Amendment SA4-SSA2-SB45

SB45-SSA2-SA4,207 Section 207. 609.74 of the statutes is created to read:

SB45-SSA2-SA4,132,20 609.74 Coverage of infertility services. Defined network plans and preferred provider plans are subject to s. 632.895 (15m).

SB45-SSA2-SA4,208 Section 208. 609.815 of the statutes is created to read:

SB45-SSA2-SA4,132,24 609.815 Exemption from prior authorization requirements. Limited service health organizations, preferred provider plans, and defined network plans are subject to any rules promulgated by the commissioner under s. 632.848.

SB45-SSA2-SA4,209 Section 209. 609.823 of the statutes is created to read:

SB45-SSA2-SA4,133,4 609.823 Coverage without prior authorization for inpatient mental health services. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.891.

SB45-SSA2-SA4,210 Section 210. 609.825 of the statutes is created to read:

SB45-SSA2-SA4,133,7 609.825 Coverage of emergency ambulance services. (1) In this section:

SB45-SSA2-SA4,133,8 (a) “Ambulance service provider” has the meaning given in s. 256.01 (3).

SB45-SSA2-SA4,133,12 (b) “Self-insured governmental plan” means a self-insured health plan of the state or a county, city, village, town, or school district that has a network of participating providers and imposes on enrollees in the self-insured health plan different requirements for using providers that are not participating providers.

SB45-SSA2-SA4,133,17 (2) A defined network plan, preferred provider plan, or self-insured governmental plan that provides coverage of emergency medical services shall cover emergency ambulance services provided by an ambulance service provider that is not a participating provider at a rate that is not lower than the greatest rate that is any of the following:

SB45-SSA2-SA4,133,19 (a) A rate that is set or approved by a local governmental entity in the jurisdiction in which the emergency ambulance services originated.

SB45-SSA2-SA4,134,2 (b) A rate that is 400 percent of the current published rate for the provided emergency ambulance services established by the federal centers for medicare and medicaid services under title XVIII of the federal Social Security Act, 42 USC 1395 et seq., in the same geographic area or a rate that is equivalent to the rate billed by the ambulance service provider for emergency ambulance services provided, whichever is less.

SB45-SSA2-SA4,134,5 (c) The contracted rate at which the defined network plan, preferred provider plan, or self-insured governmental plan would reimburse a participating ambulance service provider for the same emergency ambulance services.

SB45-SSA2-SA4,134,11 (3) No defined network plan, preferred provider plan, or self-insured governmental plan may impose a cost-sharing amount on an enrollee for emergency ambulance services provided by an ambulance service provider that is not a participating provider at a rate that is greater than the requirements that would apply if the emergency ambulance services were provided by a participating ambulance service provider.

SB45-SSA2-SA4,134,15 (4) No ambulance service provider that receives reimbursement under this section may bill an enrollee for any additional amount for emergency ambulance services except for any copayment, coinsurance, deductible, or other cost-sharing responsibilities required to be paid by the enrollee.

SB45-SSA2-SA4,134,17 (5) For purposes of this section, “emergency ambulance services” does not include air ambulance services.

SB45-SSA2-SA4,211 Section 211. 609.83 of the statutes is amended to read:

SB45-SSA2-SA4,134,22 609.83 Coverage of drugs and devices; application of payments. Limited service health organizations, preferred provider plans, and defined network plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (6) (b), (16t), and (16v).

SB45-SSA2-SA4,212 Section 212. 609.847 of the statutes is created to read:

SB45-SSA2-SA4,135,2 609.847 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.

SB45-SSA2-SA4,213 Section 213. 625.12 (1) (a) of the statutes is amended to read:

SB45-SSA2-SA4,135,5 625.12 (1) (a) Past and prospective loss and expense experience within and outside of this state, except as provided in s. 632.728.

SB45-SSA2-SA4,214 Section 214. 625.12 (1) (e) of the statutes is amended to read:

SB45-SSA2-SA4,135,8 625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, including the judgment of technical personnel.

