Amendment AA3-SB70

SB70-AA3,115,14 (6) Rulemaking. The commissioner may promulgate any rules necessary to implement this section.

SB70-AA3,131 Section 131. 601.59 of the statutes is created to read:

SB70-AA3,115,16 601.59 State-based exchange. (1) Definitions. In this section:

SB70-AA3,115,17 (a) “Exchange” has the meaning given in 45 CFR 155.20.

SB70-AA3,115,20 (b) “State-based exchange on the federal platform” means an exchange that is described in and meets the requirements of 45 CFR 155.200 (f) and is approved by the federal secretary of health and human services under 45 CFR 155.106.

SB70-AA3,115,24 (c) “State-based exchange without the federal platform” means an exchange, other than one described in 45 CFR 155.200 (f), that performs all the functions described in 45 CFR 155.200 (a) and is approved by the federal secretary of health and human services under 45 CFR 155.106.

SB70-AA3,116,7 (2) Establishment and operation of state-based exchange. The commissioner shall establish and operate an exchange that at first is a state-based exchange on the federal platform and then subsequently transitions to a state-based exchange without the federal platform. The commissioner shall develop procedures to address the transition from the state-based exchange on the federal platform to the state-based exchange without the federal platform, including the circumstances that shall be met in order for the transition to occur.

SB70-AA3,116,10 (3) Agreement with federal government. The commissioner may enter into any agreement with the federal government necessary to facilitate the implementation of this section.

SB70-AA3,116,16 (4) User fees. The commissioner shall impose a user fee, as authorized under 45 CFR 155.160 (b) (1), on each insurer that offers a health plan through the state-based exchange on the federal platform or the state-based exchange without the federal platform. The user fee shall be applied at one of the following rates on the total monthly premiums charged by an insurer for each policy under the plan for which enrollment is through the exchange:

SB70-AA3,116,18 (a) For any plan year for which the commissioner operates a state-based exchange on the federal platform, the rate is 0.5 percent.

SB70-AA3,116,22 (b) For the first 2 plan years for which the commissioner operates a state-based exchange without the federal platform, the rate is equal to the user fee rate the federal department of health and human services specifies under 45 CFR 156.50 (c) (1) for the federally facilitated exchanges for the applicable plan year.

SB70-AA3,116,25 (c) Beginning with the 3rd plan year for which the commissioner operates a state-based exchange without the federal platform and for each plan year thereafter, the rate shall be set by the commissioner by rule.

SB70-AA3,117,2 (5) Rules. The commissioner may promulgate rules necessary to implement this section.

SB70-AA3,132 Section 132. 601.83 (1) (h) of the statutes is renumbered 601.83 (1) (h) (intro.) and amended to read:

SB70-AA3,117,10 601.83 (1) (h) (intro.) In 2019 and in each subsequent year Unless the joint committee on finance under s. 13.10 increases the amount upon request by the commissioner, the commissioner may expend no more than $200,000,000 the following amounts from all revenue sources for the healthcare stability plan under this section, unless the joint committee on finance under s. 13.10 has increased this amount upon request by the commissioner.:

SB70-AA3,117,14 (he) The commissioner shall ensure that sufficient funds are available for the healthcare stability plan under this section to operate as described in the approval of the federal department of health and human services dated July 29, 2018, and in any waiver extension approvals.

SB70-AA3,133 Section 133. 601.83 (1) (h) 1. and 3. of the statutes are created to read:

SB70-AA3,117,16 601.83 (1) (h) 1. In 2019, 2020, and 2021, $200,000,000.

SB70-AA3,117,25 3. In 2025 and in each year thereafter, the maximum expenditure amount for the previous year, adjusted to reflect the percentage increase, if any, in the consumer price index for all urban consumers, U.S. city average, for the medical care group, as determined by the U.S. department of labor, for the 12-month period ending on December 31 of the year before the year in which the amount is determined. The commissioner shall determine the annual adjustment amount for a particular year in January of the previous year. The commissioner shall publish the new maximum expenditure amount under this subdivision each year in the Wisconsin Administrative Register.

SB70-AA3,134 Section 134. 601.83 (1) (hm) of the statutes is renumbered 601.83 (1) (h) 2. and amended to read:

SB70-AA3,118,5 601.83 (1) (h) 2. Notwithstanding par. (h), in In 2022 and in each year thereafter, the commissioner may expend from all revenue sources , 2023, and 2024, $230,000,000 or less for the healthcare stability plan under this section.

