Amendment SA2-AB56

AB56-SA2,66,19 (a) “Health benefit plan” has the meaning given in s. 632.745 (11).

AB56-SA2,66,20 (b) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB56-SA2,67,2 (2) Guaranteed issue. (a) Every individual health benefit plan shall accept every individual in this state who, and every group health benefit plan shall accept every employer in this state that, applies for coverage, regardless of sexual orientation, gender identity, or whether or not any employee or individual has a preexisting condition. A health benefit plan may restrict enrollment in coverage described in this paragraph to open or special enrollment periods.

AB56-SA2,67,5 (b) The commissioner shall establish a statewide open enrollment period of no shorter than 30 days for every individual health benefit plan to allow individuals, including individuals who do not have coverage, to enroll in coverage.

AB56-SA2,67,10 (3) Prohibiting discrimination based on health status. (a) An individual health benefit plan or a self-insured health plan may not establish rules for the eligibility of any individual to enroll, or for the continued eligibility of any individual to remain enrolled, under the plan based on any of the following health status-related factors in relation to the individual or a dependent of the individual:

AB56-SA2,67,11 1. Health status.

AB56-SA2,67,12 2. Medical condition, including both physical and mental illnesses.

AB56-SA2,67,13 3. Claims experience.

AB56-SA2,67,14 4. Receipt of health care.

AB56-SA2,67,15 5. Medical history.

AB56-SA2,67,16 6. Genetic information.

AB56-SA2,67,18 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

AB56-SA2,67,19 8. Disability.

AB56-SA2,68,2 (b) An insurer offering an individual health benefit plan or a self-insured health plan may not require any individual, as a condition of enrollment or continued enrollment under the plan, to pay, on the basis of any health status-related factor 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 plan.

AB56-SA2,68,6 (c) Nothing in this subsection prevents an insurer offering an individual health benefit plan or a self-insured health plan from establishing premium discounts or rebates or modifying otherwise applicable cost sharing in return for adherence to programs of health promotion and disease prevention.

AB56-SA2,68,9 (4) Premium rate variation. A health benefit plan offered on the individual or small employer market or a self-insured health plan may vary premium rates for a specific plan based only on the following considerations:

AB56-SA2,68,10 (a) Whether the policy or plan covers an individual or a family.

AB56-SA2,68,11 (b) Rating area in the state, as established by the commissioner.

AB56-SA2,68,14 (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.

AB56-SA2,68,15 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

AB56-SA2,68,17 (5) Annual and lifetime limits. An individual or group health benefit plan or a self-insured health plan may not establish any of the following:

AB56-SA2,68,19 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB56-SA2,68,21 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB56-SA2,69,4 (6) Short-term plans. This section and s. 632.76 apply to every short-term, limited-duration health insurance policy. In this subsection, “short-term, limited-duration health insurance policy” means health coverage that is provided under a contract with an insurer, has an expiration date specified in the contract that is less than 12 months after the original effective date of the contract, and, taking into account renewals or extensions, has a duration of no longer than 36 months in total. “Short-term, limited-duration health insurance policy” includes any short-term policy subject to s. 632.7495 (4).

AB56-SA2,2080i Section 2080i. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and amended to read:

AB56-SA2,69,13 632.746 (1) Subject to subs. (2) and (3), an An insurer that offers a group health benefit plan may, with respect to a participant or beneficiary under the plan, not impose a preexisting condition exclusion only if the exclusion relates to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period ending on the participant's or beneficiary's enrollment date under the plan on a participant or beneficiary under the plan.

AB56-SA2,2081i Section 2081i. 632.746 (1) (b) of the statutes is repealed.

AB56-SA2,2082i Section 2082i. 632.746 (2) (a) of the statutes is amended to read:

AB56-SA2,69,19 632.746 (2) (a) An insurer offering a group health benefit plan may not treat impose a preexisting condition exclusion based on genetic information as a preexisting condition under sub. (1) without a diagnosis of a condition related to the information.

AB56-SA2,2083i Section 2083i. 632.746 (2) (c), (d) and (e) of the statutes are repealed.

AB56-SA2,2084i Section 2084i. 632.746 (3) (a) of the statutes is repealed.

AB56-SA2,2085i Section 2085i. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).

AB56-SA2,2086i Section 2086i. 632.746 (3) (d) 2. and 3. of the statutes are repealed.

AB56-SA2,2087i Section 2087i. 632.746 (5) of the statutes is repealed.

