SB45-SSA2-SA4,131,2120609.40 Special enrollment period for pregnancy. Preferred provider 21plans and defined network plans are subject to s. 632.7498. SB45-SSA2-SA4,132,223609.712 Essential health benefits; preventive services. Defined
1network plans and preferred provider plans are subject to s. 632.895 (13m) and 2(14m). SB45-SSA2-SA4,132,64609.713 Qualified treatment trainee coverage. Limited service health 5organizations, preferred provider plans, and defined network plans are subject to s. 6632.87 (7). SB45-SSA2-SA4,132,108609.714 Substance abuse counselor coverage. Limited service health 9organizations, preferred provider plans, and defined network plans are subject to s. 10632.87 (8). SB45-SSA2-SA4,132,1312609.718 Dental therapist coverage. Limited service health organizations, 13preferred provider plans, and defined network plans are subject to s. 632.87 (4e). SB45-SSA2-SA4,132,1715609.719 Coverage for telehealth services. Limited service health 16organizations, preferred provider plans, and defined network plans are subject to s. 17632.871. SB45-SSA2-SA4,132,2019609.74 Coverage of infertility services. Defined network plans and 20preferred provider plans are subject to s. 632.895 (15m). SB45-SSA2-SA4,132,2422609.815 Exemption from prior authorization requirements. Limited 23service health organizations, preferred provider plans, and defined network plans 24are subject to any rules promulgated by the commissioner under s. 632.848. SB45-SSA2-SA4,133,42609.823 Coverage without prior authorization for inpatient mental 3health services. Limited service health organizations, preferred provider plans, 4and defined network plans are subject to s. 632.891. SB45-SSA2-SA4,133,76609.825 Coverage of emergency ambulance services. (1) In this 7section: SB45-SSA2-SA4,133,88(a) “Ambulance service provider” has the meaning given in s. 256.01 (3). SB45-SSA2-SA4,133,129(b) “Self-insured governmental plan” means a self-insured health plan of the 10state or a county, city, village, town, or school district that has a network of 11participating providers and imposes on enrollees in the self-insured health plan 12different requirements for using providers that are not participating providers. SB45-SSA2-SA4,133,1713(2) A defined network plan, preferred provider plan, or self-insured 14governmental plan that provides coverage of emergency medical services shall 15cover emergency ambulance services provided by an ambulance service provider 16that is not a participating provider at a rate that is not lower than the greatest rate 17that is any of the following: SB45-SSA2-SA4,133,1918(a) A rate that is set or approved by a local governmental entity in the 19jurisdiction in which the emergency ambulance services originated. SB45-SSA2-SA4,134,220(b) A rate that is 400 percent of the current published rate for the provided 21emergency ambulance services established by the federal centers for medicare and 22medicaid services under title XVIII of the federal Social Security Act, 42 USC 1395 23et seq., in the same geographic area or a rate that is equivalent to the rate billed by
1the ambulance service provider for emergency ambulance services provided, 2whichever is less. SB45-SSA2-SA4,134,53(c) The contracted rate at which the defined network plan, preferred provider 4plan, or self-insured governmental plan would reimburse a participating 5ambulance service provider for the same emergency ambulance services. SB45-SSA2-SA4,134,116(3) No defined network plan, preferred provider plan, or self-insured 7governmental plan may impose a cost-sharing amount on an enrollee for emergency 8ambulance services provided by an ambulance service provider that is not a 9participating provider at a rate that is greater than the requirements that would 10apply if the emergency ambulance services were provided by a participating 11ambulance service provider. SB45-SSA2-SA4,134,1512(4) No ambulance service provider that receives reimbursement under this 13section may bill an enrollee for any additional amount for emergency ambulance 14services except for any copayment, coinsurance, deductible, or other cost-sharing 15responsibilities required to be paid by the enrollee. SB45-SSA2-SA4,134,1716(5) For purposes of this section, “emergency ambulance services” does not 17include air ambulance services. SB45-SSA2-SA4,134,2219609.83 Coverage of drugs and devices; application of payments. 20Limited service health organizations, preferred provider plans, and defined 21network plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (6) (b), 22(16t), and (16v). SB45-SSA2-SA4,135,224609.847 Preexisting condition discrimination and certain benefit
