Amendment AA16-ASA2-AB50

AB50-ASA2-AA16,42,20 52. Low-dose aspirin after 12 weeks of gestation for pregnant women at high risk for miscarriage, preeclampsia, or clotting disorders.

AB50-ASA2-AA16,42,21 53. Screenings for hepatitis B and bacteriuria for pregnant women.

AB50-ASA2-AA16,43,2 54. Screening for gonorrhea for pregnant and sexually active females 24 years of age or younger and females older than 24 years of age who are at risk for infection.

AB50-ASA2-AA16,43,5 55. Screening for chlamydia for pregnant and sexually active females 24 years of age and younger and females older than 24 years of age who are at risk for infection.

AB50-ASA2-AA16,43,7 56. Screening for syphilis for pregnant women and adults who are at high risk for infection.

AB50-ASA2-AA16,43,10 57. Human immunodeficiency virus screening for adults who have attained the age of 15 years but have not attained the age of 66 years and individuals at high risk of infection who are younger than 15 years of age or older than 65 years of age.

AB50-ASA2-AA16,43,11 58. All contraceptives and services in accordance with sub. (17).

AB50-ASA2-AA16,43,13 59. Any services not already specified under this paragraph having an A or B rating in current recommendations from the U.S. preventive services task force.

AB50-ASA2-AA16,43,16 60. Any preventive services not already specified under this paragraph that are recommended by the federal health resources and services administration’s Bright Futures project.

AB50-ASA2-AA16,43,19 61. Any immunizations, not already specified under sub. (14), that are recommended and determined to be for routine use by the federal advisory committee on immunization practices.

AB50-ASA2-AA16,43,23 (c) Subject to par. (d), no disability insurance policy, except any disability insurance policy that is described in s. 632.745 (11) (b) 1. to 12., and no self-insured health plan may subject the coverage of any of the preventive services under par. (b) to any deductibles, copayments, or coinsurance under the policy or plan.

AB50-ASA2-AA16,44,4 (d) 1. If an office visit and a preventive service specified under par. (b) are billed separately by the health care provider, the disability insurance policy or self- insured health plan may apply deductibles to and impose copayments or coinsurance on the office visit but not on the preventive service.

AB50-ASA2-AA16,44,7 2. If the primary reason for an office visit is not to obtain a preventive service specified under par. (b), the disability insurance policy or self-insured health plan may apply deductibles to and impose copayments or coinsurance on the office visit.

AB50-ASA2-AA16,44,17 3. Except as otherwise provided in this subdivision, if a preventive service specified under par. (b) is provided by a health care provider that is outside the disability insurance policy’s or self-insured health plan’s network of providers, the policy or plan may apply deductibles to and impose copayments or coinsurance on the office visit and the preventive service. If a preventive service specified under par. (b) is provided by a health care provider that is outside the disability insurance policy’s or self-insured health plan’s network of providers because there is no available health care provider in the policy’s or plan’s network of providers that provides the preventive service, the policy or plan may not apply deductibles to or impose copayments or coinsurance on the preventive service.

AB50-ASA2-AA16,44,22 4. If more than one well-woman visit described under par. (b) 47. is necessary to provide all necessary preventive services as determined by a qualified health care provider and in accordance with applicable recommendations for preventive services, the disability insurance policy or self-insured health plan may not apply a deductible to or impose a copayment or coinsurance on any such well-woman visit.

AB50-ASA2-AA16,54 Section 54. 632.895 (14) (a) 1. i. and j. of the statutes are amended to read:

AB50-ASA2-AA16,45,1 632.895 (14) (a) 1. i. Hepatitis A and B.

AB50-ASA2-AA16,45,2 j. Varicella and herpes zoster.

AB50-ASA2-AA16,55 Section 55. 632.895 (14) (a) 1. k. to o. of the statutes are created to read:

AB50-ASA2-AA16,45,4 632.895 (14) (a) 1. k. Human papillomavirus.

AB50-ASA2-AA16,45,5 L. Meningococcal meningitis.

AB50-ASA2-AA16,45,6 m. Pneumococcal pneumonia.

AB50-ASA2-AA16,45,7 n. Influenza.

AB50-ASA2-AA16,45,8 o. Rotavirus.