AB56-SA2,2088i Section 2088i. 632.746 (8) (a) (intro.) of the statutes is amended to read:

AB56-SA2,70,4 632.746 (8) (a) (intro.) A health maintenance organization that offers a group health benefit plan and that does not impose any preexisting condition exclusion under sub. (1) with respect to a particular coverage option may impose an affiliation period for that coverage option, but only if all of the following apply:

AB56-SA2,2089i Section 2089i. 632.748 (2) of the statutes is amended to read:

AB56-SA2,70,12 632.748 (2) An insurer offering a group health benefit plan may not require any individual, as a condition of enrollment or continued enrollment under the plan, to pay, on the basis of any health status-related factor 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 plan.

AB56-SA2,2090i Section 2090i. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to read:

AB56-SA2,70,22 632.76 (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).

AB56-SA2,71,3 (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.

AB56-SA2,71,10 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.

AB56-SA2,2091i Section 2091i. 632.76 (2) (ac) 3. of the statutes is repealed.

AB56-SA2,2092i Section 2092i. 632.795 (4) (a) of the statutes is amended to read:

AB56-SA2,71,24 632.795 (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.

AB56-SA2,2093k Section 2093k. 632.796 of the statutes is created to read:

AB56-SA2,72,2 632.796 Drug cost report. (1) Definition. In this section, “disability insurance policy” has the meaning given in s. 632.895 (1) (a).

AB56-SA2,72,8 (2) Report required. Annually, at the time the insurer files its rate request with the commissioner, each insurer that offers a disability insurance policy that covers prescription drugs shall submit to the commissioner a report that identifies the 25 prescription drugs that are the highest cost to the insurer and the 25 prescription drugs that have the highest cost increases over the 12 months before the submission of the report.

AB56-SA2,2094k Section 2094k. 632.865 (3) of the statutes is created to read:

AB56-SA2,72,12 632.865 (3) Registration required. (a) No person may perform any activities of a pharmacy benefit manager in this state without first registering with the commissioner under this subsection.

AB56-SA2,72,15 (b) The commissioner shall establish a registration procedure for pharmacy benefit managers. The commissioner may promulgate any rules necessary to implement the registration procedure under this paragraph.

AB56-SA2,2095k Section 2095k. 632.866 of the statutes is created to read:

AB56-SA2,72,17 632.866 Prescription drug cost reporting. (1) Definitions. In this section:

AB56-SA2,72,19 (a) “Brand-name drug” means a prescription drug approved under 21 USC 355 (b) or 42 USC 262.

AB56-SA2,72,21 (b) “Covered hospital” means an entity described in 42 USC 256b (a) (4) (L) to (N) that participates in the federal drug-pricing program under 42 USC 256b.

AB56-SA2,72,22 (c) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

AB56-SA2,72,23 (d) “Generic drug” means a prescription drug approved under 21 USC 355 (j).

AB56-SA2,73,3 (e) “Manufacturer” has the meaning given in s. 450.01 (12). “Manufacturer” does not include an entity that is engaged only in the dispensing, as defined in s. 450.01 (7), of a brand-name drug or a generic drug.

AB56-SA2,73,7 (f) “Manufacturer-sponsored assistance program” means a program offered by a manufacturer or an intermediary under contract with a manufacturer through which a brand-name drug or a generic drug is provided to a patient at no charge or at a discount.

AB56-SA2,73,11 (g) “Margin” means, for a covered hospital, the difference between the net cost of a brand-name drug or generic drug covered under the federal drug-pricing program under 42 USC 256b and the net payment by the covered hospital for that brand-name drug or generic drug.

AB56-SA2,73,13 (h) “Net payment” means the amount paid for a brand-name drug or generic drug after all discounts and rebates have been applied.

AB56-SA2,73,14 (i) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).

AB56-SA2,73,18 (j) “Wholesale acquisition cost” means the most recently reported manufacturer list or catalog price for a brand-name drug or a generic drug available to wholesalers or direct purchasers in the United States, before application of discounts, rebates, or reductions in price.

AB56-SA2,73,24 (2) Price increase or introduction notice; justification report. (a) A manufacturer shall notify the commissioner if it is increasing the wholesale acquisition cost of a brand-name drug on the market in this state by more than 10 percent or by more than $10,000 during any 12-month period or if it intends to introduce to market in this state a brand-name drug that has an annual wholesale acquisition cost of $30,000 or more.

AB56-SA2,74,4 (b) A manufacturer shall notify the commissioner if it is increasing the wholesale acquisition cost of a generic drug by more than 25 percent or by more than $300 during any 12-month period or if it intends to introduce to market a generic drug that has an annual wholesale acquisition cost of $3,000 or more.

AB56-SA2,74,10 (c) The manufacturer shall provide the notice under par. (a) or (b) in writing at least 30 days before the planned effective date of the cost increase or drug introduction with a justification that includes all documents and research related to the manufacturer's selection of the cost increase or introduction price and a description of life cycle management, market competition and context, and estimated value or cost-effectiveness of the product.