SB70-AA3,135 Section 135. 609.714 of the statutes is created to read:

SB70-AA3,118,9 609.714 Substance abuse counselor coverage. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.87 (8).

SB70-AA3,136 Section 136. 609.719 of the statutes is created to read:

SB70-AA3,118,13 609.719 Coverage for telehealth services. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.871.

SB70-AA3,137 Section 137. 609.83 of the statutes is amended to read:

SB70-AA3,118,18 609.83 Coverage of drugs and devices ; application of payments. Limited service health organizations, preferred provider plans, and defined network plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (6) (b), (16t), and (16v).

SB70-AA3,138 Section 138. 628.495 of the statutes is created to read:

SB70-AA3,118,22 628.495 Pharmacy benefit management broker and consultant licenses. (1) Definition. In this section, “pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).

SB70-AA3,119,2 (2) License required. Beginning on the first day of the 12th month beginning after the effective date of this subsection .... [LRB inserts date], no individual may act as a pharmacy benefit management broker or consultant or any other individual who procures the services of a pharmacy benefit manager on behalf of a client without being licensed by the commissioner under this section.

SB70-AA3,119,5 (3) Rules. The commissioner may promulgate rules to establish criteria and procedures for initial licensure and renewal of licensure and to implement licensure under this section.

SB70-AA3,139 Section 139. 632.7495 (4) (b) of the statutes is amended to read:

SB70-AA3,119,7 632.7495 (4) (b) The coverage has a term of not more than 12 3 months.

SB70-AA3,140 Section 140. 632.7495 (4) (c) of the statutes is amended to read:

SB70-AA3,119,13 632.7495 (4) (c) The coverage term aggregated with all consecutive periods of the insurer's coverage of the insured by individual health benefit plan coverage not required to be renewed under this subsection does not exceed 18 6 months. For purposes of this paragraph, coverage periods are consecutive if there are no more than 63 days between the coverage periods.

SB70-AA3,141 Section 141. 632.7496 of the statutes is created to read:

SB70-AA3,119,17 632.7496 Coverage requirements for short-term plans. (1) Definition. In this section, “short-term, limited duration plan” means an individual health benefit plan described in s. 632.7495 (4).

SB70-AA3,119,20 (2) Guaranteed issue. An insurer that offers a short-term, limited duration plan shall accept every individual in this state who applies for coverage regardless of whether the individual has a preexisting condition.

SB70-AA3,120,2 (3) Prohibiting discrimination based on health status. (a) An insurer that offers a short-term, limited duration 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 a short-term, limited duration plan based on any of the following health status-related factors with respect to the individual or a dependent of the individual:

SB70-AA3,120,3 1. Health status.

SB70-AA3,120,4 2. Medical condition, including both physical and mental illnesses.

SB70-AA3,120,5 3. Claims experience.

SB70-AA3,120,6 4. Receipt of health care.

SB70-AA3,120,7 5. Medical history.

SB70-AA3,120,8 6. Genetic information.

SB70-AA3,120,10 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

SB70-AA3,120,11 8. Disability.

SB70-AA3,120,19 (b) An insurer that offers a short-term, limited duration plan may not require any individual, as a condition of enrollment or continued enrollment under the short-term, limited duration plan, to pay, on the basis of any health status-related factor described 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 short-term, limited duration plan.

SB70-AA3,120,22 (4) Premium rate variation. An insurer that offers a short-term, limited duration plan may vary premium rates for a specific short-term, limited duration plan based only on the following considerations:

SB70-AA3,120,24 (a) Whether the short-term, limited duration plan covers an individual or a family.

SB70-AA3,120,25 (b) Rating area in the state, as established by the commissioner.

SB70-AA3,121,3 (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.

SB70-AA3,121,4 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

SB70-AA3,121,6 (5) Annual and lifetime limits. A short-term, limited duration plan may not establish any of the following:

SB70-AA3,121,8 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the short-term, limited duration plan.

SB70-AA3,121,11 (b) Limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the short-term, limited duration plan for a term of coverage or for the aggregate duration of the short-term, limited duration plan.