SB45-SSA2-SA4,215 Section 215. 625.12 (2) of the statutes is amended to read:

SB45-SSA2-SA4,135,18 625.12 (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).

SB45-SSA2-SA4,216 Section 216. 625.15 (1) of the statutes is amended to read:

SB45-SSA2-SA4,136,4 625.15 (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.

SB45-SSA2-SA4,217 Section 217. 628.34 (3) (a) of the statutes is amended to read:

SB45-SSA2-SA4,136,13 628.34 (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.

SB45-SSA2-SA4,218 Section 218. 628.42 of the statutes is created to read:

SB45-SSA2-SA4,136,16 628.42 Disclosure and review of prior authorization requirements. (1) In this section:

SB45-SSA2-SA4,136,17 (a) “Health care plan” has the meaning given in s. 628.36 (2) (a) 1.

SB45-SSA2-SA4,136,20 (b) 1. “Prior authorization” means the process by which a health care plan or a contracted utilization review organization determines the medical necessity and medical appropriateness of otherwise covered health care services.

SB45-SSA2-SA4,136,23 2. “Prior authorization” includes any requirement that an enrollee or provider notify the health care plan or a contracted utilization review organization before, at the time of, or concurrent to providing a health care service.

SB45-SSA2-SA4,136,24 (b) “Provider” has the meaning given in s. 628.36 (2) (a) 2.

SB45-SSA2-SA4,137,3 (2) (a) A health care plan shall maintain a complete list of services for which prior authorization is required, including services where prior authorization is performed by an entity under contract with the health care plan.

SB45-SSA2-SA4,137,6 (b) A health care plan shall publish the list under par. (a) on its website. The list shall be accessible by members of the general public without requiring the creation of any of an account or the entry of any credentials or personal information.

SB45-SSA2-SA4,137,8 (c) The list under par. (a) is not required to contain any clinical review criteria applicable to the services.

SB45-SSA2-SA4,137,16 (3) (a) A health care plan shall make any current prior authorization requirements and restrictions along with the clinical review criteria applicable to those requirements or restrictions accessible and conspicuously posted on its website to enrollees and providers. Content published by a 3rd party and licensed for use by a health care plan or a contracted utilization review organization may satisfy this subsection if it is available to access through the website of the health care plan or the contracted utilization review organization as long as the website does not unreasonably restrict access.

SB45-SSA2-SA4,137,19 (b) The prior authorization requirements and restrictions under par. (a) shall be described in detail, and shall be written in easily understandable, plain language.

SB45-SSA2-SA4,137,22 (c) The prior authorization requirements and restrictions under par. (a) shall indicate all of the following for each service subject to the prior authorization requirements and restrictions:

SB45-SSA2-SA4,137,24 1. When the requirement or restriction began for policies issued or delivered in this state, including effective dates and any termination dates.

SB45-SSA2-SA4,138,2 2. The date that the requirement or restriction was listed on the website of the health care plan or a contracted utilization review organization.

SB45-SSA2-SA4,138,3 3. The date that the requirement or restriction was removed in this state.

SB45-SSA2-SA4,138,5 4. A method to access a standardized electronic prior authorization request transaction process.

SB45-SSA2-SA4,138,7 (4) Any clinical review criteria on which a prior authorization requirement or restriction is based shall satisfy all of the following:

SB45-SSA2-SA4,138,9 (a) The criteria are based on nationally recognized, generally accepted standards except where provided by law.

SB45-SSA2-SA4,138,11 (b) The criteria are developed in accordance with the current standards of a national medical accreditation entity.

SB45-SSA2-SA4,138,13 (c) The criteria ensure quality of care and access to needed health care services.

SB45-SSA2-SA4,138,14 (d) The criteria are evidence-based.

SB45-SSA2-SA4,138,16 (e) The criteria are sufficiently flexible to allow deviations from current standards when justified.

SB45-SSA2-SA4,138,18 (f) The criteria are evaluated and updated when necessary and no less frequently than once every year.

SB45-SSA2-SA4,138,21 (5) No health care plan may deny a claim for failure to obtain prior authorization if the prior authorization requirement was not in effect on the date that the service was provided.