AB56-SA2,74,14 (3) Net prices paid by pharmacy benefit managers. By March 1 annually, the manufacturer shall report to the commissioner the value of price concessions, expressed as a percentage of the wholesale acquisition cost, provided to each pharmacy benefit manager for each drug sold in this state.

AB56-SA2,74,19 (4) Rebates and price concessions. By March 1 annually, each pharmacy benefit manager shall report to the commissioner the amount received from manufacturers as drug rebates and the value of price concessions, expressed as a percentage of the wholesale acquisition cost, provided by manufacturers for each drug.

AB56-SA2,74,24 (5) Hospital margin spending. By March 1 annually, each covered hospital operating in this state shall report to the commissioner the per unit margin for each drug covered under the federal drug pricing program under 42 USC 256b dispensed in the previous year multiplied by the number of units dispensed at that margin and how the margin revenue was used.

AB56-SA2,75,4 (6) Manufacturer-sponsored assistance programs. By March 1 annually, each manufacturer shall provide the commissioner with a description of each manufacturer-sponsored patient assistance program in effect during the previous year that includes all of the following:

AB56-SA2,75,5 (a) The terms of the programs.

AB56-SA2,75,6 (b) The number of prescriptions provided to state residents under the program.

AB56-SA2,75,8 (c) The total market value of assistance provided to residents of this state under the program.

AB56-SA2,75,13 (7) Certification and penalties for noncompliance. Each manufacturer and covered hospital that is required to report under this section shall certify each report as accurate under the penalty of perjury. A manufacturer or covered hospital that fails to submit a report required under this section is subject to a forfeiture of no more than $10,000 each day the report is overdue.

AB56-SA2,75,17 (8) Hearing and public reporting. (a) The commissioner shall publicly post manufacturer price justification documents and covered hospital documentation of how each hospital spends the margin revenue. The commissioner shall keep any trade secret or proprietary information confidential.

AB56-SA2,75,25 (b) The commissioner shall analyze data collected under this section and publish annually a report on emerging trends in prescription prices and price increases, and shall annually conduct a public hearing based on the analysis under this paragraph. The report under this paragraph shall include analysis of manufacturer prices and price increases, analysis of hospital-specific margins and how that revenue is spent or allocated on a hospital-specific basis, and analysis of how pharmacy benefit manager discounts and net costs compare to retail prices paid by patients.

AB56-SA2,76,8 (9) Allowing cost disclosure to insured. The commissioner shall ensure that every disability insurance policy that covers prescription drugs or biological products does not restrict a pharmacy or pharmacist that dispenses a prescription drug or biological product from informing and does not penalize a pharmacy or pharmacist for informing an insured under a policy of a difference between the negotiated price of, or copayment or coinsurance for, the drug or biological product under the policy and the price the insured would pay for the drug or biological product if the insured obtained the drug or biological product without using any health insurance coverage.

AB56-SA2,2097i Section 2097i. 632.895 (8) (d) of the statutes is amended to read:

AB56-SA2,76,16 632.895 (8) (d) Coverage is required under this subsection despite whether the woman shows any symptoms of breast cancer. Except as provided in pars. (b), (c), and (e), coverage under this subsection may only be subject to exclusions and limitations, including deductibles, copayments and restrictions on excessive charges, that are applied to other radiological examinations covered under the disability insurance policy. Coverage under this subsection may not be subject to any deductibles, copayments, or coinsurance.

AB56-SA2,2098i Section 2098i. 632.895 (13m) of the statutes is created to read:

AB56-SA2,76,19 632.895 (13m) Preventive services. (a) In this section, “self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB56-SA2,76,22 (b) Every disability insurance policy, except any disability insurance policy that is described in s. 632.745 (11) (b) 1. to 12., and every self-insured health plan shall provide coverage for all of the following preventive services:

AB56-SA2,76,23 1. Mammography in accordance with sub. (8).

AB56-SA2,76,25 2. Genetic breast cancer screening and counseling and preventive medication for adult women at high risk for breast cancer.

AB56-SA2,77,2 3. Papanicolaou test for cancer screening for women 21 years of age or older with an intact cervix.

AB56-SA2,77,4 4. Human papillomavirus testing for women who have attained the age of 30 years but have not attained the age of 66 years.

AB56-SA2,77,5 5. Colorectal cancer screening in accordance with sub. (16m).

AB56-SA2,77,8 6. Annual tomography for lung cancer screening for adults who have attained the age of 55 years but have not attained the age of 80 years and who have health histories demonstrating a risk for lung cancer.

AB56-SA2,77,10 7. Skin cancer screening for individuals who have attained the age of 10 years but have not attained the age of 22 years.