SB70-AA3,142 Section 142. 632.76 (2) (ac) 3. (intro.) of the statutes is amended to read:

SB70-AA3,121,15 632.76 (2) (ac) 3. (intro.) Except as the commissioner provides by rule under s. 632.7495 (5), all of the following apply to an individual disability insurance policy that is a short-term policy, limited duration plan subject to s. 632.7495 (4) and (5):

SB70-AA3,143 Section 143. 632.76 (2) (ac) 3. b. of the statutes is amended to read:

SB70-AA3,121,22 632.76 (2) (ac) 3. b. The policy shall reduce the length of time during which a may not impose any preexisting condition exclusion may be imposed by the aggregate of the insured's consecutive periods of coverage under the insurer's individual disability insurance policies that are short-term policies subject to s. 632.7495 (4) and (5). For purposes of this subd. 3. b., coverage periods are consecutive if there are no more than 63 days between the coverage periods.

SB70-AA3,144 Section 144. 632.862 of the statutes is created to read:

SB70-AA3,121,25 632.862 Application of prescription drug payments. (1) Definitions. In this section:

SB70-AA3,122,1 (a) “Brand name” has the meaning given in s. 450.12 (1) (a).

SB70-AA3,122,2 (b) “Brand name drug” means any of the following:

SB70-AA3,122,4 1. A prescription drug that contains a brand name and that has no generic equivalent.

SB70-AA3,122,9 2. A prescription drug that contains a brand name and has a generic equivalent but for which the enrollee has received prior authorization from the insurer offering the disability insurance policy or self-insured health plan or authorization from a physician to obtain the prescription drug under the disability insurance policy or self-insured health plan.

SB70-AA3,122,10 (c) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

SB70-AA3,122,11 (d) “Prescription drug” has the meaning given in s. 450.01 (20).

SB70-AA3,122,13 (e) “Self-insured health plan” means a self-insured health plan of the state or a county, city, village, town, or school district.

SB70-AA3,122,19 (2) Application of discounts. A disability insurance policy that offers a prescription drug benefit or a self-insured health plan shall apply to any calculation of an out-of-pocket maximum amount and to any deductible of the disability insurance policy or self-insured health plan for an enrollee the amount that any discount provided by the manufacturer of a brand name drug reduces the cost sharing amount charged to the enrollee for that brand name drug.

SB70-AA3,145 Section 145. 632.863 of the statutes is created to read:

SB70-AA3,122,21 632.863 Pharmaceutical representatives. (1) Definitions. In this section:

SB70-AA3,122,24 (a) “Health care professional” means a physician or other health care practitioner who is licensed to provide health care services or to prescribe pharmaceutical or biologic products.

SB70-AA3,123,2 (b) “Pharmaceutical” means a medication that may legally be dispensed only with a valid prescription from a health care professional.

SB70-AA3,123,5 (c) “Pharmaceutical representative” means an individual who markets or promotes pharmaceuticals to health care professionals on behalf of a pharmaceutical manufacturer for compensation.

SB70-AA3,123,12 (2) Licensure. Beginning on the first day of the 12th month beginning after the effective date of this subsection .... [LRB inserts date], no individual may act as a pharmaceutical representative in this state without being licensed by the commissioner as a pharmaceutical representative under this section. In order to obtain a license, the individual shall apply to the commissioner in the form and manner prescribed by the commissioner. The term of a license issued under this subsection is one year and is renewable.

SB70-AA3,123,15 (3) Display of license. A pharmaceutical representative licensed under sub. (2) shall display the pharmaceutical representative's license during each visit with a health care professional.

SB70-AA3,123,18 (4) Enforcement. (a) Any individual who violates this section shall be fined not less than $1,000 nor more than $3,000 for each offense. Each day of continued violation constitutes a separate offense.

SB70-AA3,123,22 (b) The commissioner may suspend or revoke the license of a pharmaceutical representative who violates this section. A suspended or revoked license may not be reinstated until the pharmaceutical representative remedies all violations related to the suspension or revocation and pays all assessed penalties and fees.

SB70-AA3,123,25 (5) Rules. The commissioner shall promulgate rules to implement this section, including rules that require pharmaceutical representatives to complete continuing educational coursework as a condition of licensure.

SB70-AA3,146 Section 146. 632.864 of the statutes is created to read:

SB70-AA3,124,3 632.864 Pharmacy services administrative organizations. (1) Definitions. In this section:

SB70-AA3,124,4 (a) “Administrative service” means any of the following:

SB70-AA3,124,5 1. Assisting with claims.

SB70-AA3,124,6 2. Assisting with audits.

SB70-AA3,124,7 3. Providing centralized payment.

SB70-AA3,124,8 4. Performing certification in a specialized care program.

SB70-AA3,124,9 5. Providing compliance support.

SB70-AA3,124,10 6. Setting flat fees for generic drugs.