par. (b) shall 10have a medical loss ratio of at least 85 percent. AB50,1441,1411(9) Actuarial values of plan tiers. Any health benefit plan offered on the 12individual or small employer market shall provide a level of coverage that is 13designed to provide benefits that are actuarially equivalent to at least 60 percent of 14the full actuarial value of the benefits provided under the plan. AB50,292315Section 2923. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and 16amended to read: AB50,1441,2317632.746 (1) Subject to subs. (2) and (3), an An insurer that offers a group 18health benefit plan may, with respect to a participant or beneficiary under the plan, 19not impose a preexisting condition exclusion only if the exclusion relates to a 20condition, whether physical or mental, regardless of the cause of the condition, for 21which medical advice, diagnosis, care or treatment was recommended or received 22within the 6-month period ending on the participant’s or beneficiary’s enrollment 23date under the plan on a participant or beneficiary under the plan. AB50,2924
1Section 2924. 632.746 (1) (b) of the statutes is repealed. AB50,29252Section 2925. 632.746 (2) (a) of the statutes is amended to read: AB50,1442,63632.746 (2) (a) An insurer offering a group health benefit plan may not treat 4impose a preexisting condition exclusion based on genetic information as a 5preexisting condition under sub. (1) without a diagnosis of a condition related to the 6information. AB50,29267Section 2926. 632.746 (2) (c), (d) and (e) of the statutes are repealed. AB50,29278Section 2927. 632.746 (3) (a) of the statutes is repealed. AB50,29289Section 2928. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d). AB50,292910Section 2929. 632.746 (3) (d) 2. and 3. of the statutes are repealed. AB50,293011Section 2930. 632.746 (5) of the statutes is repealed. AB50,293112Section 2931. 632.746 (8) (a) (intro.) of the statutes is amended to read: AB50,1442,1613632.746 (8) (a) (intro.) A health maintenance organization that offers a group 14health benefit plan and that does not impose any preexisting condition exclusion 15under sub. (1) with respect to a particular coverage option may impose an affiliation 16period for that coverage option, but only if all of the following apply: AB50,293217Section 2932. 632.748 (2) of the statutes is amended to read: AB50,1443,218632.748 (2) An insurer offering a group health benefit plan may not require 19any individual, as a condition of enrollment or continued enrollment under the 20plan, to pay, on the basis of any health status-related factor with respect to the 21individual or a dependent of the individual, a premium or contribution or a 22deductible, copayment, or coinsurance amount that is greater than the premium or
1contribution or deductible, copayment, or coinsurance amount, respectively, for a 2an otherwise similarly situated individual enrolled under the plan. AB50,29333Section 2933. 632.7495 (4) (b) of the statutes is amended to read: AB50,1443,44632.7495 (4) (b) The coverage has a term of not more than 12 3 months.
/2025/related/proposals/ab50
true
proposaltext
/2025/related/proposals/ab50/2919/_20
proposaltext/2025/REG/AB50,1436,9
proposaltext/2025/REG/AB50,1436,9
section
true