Amendment AA16-ASA2-AB50

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

AB50-ASA2-AA16,53,15 PRESCRIPTION DRUG

AB50-ASA2-AA16,53,16 AFFORDABILITY REVIEW BOARD

AB50-ASA2-AA16,68 Section 68. 601.78 of the statutes is created to read:

AB50-ASA2-AA16,53,18 601.78 Definitions. In this subchapter:

AB50-ASA2-AA16,53,20 (1) “Biologic” means a drug that is produced or distributed in accordance with a biologics license application approved under 21 CFR 601.20.

AB50-ASA2-AA16,53,22 (2) “Biosimilar” means a drug that is produced or distributed in accordance with a biologics license application approved under 42 USC 262 (k) (3).

AB50-ASA2-AA16,54,2 (3) “Board” means the prescription drug affordability review board established under s. 15.735 (1).

AB50-ASA2-AA16,54,5 (4) “Brand name drug” means a drug that is produced or distributed in accordance with an original new drug application approved under 21 USC 355 (c), other than an authorized generic drug, as defined in 42 CFR 447.502.

AB50-ASA2-AA16,54,9 (5) “Financial benefit” includes an honorarium, fee, stock, the value of the stock holdings of a member of the board or any immediate family member of the member of the board, and any direct financial benefit deriving from the finding of a review conducted under s. 601.79.

AB50-ASA2-AA16,54,10 (6) “Generic drug” means any of the following:

AB50-ASA2-AA16,54,12 (a) A retail drug that is marketed or distributed in accordance with an abbreviated new drug application approved under 21 USC 355 (j).

AB50-ASA2-AA16,54,13 (b) An authorized generic drug, as defined in 42 CFR 447.502.

AB50-ASA2-AA16,54,15 (c) A drug that entered the market prior to 1962 and was not originally marketed under a new drug application.

AB50-ASA2-AA16,54,18 (7) “Immediate family member” means a spouse, grandparent, parent, sibling, child, stepchild, or grandchild or the spouse of a grandparent, parent, sibling, child, stepchild, or grandchild.

AB50-ASA2-AA16,54,19 (8) “Manufacturer” means an entity that does all of the following:

AB50-ASA2-AA16,54,22 (a) Engages in the manufacture of a prescription drug product or enters into a lease with another entity to market and distribute a prescription drug product under the entity’s own name.

AB50-ASA2-AA16,55,2 (b) Sets or changes the wholesale acquisition cost of the prescription drug product described in par. (a).

AB50-ASA2-AA16,55,3 (9) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).

AB50-ASA2-AA16,55,5 (10) “Prescription drug product” means a brand name drug, a generic drug, a biologic, or a biosimilar.

AB50-ASA2-AA16,69 Section 69. 601.785 of the statutes is created to read:

AB50-ASA2-AA16,55,11 601.785 Prescription drug affordability review board. (1) Mission. The purpose of the board is to protect state residents, the state, local governments, health plans, health care providers, pharmacies licensed in this state, and other stakeholders of the health care system in this state from the high costs of prescription drug products.

AB50-ASA2-AA16,55,12 (2) Powers and duties. (a) The board shall do all of the following:

AB50-ASA2-AA16,55,15 1. Meet in open session at least 4 times per year to review prescription drug product pricing information in the manner described in subd. 2., except that the chairperson may cancel or postpone a meeting if there is no business to transact.

AB50-ASA2-AA16,55,17 2. To the extent practicable, access and assess pricing information for prescription drug products by doing all of the following:

AB50-ASA2-AA16,55,20 a. Accessing and assessing information from other states by entering into memoranda of understanding with other states to which manufacturers report pricing information.

AB50-ASA2-AA16,55,21 b. Assessing spending for specific prescription drug products in this state.

AB50-ASA2-AA16,55,22 c. Accessing other available pricing information.

AB50-ASA2-AA16,55,23 (b) The board may do any of the following:

AB50-ASA2-AA16,56,1 1. Promulgate rules for the administration of this subchapter.

AB50-ASA2-AA16,56,6 2. Enter into a contract with an independent 3rd party for any service necessary to carry out the powers and duties of the board. Unless written permission is granted by the board, any person with whom the board contracts may not release, publish, or otherwise use any information to which the person has access under the contract.

AB50-ASA2-AA16,56,9 (c) The board shall establish and maintain a website to provide public notices and make meeting materials available under sub. (3) (a) and to disclose conflicts of interest under sub. (4) (d).

AB50-ASA2-AA16,56,13 (3) Meeting requirements. (a) Pursuant to s. 19.84, the board shall provide public notice of each board meeting at least 2 weeks prior to the meeting and shall make the materials for each meeting publicly available at least one week prior to the meeting.

AB50-ASA2-AA16,56,16 (b) Notwithstanding s. 19.84 (2), the board shall provide an opportunity for public comment at each open meeting and shall provide the public with the opportunity to provide written comments on pending decisions of the board.

AB50-ASA2-AA16,56,19 (c) Notwithstanding subch. V of ch. 19, any portion of a meeting of the board concerning proprietary data and information shall be conducted in closed session and shall in all respects remain confidential.

AB50-ASA2-AA16,56,21 (d) The board may allow expert testimony at any meeting, including when the board meets in closed session.

AB50-ASA2-AA16,57,2 (4) Conflicts of interest. (a) A member of the board shall recuse himself or herself from a decision by the board relating to a prescription drug product if the member or an immediate family member of the member has received or could receive any of the following:

AB50-ASA2-AA16,57,4 1. A direct financial benefit deriving from a determination, or a finding of a study or review, by the board relating to the prescription drug product.

AB50-ASA2-AA16,57,7 2. A financial benefit in excess of $5,000 in a calendar year from any person who owns, manufactures, or provides a prescription drug product to be studied or reviewed by the board.

AB50-ASA2-AA16,57,11 (b) A conflict of interest under this subsection shall be disclosed by the board when hiring board staff, by the appointing authority when appointing members to the board, and by the board when a member of the board is recused from any decision relating to a review of a prescription drug product.

AB50-ASA2-AA16,57,15 (c) A conflict of interest under this subsection shall be disclosed no later than 5 days after the conflict is identified, except that, if the conflict is identified within 5 days of an open meeting of the board, the conflict shall be disclosed prior to the meeting.

AB50-ASA2-AA16,57,20 (d) The board shall disclose a conflict of interest under this subsection on the board’s website unless the chairperson of the board recuses the member from a final decision relating to a review of the prescription drug product. The disclosure shall include the type, nature, and magnitude of the interests of the member involved.

AB50-ASA2-AA16,57,23 (e) A member of the board or a 3rd-party contractor may not accept any gift or donation of services or property that indicates a potential conflict of interest or has the appearance of biasing the work of the board.

AB50-ASA2-AA16,70 Section 70. 601.79 of the statutes is created to read:

AB50-ASA2-AA16,58,3 601.79 Drug cost affordability review. (1) Identification of drugs. The board shall identify prescription drug products that are any of the following: