Amendment SA4-SSA2-SB70

SB70-SSA2-SA4,9423 Section 9423. Effective dates; Insurance.

SB70-SSA2-SA4,185,19 (1v) Prescription drug affordability review board. The treatment of ss. 15.07 (3) (bm) 7., 15.735, 601.78, 601.785, and 601.79 and subch. VI (title) of ch. 601 and Section 9123 (1u) of this act take effect on the first day of the 7th month beginning after publication.”.

SB70-SSA2-SA4,185,20 204. Page 374, line 11: after that line insert:

SB70-SSA2-SA4,185,21 “ Section 218. 632.895 (6) (title) of the statutes is amended to read:

SB70-SSA2-SA4,185,22 632.895 (6) (title) Equipment and supplies for treatment of diabetes; insulin.

SB70-SSA2-SA4,219 Section 219. 632.895 (6) of the statutes is renumbered 632.895 (6) (a) and amended to read:

SB70-SSA2-SA4,186,11 632.895 (6) (a) Every disability insurance policy which that provides coverage of expenses incurred for treatment of diabetes shall provide coverage for expenses incurred by the installation and use of an insulin infusion pump, coverage for all other equipment and supplies, including insulin or any other prescription medication, used in the treatment of diabetes, and coverage of diabetic self-management education programs. Coverage Except as provided in par. (b), coverage required under this subsection shall be subject to the same exclusions, limitations, deductibles, and coinsurance provisions of the policy as other covered expenses, except that insulin infusion pump coverage may be limited to the purchase of one pump per year and the insurer may require the insured to use a pump for 30 days before purchase.

SB70-SSA2-SA4,220 Section 220. 632.895 (6) (b) of the statutes is created to read:

SB70-SSA2-SA4,186,13 632.895 (6) (b) 1. In this paragraph:

SB70-SSA2-SA4,186,15 a. “Cost sharing” means the total of any deductible, copayment, or coinsurance amounts imposed on a person covered under a policy or plan.

SB70-SSA2-SA4,186,16 b. “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

SB70-SSA2-SA4,186,19 2. Every disability insurance policy and self-insured health plan that cover insulin and impose cost sharing on prescription drugs may not impose cost sharing on insulin in an amount that exceeds $35 for a one-month supply of insulin.

SB70-SSA2-SA4,186,24 3. Nothing in this paragraph prohibits a disability insurance policy or self-insured health plan from imposing cost sharing on insulin in an amount less than the amount specified under subd. 2. Nothing in this paragraph requires a disability insurance policy or self-insured health plan to impose any cost sharing on insulin.

SB70-SSA2-SA4,9423 Section 9423. Effective dates; Insurance.

SB70-SSA2-SA4,187,4 (1) Cost-sharing cap on insulin. The treatment of ss. 609.83 and 632.895 (6) (title), the renumbering and amendment of s. 632.895 (6), and the creation of s. 632.895 (6) (b) take effect on the first day of the 4th month beginning after publication.”.

SB70-SSA2-SA4,187,5 205. Page 374, line 11: after that line insert:

SB70-SSA2-SA4,187,6 “ Section 221. 601.41 (13) of the statutes is created to read:

SB70-SSA2-SA4,187,12 601.41 (13) Value-based diabetes medication pilot project. The commissioner shall develop a pilot project to direct a pharmacy benefit manager, as defined in s. 632.865 (1) (c), and a pharmaceutical manufacturer to create a value-based, sole-source arrangement to reduce the costs of prescription medication used to treat diabetes. The commissioner may promulgate rules to implement this subsection.”.

SB70-SSA2-SA4,187,13 206. Page 374, line 11: after that line insert:

SB70-SSA2-SA4,187,14 “ Section 222. 632.869 of the statutes is created to read:

SB70-SSA2-SA4,187,16 632.869 Reimbursement to federal drug pricing program participants. (1) In this section:

SB70-SSA2-SA4,187,20 (a) “Covered entity” means an entity described in 42 USC 256b (a) (4) (A), (D), (E), (J), or (N) that participates in the federal drug pricing program under 42 USC 256b, a pharmacy of the entity, or a pharmacy contracted with the entity to dispense drugs purchased through the federal drug pricing program under 42 USC 256b.

SB70-SSA2-SA4,187,21 (b) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).

