Amendment SA4-SSA2-SB45

SB45-SSA2-SA4,91,17 “Section 169. 15.07 (3) (bm) 7. of the statutes is created to read:

SB45-SSA2-SA4,91,19 15.07 (3) (bm) 7. The prescription drug affordability review board shall meet at least 4 times each year.

SB45-SSA2-SA4,170 Section 170. 15.732 of the statutes is created to read:

SB45-SSA2-SA4,91,23 15.732 Same; attached office. (1) Office of the public intervenor. There is created an office of the public intervenor which is attached to the office of the commissioner of insurance.

SB45-SSA2-SA4,171 Section 171. 15.735 of the statutes is created to read:

SB45-SSA2-SA4,92,3 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:

SB45-SSA2-SA4,92,4 (a) The commissioner of insurance or his or her designee.

SB45-SSA2-SA4,92,8 (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.

SB45-SSA2-SA4,92,10 (c) Two members appointed for 4-year terms who represent the health insurance industry, including insurers and pharmacy benefit managers.

SB45-SSA2-SA4,92,14 (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.

SB45-SSA2-SA4,92,16 (e) Two members appointed for 4-year terms who represent the interests of the public.

SB45-SSA2-SA4,92,19 (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.

SB45-SSA2-SA4,93,2 (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).

SB45-SSA2-SA4,172 Section 172. 20.145 (1) (a) of the statutes is created to read:

SB45-SSA2-SA4,93,5 20.145 (1) (a) State operations. The amounts in the schedule for general program operations.

SB45-SSA2-SA4,173 Section 173. 20.145 (1) (g) (intro.) of the statutes is amended to read:

SB45-SSA2-SA4,93,16 20.145 (1) (g) General program operations. (intro.) The amounts in the schedule for general program operations, including organizational support services and, oversight of care management organizations, development of a public option health insurance plan, and operation of a state-based exchange under s. 601.59, and for transferring to the appropriation account under s. 20.435 (4) (kv) the amount allocated by the commissioner of insurance. Notwithstanding s. 20.001 (3) (a), at the end of each fiscal year, the unencumbered balance in this appropriation account that exceeds 10 percent of that fiscal year’s expenditure under this appropriation shall lapse to the general fund. All of the following shall be credited to this appropriation account:

SB45-SSA2-SA4,174 Section 174. 20.145 (1) (g) 1. of the statutes is amended to read:

SB45-SSA2-SA4,93,20 20.145 (1) (g) 1. All moneys received under ss. 601.25 (2), 601.31, 601.32, 601.42 (7), 601.45, and 601.47 and by the commissioner for expenses related to insurance company restructurings, except for restructurings specified in par. (h).

SB45-SSA2-SA4,175 Section 175. 20.145 (1) (g) 4. of the statutes is created to read:

SB45-SSA2-SA4,93,22 20.145 (1) (g) 4. All moneys received under s. 601.59.

SB45-SSA2-SA4,176 Section 176. 20.145 (1) (g) 5. of the statutes is created to read:

SB45-SSA2-SA4,94,4 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.

SB45-SSA2-SA4,177 Section 177. 40.51 (8) of the statutes is amended to read:

SB45-SSA2-SA4,94,11 40.51 (8) Every health care coverage plan offered by the state under sub. (6) shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.722, 632.729, 632.746 (1) to (8) and (10), 632.747, 632.748, 632.7498, 632.798, 632.83, 632.835, 632.848, 632.85, 632.851, 632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (3) to (6) (8), 632.871, 632.885, 632.89, 632.891, 632.895 (5m) and (8) to (17), and 632.896.

SB45-SSA2-SA4,178 Section 178. 40.51 (8m) of the statutes is amended to read:

SB45-SSA2-SA4,94,17 40.51 (8m) Every health care coverage plan offered by the group insurance board under sub. (7) shall comply with ss. 631.95, 632.722, 632.729, 632.746 (1) to (8) and (10), 632.747, 632.748, 632.7498, 632.798, 632.83, 632.835, 632.848, 632.85, 632.851, 632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (4e), (7), and (8), 632.871, 632.885, 632.89, 632.891, and 632.895 (11) to (17).

SB45-SSA2-SA4,179 Section 179. 66.0137 (4) of the statutes is amended to read:

SB45-SSA2-SA4,95,2 66.0137 (4) Self-insured health plans. If a city, including a 1st class city, or a village provides health care benefits under its home rule power, or if a town provides health care benefits, to its officers and employees on a self-insured basis, the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.722, 632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.7498, 632.798, 632.848, 632.85, 632.851, 632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (4) to (6) (8), 632.871, 632.885, 632.89, 632.891, 632.895 (9) to (17), 632.896, and 767.513 (4).

SB45-SSA2-SA4,180 Section 180. 120.13 (2) (g) of the statutes is amended to read:

SB45-SSA2-SA4,95,8 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.722, 632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.7498, 632.798, 632.848, 632.85, 632.851, 632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (4) to (6) (8), 632.871, 632.885, 632.89, 632.891, 632.895 (9) to (17), 632.896, and 767.513 (4).