AB50-ASA2-AA16,56 Section 56. 632.895 (14) (b) of the statutes is amended to read:

AB50-ASA2-AA16,45,15 632.895 (14) (b) Except as provided in par. (d), every disability insurance policy, and every self-insured health plan of the state or a county, city, town, village, or school district, that provides coverage for a dependent of the insured shall provide coverage of appropriate and necessary immunizations, from birth to the age of 6 years, for an insured or plan participant, including a dependent who is a child of the insured or plan participant.

AB50-ASA2-AA16,57 Section 57. 632.895 (14) (c) of the statutes is amended to read:

AB50-ASA2-AA16,45,21 632.895 (14) (c) The coverage required under par. (b) may not be subject to any deductibles, copayments, or coinsurance under the policy or plan. This paragraph applies to a defined network plan, as defined in s. 609.01 (1b), only with respect to appropriate and necessary immunizations provided by providers participating, as defined in s. 609.01 (3m), in the plan.

AB50-ASA2-AA16,58 Section 58. 632.895 (14) (d) 3. of the statutes is amended to read:

AB50-ASA2-AA16,46,2 632.895 (14) (d) 3. A health care plan offered by a limited service health organization, as defined in s. 609.01 (3), or by a preferred provider plan, as defined in s. 609.01 (4), that is not a defined network plan, as defined in s. 609.01 (1b).

AB50-ASA2-AA16,59 Section 59. 632.895 (14m) of the statutes is created to read:

AB50-ASA2-AA16,46,5 632.895 (14m) Essential health benefits. (a) In this subsection, “self- insured health plan” has the meaning given in s. 632.85 (1) (c).

AB50-ASA2-AA16,46,9 (b) On a date specified by the commissioner, by rule, every disability insurance policy, except as provided in par. (g), and every self-insured health plan shall provide coverage for essential health benefits as determined by the commissioner, by rule, subject to par. (c).

AB50-ASA2-AA16,46,11 (c) In determining the essential health benefits for which coverage is required under par. (b), the commissioner shall do all of the following:

AB50-ASA2-AA16,46,13 1. Include benefits, items, and services in, at least, all of the following categories:

AB50-ASA2-AA16,46,14 a. Ambulatory patient services.

AB50-ASA2-AA16,46,15 b. Emergency services.

AB50-ASA2-AA16,46,16 c. Hospitalization.

AB50-ASA2-AA16,46,17 d. Maternity and newborn care.

AB50-ASA2-AA16,46,19 e. Mental health and substance use disorder services, including behavioral health treatment.

AB50-ASA2-AA16,46,20 f. Prescription drugs.

AB50-ASA2-AA16,46,21 g. Rehabilitative and habilitative services and devices.

AB50-ASA2-AA16,46,22 h. Laboratory services.

AB50-ASA2-AA16,46,23 i. Preventive and wellness services and chronic disease management.

AB50-ASA2-AA16,47,1 j. Pediatric services, including oral and vision care.

AB50-ASA2-AA16,47,6 2. Conduct a survey of employer-sponsored coverage to determine benefits typically covered by employers and ensure that the scope of essential health benefits for which coverage is required under this subsection is equal to the scope of benefits covered under a typical disability insurance policy offered by an employer to its employees.

AB50-ASA2-AA16,47,9 3. Ensure that essential health benefits reflect a balance among the categories described in subd. 1. such that benefits are not unduly weighted toward one category.

AB50-ASA2-AA16,47,11 4. Ensure that essential health benefit coverage is provided with no or limited cost-sharing requirements.

AB50-ASA2-AA16,47,15 5. Require that disability insurance policies and self-insured health plans do not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life.

AB50-ASA2-AA16,47,18 6. Establish essential health benefits in a way that takes into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups.

AB50-ASA2-AA16,47,22 7. Ensure that essential health benefits established under this subsection are not subject to a coverage denial based on an insured’s or plan participant’s age, expected length of life, present or predicted disability, degree of dependency on medical care, or quality of life.

AB50-ASA2-AA16,48,6 8. Require that disability insurance policies and self-insured health plans cover emergency department services that are essential health benefits without imposing any requirement to obtain prior authorization for those services and without limiting coverage for services provided by an emergency services provider that is not in the provider network of a policy or plan in a way that is more restrictive than requirements or limitations that apply to emergency services provided by a provider that is in the provider network of the policy or plan.

AB50-ASA2-AA16,48,11 9. Require a disability insurance policy or self-insured health plan to apply to emergency department services that are essential health benefits provided by an emergency department provider that is not in the provider network of the policy or plan the same copayment amount or coinsurance rate that applies if those services are provided by a provider that is in the provider network of the policy or plan.