SB70-SSA2-SA4,187,23 (2) No person, including a pharmacy benefit manager and 3rd-party payer, may do any of the following:

SB70-SSA2-SA4,188,4 (a) Reimburse a covered entity for a drug that is subject to an agreement under 42 USC 256b at a rate lower than that paid for the same drug to pharmacies that are not covered entities and have a similar prescription volume to that of the covered entity.

SB70-SSA2-SA4,188,7 (b) Assess a covered entity any fee, charge back, or other adjustment on the basis of the covered entity's participation in the federal drug pricing program under 42 USC 256b.

SB70-SSA2-SA4,188,10 (3) The commissioner may promulgate rules to implement this section and to establish a minimum reimbursement rate for covered entities and any other entity described under 42 USC 256b (a) (4).”.

SB70-SSA2-SA4,188,11 207. Page 374, line 11: after that line insert:

SB70-SSA2-SA4,188,12 “ Section 223. 632.865 (2m) of the statutes is created to read:

SB70-SSA2-SA4,188,16 632.865 (2m) Fiduciary duty and disclosures to health benefit plan sponsors. (a) A pharmacy benefit manager owes a fiduciary duty to the health benefit plan sponsor to act according to the health benefit plan sponsor's instructions and in the best interests of the health benefit plan sponsor.

SB70-SSA2-SA4,188,19 (b) A pharmacy benefit manager shall annually provide, no later than the date and using the method prescribed by the commissioner by rule, the health benefit plan sponsor all of the following information from the previous calendar year:

SB70-SSA2-SA4,188,21 1. The indirect profit received by the pharmacy benefit manager from owning any interest in a pharmacy or service provider.

SB70-SSA2-SA4,188,23 2. Any payment made by the pharmacy benefit manager to a consultant or broker who works on behalf of the health benefit plan sponsor.

SB70-SSA2-SA4,189,4 3. From the amounts received from all drug manufacturers, the amounts retained by the pharmacy benefit manager, and not passed through to the health benefit plan sponsor, that are related to the health benefit plan sponsor's claims or bona fide service fees.

SB70-SSA2-SA4,189,9 4. The amounts, including pharmacy access and audit recovery fees, received from all pharmacies that are in the pharmacy benefit manager's network or have a contract to be in the network and, from these amounts, the amount retained by the pharmacy benefit manager and not passed through to the health benefit plan sponsor.”.

SB70-SSA2-SA4,189,10 208. Page 374, line 11: after that line insert:

SB70-SSA2-SA4,189,11 “ Section 224. 609.712 of the statutes is created to read:

SB70-SSA2-SA4,189,13 609.712 Essential health benefits; preventive services. Defined network plans and preferred provider plans are subject to s. 632.895 (13m) and (14m).

SB70-SSA2-SA4,225 Section 225. 609.847 of the statutes is created to read:

SB70-SSA2-SA4,189,17 609.847 Preexisting condition discrimination and certain benefit limits prohibited. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.728.

SB70-SSA2-SA4,226 Section 226. 625.12 (1) (a) of the statutes is amended to read:

SB70-SSA2-SA4,189,20 625.12 (1) (a) Past and prospective loss and expense experience within and outside of this state, except as provided in s. 632.728.

SB70-SSA2-SA4,227 Section 227. 625.12 (1) (e) of the statutes is amended to read:

SB70-SSA2-SA4,189,23 625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, including the judgment of technical personnel.

SB70-SSA2-SA4,228 Section 228. 625.12 (2) of the statutes is amended to read:

SB70-SSA2-SA4,190,9 625.12 (2) Classification. Except as provided in s. ss. 632.728 and 632.729, risks may be classified in any reasonable way for the establishment of rates and minimum premiums, except that no classifications may be based on race, color, creed or national origin, and classifications in automobile insurance may not be based on physical condition or developmental disability as defined in s. 51.01 (5). Subject to ss. 632.365, 632.728, and 632.729, rates thus produced may be modified for individual risks in accordance with rating plans or schedules that establish reasonable standards for measuring probable variations in hazards, expenses, or both. Rates may also be modified for individual risks under s. 625.13 (2).

SB70-SSA2-SA4,229 Section 229. 625.15 (1) of the statutes is amended to read:

SB70-SSA2-SA4,190,18 625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may itself establish rates and supplementary rate information for one or more market segments based on the factors in s. 625.12 and, if the rates are for motor vehicle liability insurance, subject to s. 632.365, or the insurer may use rates and supplementary rate information prepared by a rate service organization, with average expense factors determined by the rate service organization or with such modification for its own expense and loss experience as the credibility of that experience allows.