SB45-SSA2-SA4,181 Section 181. 185.983 (1) (intro.) of the statutes is amended to read:

SB45-SSA2-SA4,95,18 185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a cooperative association organized under s. 185.981 shall be exempt from chs. 600 to 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44, 601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93, 631.95, 632.72 (2), 632.722, 632.729, 632.745 to 632.749, 632.7498, 632.775, 632.79, 632.795, 632.798, 632.848, 632.85, 632.851, 632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (2) to (6) (8), 632.871, 632.885, 632.89, 632.891, 632.895 (5) and (8) to (17), 632.896, and 632.897 (10) and chs. 609, 620, 630, 635, 645, and 646, but the sponsoring association shall:

SB45-SSA2-SA4,182 Section 182. 601.25 of the statutes is created to read:

SB45-SSA2-SA4,95,23 601.25 Office of the public intervenor. (1) The office of the public intervenor shall assist individuals with insurance claims, policies, appeals, and other legal actions to pursue insurance coverage for medical procedures, prescription medications, and other health care services.

SB45-SSA2-SA4,96,4 (2) The office of the public intervenor may levy an assessment on each insurer that is authorized to engage in the business of insurance in this state. The assessment levied under this subsection shall be based on the insurer’s premium volume for disability insurance policies, as defined in s. 632.895 (1) (a), written in this state.

SB45-SSA2-SA4,96,6 (3) The commissioner may provide by rule for the governance, duties, and administration of the office of the public intervenor.

SB45-SSA2-SA4,183 Section 183. 601.31 (1) (mv) of the statutes is created to read:

SB45-SSA2-SA4,96,10 601.31 (1) (mv) For initial issuance or renewal of a license as a pharmacy benefit management broker or consultant under s. 628.495, amounts set by the commissioner by rule.

SB45-SSA2-SA4,184 Section 184. 601.31 (1) (nv) of the statutes is created to read:

SB45-SSA2-SA4,96,13 601.31 (1) (nv) For issuing or renewing a license as a pharmaceutical representative under s. 632.863, an amount to be set by the commissioner by rule.

SB45-SSA2-SA4,185 Section 185. 601.31 (1) (nw) of the statutes is created to read:

SB45-SSA2-SA4,96,17 601.31 (1) (nw) For issuing or renewing a license as a pharmacy services administrative organization under s. 632.864, an amount to be set by the commissioner by rule.

SB45-SSA2-SA4,186 Section 186. 601.41 (14) of the statutes is created to read:

SB45-SSA2-SA4,96,24 601.41 (14) 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.

SB45-SSA2-SA4,187 Section 187. 601.45 (1) of the statutes is amended to read:

SB45-SSA2-SA4,97,10 601.45 (1) Costs to be paid by examinees. The reasonable costs of examinations and audits under ss. 601.43, 601.44, 601.455, and 601.83 (5) (f) shall be paid by examinees except as provided in sub. (4), either on the basis of a system of billing for actual salaries and expenses of examiners and other apportionable expenses, including office overhead, or by a system of regular annual billings to cover the costs relating to a group of companies, or a combination of such systems, as the commissioner may by rule prescribe. Additional funding, if any, shall be governed by s. 601.32. The commissioner shall schedule annual hearings under s. 601.41 (5) to review current problems in the area of examinations.

SB45-SSA2-SA4,188 Section 188. 601.455 of the statutes is created to read:

SB45-SSA2-SA4,97,13 601.455 Fair claims processing, health insurance transparency, and claim denial rate audits. (1) Definitions. In this section:

SB45-SSA2-SA4,97,19 (a) “Claim denial” means the refusal by an insurer to provide payment under a disability insurance policy for a service, treatment, or medication recommended by a health care provider. “Claim denial” includes the prospective refusal to pay for a service, treatment, or medication when a disability insurance policy requires advance approval before a prescribed medical service, treatment, or medication is provided.

SB45-SSA2-SA4,97,20 (b) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

SB45-SSA2-SA4,97,21 (c) “Health care provider” has the meaning given in s. 146.81 (1) (a) to (p).

SB45-SSA2-SA4,97,24 (2) Claims processing. (a) Insurers shall process each claim for a disability insurance policy within a time frame that is reasonable and prevents an undue delay in an insured’s care, taking into account the medical urgency of the claim.

SB45-SSA2-SA4,98,4 (b) If an insurer determines additional information is needed to process a claim for a disability insurance policy, the insurer shall request the information from the insured within 5 business days of making the determination and shall provide at least 15 days for the insured to respond.

SB45-SSA2-SA4,98,5 (c) All claim denials shall include all of the following:

SB45-SSA2-SA4,98,7 1. A specific and detailed explanation of the reason for the denial that cites the exact medical or policy basis for the denial.