AB50-ASA2-AA16,48,13 (d) The commissioner shall periodically update, by rule, the essential health benefits under this subsection to address any gaps in access to coverage.

AB50-ASA2-AA16,48,18 (e) If an essential health benefit is also subject to mandated coverage elsewhere under this section and the coverage requirements are not identical, the disability insurance policy or self-insured health plan shall provide coverage under whichever subsection provides the insured or plan participant with more comprehensive coverage of the medical condition, item, or service.

AB50-ASA2-AA16,48,22 (f) Nothing in this subsection or rules promulgated under this subsection prohibits a disability insurance policy or a self-insured health plan from providing benefits in excess of the essential health benefit coverage required under this subsection.

AB50-ASA2-AA16,49,2 (g) This subsection does not apply to any disability insurance policy that is described in s. 632.745 (11) (b) 1. to 12.

AB50-ASA2-AA16,60 Section 60. 632.895 (16m) (b) of the statutes is amended to read:

AB50-ASA2-AA16,49,8 632.895 (16m) (b) The coverage required under this subsection may be subject to any limitations, or exclusions, or cost-sharing provisions that apply generally under the disability insurance policy or self-insured health plan. The coverage required under this subsection may not be subject to any deductibles, copayments, or coinsurance.

AB50-ASA2-AA16,61 Section 61. 632.895 (17) (b) 2. of the statutes is amended to read:

AB50-ASA2-AA16,49,14 632.895 (17) (b) 2. Outpatient consultations, examinations, procedures, and medical services that are necessary to prescribe, administer, maintain, or remove a contraceptive, if covered for any other drug benefits under the policy or plan sterilization procedures, and patient education and counseling for all females with reproductive capacity.

AB50-ASA2-AA16,62 Section 62. 632.895 (17) (c) of the statutes is amended to read:

AB50-ASA2-AA16,50,7 632.895 (17) (c) Coverage under par. (b) may be subject only to the exclusions, and limitations, or cost-sharing provisions that apply generally to the coverage of outpatient health care services, preventive treatments and services, or prescription drugs and devices that is provided under the policy or self-insured health plan. A disability insurance policy or self-insured health plan may not apply a deductible or impose a copayment or coinsurance to at least one of each type of contraceptive method approved by the federal food and drug administration for which coverage is required under this subsection. The disability insurance policy or self-insured health plan may apply reasonable medical management to a method of contraception to limit coverage under this subsection that is provided without being subject to a deductible, copayment, or coinsurance to prescription drugs without a brand name. The disability insurance policy or self-insured health plan may apply a deductible or impose a copayment or coinsurance for coverage of a contraceptive that is prescribed for a medical need if the services for the medical need would otherwise be subject to a deductible, copayment, or coinsurance.

AB50-ASA2-AA16,63 Section 63. 632.897 (11) (a) of the statutes is amended to read:

AB50-ASA2-AA16,50,17 632.897 (11) (a) Notwithstanding subs. (2) to (10), the commissioner may promulgate rules establishing standards requiring insurers to provide continuation of coverage for any individual covered at any time under a group policy who is a terminated insured or an eligible individual under any federal program that provides for a federal premium subsidy for individuals covered under continuation of coverage under a group policy, including rules governing election or extension of election periods, notice, rates, premiums, premium payment, application of preexisting condition exclusions, election of alternative coverage, and status as an eligible individual, as defined in s. 149.10 (2t), 2011 stats.

AB50-ASA2-AA16,9323 Section 9323. Initial applicability; Insurance.

AB50-ASA2-AA16,50,20 (1) Coverage of individuals with preexisting conditions, essential health benefits, and preventive services.

AB50-ASA2-AA16,51,4 (a) For policies and plans containing provisions inconsistent with these sections, the treatment of ss. 632.728, 632.746 (1) (a) and (b), (2) (a), (c), (d), and (e), (3) (a) and (d) 1., 2., and 3., (5), and (8) (a) (intro.), 632.748 (2), 632.76 (2) (a) and (ac) 1. and 2., 632.795 (4) (a), 632.895 (8) (d), (13m), (14) (a) 1. i., j., and k. to o., (b), (c), and (d) 3., (14m), (16m) (b), and (17) (b) 2. and (c), and 632.897 (11) (a) first applies to policy or plan years beginning on January 1 of the year following the year in which this paragraph takes effect, except as provided in par. (b).