1limits prohibited. Limited service health organizations, preferred provider 2plans, and defined network plans are subject to s. 632.728. SB45-SSA2-SA4,135,54625.12 (1) (a) Past and prospective loss and expense experience within and 5outside of this state, except as provided in s. 632.728. SB45-SSA2-SA4,135,87625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, 8including the judgment of technical personnel. SB45-SSA2-SA4,135,1810625.12 (2) Classification. Except as provided in s. ss. 632.728 and 632.729, 11risks may be classified in any reasonable way for the establishment of rates and 12minimum premiums, except that no classifications may be based on race, color, 13creed or national origin, and classifications in automobile insurance may not be 14based on physical condition or developmental disability as defined in s. 51.01 (5). 15Subject to ss. 632.365, 632.728, and 632.729, rates thus produced may be modified 16for individual risks in accordance with rating plans or schedules that establish 17reasonable standards for measuring probable variations in hazards, expenses, or 18both. Rates may also be modified for individual risks under s. 625.13 (2). SB45-SSA2-SA4,136,420625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may 21itself establish rates and supplementary rate information for one or more market 22segments based on the factors in s. 625.12 and, if the rates are for motor vehicle 23liability insurance, subject to s. 632.365, or the insurer may use rates and
1supplementary rate information prepared by a rate service organization, with 2average expense factors determined by the rate service organization or with such 3modification for its own expense and loss experience as the credibility of that 4experience allows. SB45-SSA2-SA4,136,136628.34 (3) (a) No insurer may unfairly discriminate among policyholders by 7charging different premiums or by offering different terms of coverage except on the 8basis of classifications related to the nature and the degree of the risk covered or the 9expenses involved, subject to ss. 632.365, 632.728, 632.729, 632.746 and, 632.748, 10and 632.7496. Rates are not unfairly discriminatory if they are averaged broadly 11among persons insured under a group, blanket or franchise policy, and terms are 12not unfairly discriminatory merely because they are more favorable than in a 13similar individual policy. SB45-SSA2-SA4,136,1615628.42 Disclosure and review of prior authorization requirements. 16(1) In this section: SB45-SSA2-SA4,136,1717(a) “Health care plan” has the meaning given in s. 628.36 (2) (a) 1. SB45-SSA2-SA4,136,2018(b) 1. “Prior authorization” means the process by which a health care plan or 19a contracted utilization review organization determines the medical necessity and 20medical appropriateness of otherwise covered health care services. SB45-SSA2-SA4,136,23212. “Prior authorization” includes any requirement that an enrollee or provider 22notify the health care plan or a contracted utilization review organization before, at 23the time of, or concurrent to providing a health care service. SB45-SSA2-SA4,136,2424(b) “Provider” has the meaning given in s. 628.36 (2) (a) 2. SB45-SSA2-SA4,137,3
1(2) (a) A health care plan shall maintain a complete list of services for which 2prior authorization is required, including services where prior authorization is 3performed by an entity under contract with the health care plan. SB45-SSA2-SA4,137,64(b) A health care plan shall publish the list under par. (a) on its website. The 5list shall be accessible by members of the general public without requiring the 6creation of any of an account or the entry of any credentials or personal information. SB45-SSA2-SA4,137,87(c) The list under par. (a) is not required to contain any clinical review criteria 8applicable to the services. SB45-SSA2-SA4,137,169(3) (a) A health care plan shall make any current prior authorization 10requirements and restrictions along with the clinical review criteria applicable to 11those requirements or restrictions accessible and conspicuously posted on its 12website to enrollees and providers. Content published by a 3rd party and licensed 13for use by a health care plan or a contracted utilization review organization may 14satisfy this subsection if it is available to access through the website of the health 15care plan or the contracted utilization review organization as long as the website 16does not unreasonably restrict access. SB45-SSA2-SA4,137,1917(b) The prior authorization requirements and restrictions under par. (a) shall 18be described in detail, and shall be written in easily understandable, plain 19language. SB45-SSA2-SA4,137,2220(c) The prior authorization requirements and restrictions under par. (a) shall 21indicate all of the following for each service subject to the prior authorization 22requirements and restrictions: SB45-SSA2-SA4,137,24231. When the requirement or restriction began for policies issued or delivered 24in this state, including effective dates and any termination dates. SB45-SSA2-SA4,138,2