SB45-SSA2-SA4,98,10 2. A copy of or a publicly accessible link to any policy, coverage rules, clinical guidelines, or medical evidence relied upon in making the denial decision, with specific citation to the provision justifying the denial.

SB45-SSA2-SA4,98,13 3. Additional documentation, medical rationale, or criteria that must be met or provided for approval of the claim, including alternative options available under the policy.

SB45-SSA2-SA4,98,16 (d) If an insurer uses artificial intelligence or algorithmic decision-making in processing a claim for a disability insurance policy, the insurer must notify the insured in writing of that fact. The notice shall include all of the following:

SB45-SSA2-SA4,98,19 1. A disclosure that artificial intelligence or algorithmic decision-making was used at any stage in reviewing the claim, even if a human later reviewed the outcome.

SB45-SSA2-SA4,98,22 2. A detailed explanation of how the artificial intelligence or algorithmic decision-making reached its decision, including any factors the artificial intelligence or algorithmic decision-making weighed.

SB45-SSA2-SA4,98,24 3. A contact point for requesting a human review of the claim if the claim was denied.

SB45-SSA2-SA4,99,3 (3) Independent review of denials. In addition to an insured’s right to an independent review under s. 632.835, as applicable, insureds have the right to request a review by the office of the public intervenor of any claim denial.

SB45-SSA2-SA4,99,5 (4) Prohibited practices. An insurer may not do any of the following with respect to a disability insurance policy:

SB45-SSA2-SA4,99,6 (a) Use vague or misleading policy terms to justify a claim denial.

SB45-SSA2-SA4,99,7 (b) Fail to provide a specific and comprehensible reason for a claim denial.

SB45-SSA2-SA4,99,9 (c) Cancel coverage under the policy after a claim is submitted due to alleged misstatements on the policy application.

SB45-SSA2-SA4,99,11 (d) Deny a claim based on hidden or ambiguous exclusions in a disability insurance policy.

SB45-SSA2-SA4,99,12 (e) Stall review of a claim to avoid timely payment.

SB45-SSA2-SA4,99,14 (f) Reject a claim without reviewing all relevant medical records or consulting qualified experts.

SB45-SSA2-SA4,99,16 (g) Fail to properly review or respond to an insured’s appeal in a timely manner.

SB45-SSA2-SA4,99,18 (h) Allow non-physician personnel to determine whether care is medically necessary.

SB45-SSA2-SA4,99,20 (i) Apply different medical necessity criteria based on financial interests rather than patient needs.

SB45-SSA2-SA4,99,22 (j) Disregard a treating health care provider’s medical assessment without a valid clinical reason.

SB45-SSA2-SA4,99,24 (k) Mandate prior approval for routine or urgent procedures in a manner that causes harmful delays.

SB45-SSA2-SA4,100,3 (L) For a disability insurance policy that provides coverage of emergency medical services, refuse to cover emergency medical services provided by out-of- network providers.

SB45-SSA2-SA4,100,5 (m) List a health care provider as in-network on a provider directory and then deny a claim by stating the health care provider is out-of-network.

SB45-SSA2-SA4,100,7 (n) Deny coverage based on age, gender, disability, or a chronic condition rather than medical necessity.

SB45-SSA2-SA4,100,9 (o) Apply stricter standards in reviewing claims related to mental health conditions than claims related to physical health conditions.

SB45-SSA2-SA4,100,11 (p) Perform a blanket denial of claims for high-cost conditions without an individualized review of each claim.

SB45-SSA2-SA4,100,12 (r) Reclassify a claim to a lower-cost treatment to reduce insurer payout.

SB45-SSA2-SA4,100,14 (s) Require an insured to fail a cheaper treatment before approving coverage for necessary care.

SB45-SSA2-SA4,100,15 (t) Manipulate cost-sharing rules to shift higher costs to insureds.

SB45-SSA2-SA4,100,20 (5) Transparency and reporting. (a) Beginning on January 1, 2027, an insurer shall annually publish a report detailing the insurer’s claim denial rates, reasons for claim denials, and the outcome of any appeal of a claim denial for the previous year for all disability insurance policies under which the insurer provides coverage.

SB45-SSA2-SA4,100,22 (b) The commissioner shall maintain a public database of insurers’ claim denial rates and the outcomes of independent reviews under s. 632.835.

SB45-SSA2-SA4,101,2 (c) Beginning on January 1, 2027, an insurer that uses artificial intelligence or algorithmic decision-making in claims processing shall annually publish a report detailing all of the following for the previous year for all disability insurance policies under which the insurer provides coverage:

SB45-SSA2-SA4,101,4 1. The percentage of claims submitted to the insurer that were reviewed by artificial intelligence or algorithmic decision-making.

SB45-SSA2-SA4,101,7 2. The claim denial rate of claims reviewed by artificial intelligence or algorithmic decision-making compared to the claim denial rate of claims reviewed by humans.

SB45-SSA2-SA4,101,9 3. The steps the insurer takes to ensure fairness and accuracy in decisions made by artificial intelligence or algorithmic decision-making.