AB50-ASA2-AA16,51,13 (b) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with these sections, the treatment of ss. 632.728, 632.746 (1) (a) and (b), (2) (a), (c), (d), and (e), (3) (a) and (d) 1., 2., and 3., (5), and (8) (a) (intro.), 632.748 (2), 632.76 (2) (a) and (ac) 1. and 2., 632.795 (4) (a), 632.895 (8) (d), (13m), (14) (a) 1. i., j., and k. to o., (b), (c), and (d) 3., (14m), (16m) (b), and (17) (b) 2. and (c), and 632.897 (11) (a) first applies to policy or plan years beginning on the effective date of this paragraph or on the day on which the collective bargaining agreement is entered into, extended, modified, or renewed, whichever is later.

AB50-ASA2-AA16,9423 Section 9423. Effective dates; Insurance.

AB50-ASA2-AA16,51,21 (1) Coverage of individuals with preexisting conditions, essential health benefits, and preventive services. The treatment of ss. 632.728, 632.746 (1) (a) and (b), (2) (a), (c), (d), and (e), (3) (a) and (d) 1., 2., and 3., (5), and (8) (a) (intro.), 632.748 (2), 632.76 (2) (a) and (ac) 1. and 2., 632.795 (4) (a), 632.895 (8) (d), (13m), (14) (a) 1. i., j., and k. to o., (b), (c), and (d) 3., (14m), (16m) (b), and (17) (b) 2. and (c), and 632.897 (11) (a) and Section 9323 (1) of this act take effect on the first day of the 4th month beginning after publication.”.

AB50-ASA2-AA16,51,22 20. At the appropriate places, insert all of the following:

AB50-ASA2-AA16,51,23 “Section 64. 20.145 (1) (g) 5. of the statutes is created to read:

AB50-ASA2-AA16,52,4 20.145 (1) (g) 5. All moneys received from the regulation of pharmacy benefit managers, pharmacy benefit management brokers, pharmacy benefit management consultants, pharmacy services administration organizations, and pharmaceutical representatives.”.

AB50-ASA2-AA16,52,5 21. At the appropriate places, insert all of the following:

AB50-ASA2-AA16,52,6 “Section 65. 15.07 (3) (bm) 7. of the statutes is created to read:

AB50-ASA2-AA16,52,8 15.07 (3) (bm) 7. The prescription drug affordability review board shall meet at least 4 times each year.

AB50-ASA2-AA16,66 Section 66. 15.735 of the statutes is created to read:

AB50-ASA2-AA16,52,12 15.735 Same; attached board. (1) There is created a prescription drug affordability review board attached to the office of the commissioner of insurance under s. 15.03. The board shall consist of the following members:

AB50-ASA2-AA16,52,13 (a) The commissioner of insurance or his or her designee.

AB50-ASA2-AA16,52,17 (b) Two members appointed for 4-year terms who represent the pharmaceutical drug industry, including pharmaceutical drug manufacturers and wholesalers. At least one of the members appointed under this paragraph shall be a licensed pharmacist.

AB50-ASA2-AA16,52,19 (c) Two members appointed for 4-year terms who represent the health insurance industry, including insurers and pharmacy benefit managers.

AB50-ASA2-AA16,52,23 (d) Two members appointed for 4-year terms who represent the health care industry, including hospitals, physicians, pharmacies, and pharmacists. At least one of the members appointed under this paragraph shall be a licensed practitioner.

AB50-ASA2-AA16,53,2 (e) Two members appointed for 4-year terms who represent the interests of the public.

AB50-ASA2-AA16,53,5 (2) A member appointed under sub. (1), except for a member appointed under sub. (1) (b), may not be an employee of, a board member of, or a consultant to a drug manufacturer or trade association for drug manufacturers.

AB50-ASA2-AA16,53,10 (3) Any conflict of interest, including any financial or personal association, that has the potential to bias or has the appearance of biasing an individual’s decision in matters related to the board or the conduct of the board’s activities shall be considered and disclosed when appointing that individual to the board under sub. (1).

AB50-ASA2-AA16,67 Section 67. Subchapter VI (title) of chapter 601 [precedes 601.78] of the statutes is created to read:

AB50-ASA2-AA16,53,13 CHAPTER 601

AB50-ASA2-AA16,53,14 SUBCHAPTER VI