12. The date that the requirement or restriction was listed on the website of the 2health care plan or a contracted utilization review organization. SB45-SSA2-SA4,138,333. The date that the requirement or restriction was removed in this state. SB45-SSA2-SA4,138,544. A method to access a standardized electronic prior authorization request 5transaction process. SB45-SSA2-SA4,138,76(4) Any clinical review criteria on which a prior authorization requirement or 7restriction is based shall satisfy all of the following: SB45-SSA2-SA4,138,98(a) The criteria are based on nationally recognized, generally accepted 9standards except where provided by law. SB45-SSA2-SA4,138,1110(b) The criteria are developed in accordance with the current standards of a 11national medical accreditation entity. SB45-SSA2-SA4,138,1312(c) The criteria ensure quality of care and access to needed health care 13services. SB45-SSA2-SA4,138,1414(d) The criteria are evidence-based. SB45-SSA2-SA4,138,1615(e) The criteria are sufficiently flexible to allow deviations from current 16standards when justified. SB45-SSA2-SA4,138,1817(f) The criteria are evaluated and updated when necessary and no less 18frequently than once every year. SB45-SSA2-SA4,138,2119(5) No health care plan may deny a claim for failure to obtain prior 20authorization if the prior authorization requirement was not in effect on the date 21that the service was provided. SB45-SSA2-SA4,139,222(6) No health care plan nor any utilization review organization contracted 23with a health care plan may deem supplies or services as incidental or deny a claim 24for supplies or services if a provided health care service associated with the
1supplies or services receives prior authorization or if a provided health care service 2associated with the supplies or services does not require prior authorization. SB45-SSA2-SA4,139,143(7) If a health care plan intends to impose a new prior authorization 4requirement or restriction or intends to amend a prior authorization requirement 5or restriction, the health care plan shall provide all providers contracted with the 6health care plan advanced written notice of the new or amended requirement or 7restriction no less than 60 days before the new or amended requirement or 8restriction is implemented. The advanced written notice may be provided in an 9electronic format if the provider has agreed in advance to receive the notices 10electronically. No health care plan may implement a new or amended prior 11authorization requirement or restriction unless the health care plan or a contracted 12utilization review organization has updated the post on its website required under 13sub. (3) to reflect the new or amended prior authorization requirement or 14restriction. SB45-SSA2-SA4,139,1816628.495 Pharmacy benefit management broker and consultant 17licenses. (1) Definition. In this section, “pharmacy benefit manager” has the 18meaning given in s. 632.865 (1) (c). SB45-SSA2-SA4,139,2319(2) License required. Beginning on the first day of the 12th month 20beginning after the effective date of this subsection .... [LRB inserts date], no 21individual may act as a pharmacy benefit management broker or consultant and no 22individual may act to procure the services of a pharmacy benefit manager on behalf 23of a client without being licensed by the commissioner under this section. SB45-SSA2-SA4,140,224(3) Rules. The commissioner may promulgate rules to establish criteria and
1procedures for initial licensure and renewal of licensure and to implement licensure 2under this section. SB45-SSA2-SA4,140,54632.728 Coverage of persons with preexisting conditions; guaranteed 5issue; benefit limits. (1) Definitions. In this section: SB45-SSA2-SA4,140,76(a) “Cost sharing” includes deductibles, coinsurance, copayments, or similar 7charges. SB45-SSA2-SA4,140,88(b) “Health benefit plan” has the meaning given in s. 632.745 (11). SB45-SSA2-SA4,140,99(c) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c). SB45-SSA2-SA4,140,1610(2) Guaranteed issue. (a) Every individual health benefit plan shall accept 11every individual in this state who, and every group health benefit plan shall accept 12every employer in this state that, applies for coverage, regardless of the sexual 13orientation, the gender identity, or any preexisting condition of any individual or 14employee who will be covered by the plan. A health benefit plan may restrict 15enrollment in coverage described in this paragraph to open or special enrollment 16periods. SB45-SSA2-SA4,140,2017(b) The commissioner shall establish a statewide open enrollment period that 18is no shorter than 30 days, during which every individual health benefit plan shall 19allow individuals, including individuals who do not have coverage, to enroll in 20coverage. SB45-SSA2-SA4,141,221(3) Prohibiting discrimination based on health status. (a) An 22individual health benefit plan or a self-insured health plan may not establish rules 23for the eligibility of any individual to enroll, or for the continued eligibility of any
1individual to remain enrolled, under the plan based on any of the following health 2status-related factors in relation to the individual or a dependent of the individual: SB45-SSA2-SA4,141,442. Medical condition, including both physical and mental illnesses. SB45-SSA2-SA4,141,553. Claims experience. SB45-SSA2-SA4,141,664. Receipt of health care. SB45-SSA2-SA4,141,775. Medical history. SB45-SSA2-SA4,141,886. Genetic information. SB45-SSA2-SA4,141,1097. Evidence of insurability, including conditions arising out of acts of domestic 10violence.
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