SB70-SSA2-SA4,230 Section 230. 628.34 (3) (a) of the statutes is amended to read:

SB70-SSA2-SA4,191,2 628.34 (3) (a) No insurer may unfairly discriminate among policyholders by charging different premiums or by offering different terms of coverage except on the basis of classifications related to the nature and the degree of the risk covered or the expenses involved, subject to ss. 632.365, 632.728, 632.729, 632.746 and, 632.748, and 632.7496. Rates are not unfairly discriminatory if they are averaged broadly among persons insured under a group, blanket or franchise policy, and terms are not unfairly discriminatory merely because they are more favorable than in a similar individual policy.

SB70-SSA2-SA4,231 Section 231. 632.728 of the statutes is created to read:

SB70-SSA2-SA4,191,5 632.728 Coverage of persons with preexisting conditions; guaranteed issue; benefit limits. (1) Definitions. In this section:

SB70-SSA2-SA4,191,7 (a) “Cost sharing” includes deductibles, coinsurance, copayments, or similar charges.

SB70-SSA2-SA4,191,8 (b) “Health benefit plan” has the meaning given in s. 632.745 (11).

SB70-SSA2-SA4,191,9 (c) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

SB70-SSA2-SA4,191,15 (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.

SB70-SSA2-SA4,191,18 (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.

SB70-SSA2-SA4,191,23 (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:

SB70-SSA2-SA4,191,24 1. Health status.

SB70-SSA2-SA4,191,25 2. Medical condition, including both physical and mental illnesses.

SB70-SSA2-SA4,192,1 3. Claims experience.

SB70-SSA2-SA4,192,2 4. Receipt of health care.

SB70-SSA2-SA4,192,3 5. Medical history.

SB70-SSA2-SA4,192,4 6. Genetic information.

SB70-SSA2-SA4,192,6 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

SB70-SSA2-SA4,192,7 8. Disability.

SB70-SSA2-SA4,192,14 (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.

SB70-SSA2-SA4,192,18 (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.

SB70-SSA2-SA4,192,21 (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:

SB70-SSA2-SA4,192,22 (a) Whether the policy or plan covers an individual or a family.

SB70-SSA2-SA4,192,23 (b) Rating area in the state, as established by the commissioner.

SB70-SSA2-SA4,193,3 (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-SSA2-SA4,193,4 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

SB70-SSA2-SA4,193,9 (5) Statewide risk pool. An insurer offering a health benefit plan may not segregate enrollees into risk pools other than a single statewide risk pool for the individual market and a single statewide risk pool for the small employer market or a single statewide risk pool that combines the individual and small employer markets.

SB70-SSA2-SA4,193,11 (6) Annual and lifetime limits. An individual or group health benefit plan or a self-insured health plan may not establish any of the following:

SB70-SSA2-SA4,193,13 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

SB70-SSA2-SA4,193,15 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

SB70-SSA2-SA4,193,19 (7) Cost sharing maximum. A health benefit plan offered on the individual or small employer market may not require an enrollee under the plan to pay more in cost sharing than the maximum amount calculated under 42 USC 18022 (c), including the annual indexing of the limits.

SB70-SSA2-SA4,193,22 (8) Medical loss ratio. (a) In this subsection, “medical loss ratio” means the proportion, expressed as a percentage, of premium revenues spent by a health benefit plan on clinical services and quality improvement.

SB70-SSA2-SA4,193,24 (b) A health benefit plan on the individual or small employer market shall have a medical loss ratio of at least 80 percent.

SB70-SSA2-SA4,194,2 (c) A group health benefit plan other than one described under par. (b) shall have a medical loss ratio of at least 85 percent.

SB70-SSA2-SA4,194,6 (9) Actuarial values of plan tiers. Any health benefit plan offered on the individual or small employer market shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to at least 60 percent of the full actuarial value of the benefits provided under the plan.

SB70-SSA2-SA4,232 Section 232. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and amended to read:

SB70-SSA2-SA4,194,15 632.746 (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.

SB70-SSA2-SA4,233 Section 233. 632.746 (1) (b) of the statutes is repealed.

SB70-SSA2-SA4,234 Section 234. 632.746 (2) (a) of the statutes is amended to read:

SB70-SSA2-SA4,194,21 632.746 (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.

SB70-SSA2-SA4,235 Section 235. 632.746 (2) (c), (d) and (e) of the statutes are repealed.

SB70-SSA2-SA4,236 Section 236. 632.746 (3) (a) of the statutes is repealed.