SB45-SSA2-SA4,139,2 (6) No health care plan nor any utilization review organization contracted with a health care plan may deem supplies or services as incidental or deny a claim for supplies or services if a provided health care service associated with the supplies or services receives prior authorization or if a provided health care service associated with the supplies or services does not require prior authorization.

SB45-SSA2-SA4,139,14 (7) If a health care plan intends to impose a new prior authorization requirement or restriction or intends to amend a prior authorization requirement or restriction, the health care plan shall provide all providers contracted with the health care plan advanced written notice of the new or amended requirement or restriction no less than 60 days before the new or amended requirement or restriction is implemented. The advanced written notice may be provided in an electronic format if the provider has agreed in advance to receive the notices electronically. No health care plan may implement a new or amended prior authorization requirement or restriction unless the health care plan or a contracted utilization review organization has updated the post on its website required under sub. (3) to reflect the new or amended prior authorization requirement or restriction.

SB45-SSA2-SA4,219 Section 219. 628.495 of the statutes is created to read:

SB45-SSA2-SA4,139,18 628.495 Pharmacy benefit management broker and consultant licenses. (1) Definition. In this section, “pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).

SB45-SSA2-SA4,139,23 (2) License required. Beginning on the first day of the 12th month beginning after the effective date of this subsection .... [LRB inserts date], no individual may act as a pharmacy benefit management broker or consultant and no individual may act to procure the services of a pharmacy benefit manager on behalf of a client without being licensed by the commissioner under this section.

SB45-SSA2-SA4,140,2 (3) Rules. The commissioner may promulgate rules to establish criteria and procedures for initial licensure and renewal of licensure and to implement licensure under this section.

SB45-SSA2-SA4,220 Section 220. 632.728 of the statutes is created to read:

SB45-SSA2-SA4,140,5 632.728 Coverage of persons with preexisting conditions; guaranteed issue; benefit limits. (1) Definitions. In this section:

SB45-SSA2-SA4,140,7 (a) “Cost sharing” includes deductibles, coinsurance, copayments, or similar charges.

SB45-SSA2-SA4,140,8 (b) “Health benefit plan” has the meaning given in s. 632.745 (11).

SB45-SSA2-SA4,140,9 (c) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

SB45-SSA2-SA4,140,16 (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 the sexual orientation, the gender identity, or any preexisting condition of any individual or employee who will be covered by the plan. A health benefit plan may restrict enrollment in coverage described in this paragraph to open or special enrollment periods.

SB45-SSA2-SA4,140,20 (b) The commissioner shall establish a statewide open enrollment period that is no shorter than 30 days, during which every individual health benefit plan shall allow individuals, including individuals who do not have coverage, to enroll in coverage.

SB45-SSA2-SA4,141,2 (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:

SB45-SSA2-SA4,141,3 1. Health status.

SB45-SSA2-SA4,141,4 2. Medical condition, including both physical and mental illnesses.

SB45-SSA2-SA4,141,5 3. Claims experience.

SB45-SSA2-SA4,141,6 4. Receipt of health care.

SB45-SSA2-SA4,141,7 5. Medical history.

SB45-SSA2-SA4,141,8 6. Genetic information.

SB45-SSA2-SA4,141,10 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

SB45-SSA2-SA4,141,11 8. Disability.

SB45-SSA2-SA4,141,19 (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 an otherwise similarly situated individual enrolled under the plan.

SB45-SSA2-SA4,141,23 (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.

SB45-SSA2-SA4,142,3 (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:

SB45-SSA2-SA4,142,4 (a) Whether the policy or plan covers an individual or a family.

SB45-SSA2-SA4,142,5 (b) Rating area in the state, as established by the commissioner.

SB45-SSA2-SA4,142,8 (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.

SB45-SSA2-SA4,142,9 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

SB45-SSA2-SA4,142,14 (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.

SB45-SSA2-SA4,142,16 (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:

SB45-SSA2-SA4,142,18 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

SB45-SSA2-SA4,142,20 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

SB45-SSA2-SA4,143,2 (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.