Amendment SA4-SSA2-SB45

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.

SB45-SSA2-SA4,143,5 (8) Medical loss ratio. (a) In this subsection, “medical loss ratio” means the proportion, expressed as a percentage, of premium revenues spent by a health benefit plan on clinical services and quality improvement.

SB45-SSA2-SA4,143,7 (b) A health benefit plan on the individual or small employer market shall have a medical loss ratio of at least 80 percent.

SB45-SSA2-SA4,143,9 (c) A group health benefit plan other than one described under par. (b) shall have a medical loss ratio of at least 85 percent.

SB45-SSA2-SA4,143,13 (9) Actuarial values of plan tiers. Any health benefit plan offered on the individual or small employer market shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to at least 60 percent of the full actuarial value of the benefits provided under the plan.

SB45-SSA2-SA4,221 Section 221. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and amended to read:

SB45-SSA2-SA4,143,22 632.746 (1) Subject to subs. (2) and (3), an An insurer that offers a group health benefit plan may, with respect to a participant or beneficiary under the plan, not impose a preexisting condition exclusion only if the exclusion relates to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period ending on the participant’s or beneficiary’s enrollment date under the plan on a participant or beneficiary under the plan.

SB45-SSA2-SA4,222 Section 222. 632.746 (1) (b) of the statutes is repealed.

SB45-SSA2-SA4,223 Section 223. 632.746 (2) (a) of the statutes is amended to read:

SB45-SSA2-SA4,144,5 632.746 (2) (a) An insurer offering a group health benefit plan may not treat impose a preexisting condition exclusion based on genetic information as a preexisting condition under sub. (1) without a diagnosis of a condition related to the information.

SB45-SSA2-SA4,224 Section 224. 632.746 (2) (c), (d) and (e) of the statutes are repealed.

SB45-SSA2-SA4,225 Section 225. 632.746 (3) (a) of the statutes is repealed.

SB45-SSA2-SA4,226 Section 226. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).

SB45-SSA2-SA4,227 Section 227. 632.746 (3) (d) 2. and 3. of the statutes are repealed.

SB45-SSA2-SA4,228 Section 228. 632.746 (5) of the statutes is repealed.

SB45-SSA2-SA4,229 Section 229. 632.746 (8) (a) (intro.) of the statutes is amended to read:

SB45-SSA2-SA4,144,15 632.746 (8) (a) (intro.) A health maintenance organization that offers a group health benefit plan and that does not impose any preexisting condition exclusion under sub. (1) with respect to a particular coverage option may impose an affiliation period for that coverage option, but only if all of the following apply:

SB45-SSA2-SA4,230 Section 230. 632.748 (2) of the statutes is amended to read:

SB45-SSA2-SA4,144,23 632.748 (2) An insurer offering a group health benefit 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 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 a an otherwise similarly situated individual enrolled under the plan.

SB45-SSA2-SA4,231 Section 231. 632.7495 (4) (b) of the statutes is amended to read:

SB45-SSA2-SA4,145,2 632.7495 (4) (b) The coverage has a term of not more than 12 3 months.

SB45-SSA2-SA4,232 Section 232. 632.7495 (4) (c) of the statutes is amended to read:

SB45-SSA2-SA4,145,8 632.7495 (4) (c) The coverage term aggregated with all consecutive periods of the insurer’s coverage of the insured by individual health benefit plan coverage not required to be renewed under this subsection does not exceed 18 6 months. For purposes of this paragraph, coverage periods are consecutive if there are no more than 63 days between the coverage periods.

SB45-SSA2-SA4,233 Section 233. 632.7496 of the statutes is created to read:

SB45-SSA2-SA4,145,12 632.7496 Coverage requirements for short-term plans. (1) Definition. In this section, “short-term, limited duration plan” means an individual health benefit plan described in s. 632.7495 (4).

SB45-SSA2-SA4,145,15 (2) Guaranteed issue. An insurer that offers a short-term, limited duration plan shall accept every individual in this state who applies for coverage regardless of whether the individual has a preexisting condition.

SB45-SSA2-SA4,145,21 (3) Prohibiting discrimination based on health status. (a) An insurer that offers a short-term, limited duration 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 a short-term, limited duration plan based on any of the following health status-related factors with respect to the individual or a dependent of the individual:

SB45-SSA2-SA4,145,22 1. Health status.

SB45-SSA2-SA4,145,23 2. Medical condition, including both physical and mental illnesses.

SB45-SSA2-SA4,146,1 3. Claims experience.

SB45-SSA2-SA4,146,2 4. Receipt of health care.

SB45-SSA2-SA4,146,3 5. Medical history.

SB45-SSA2-SA4,146,4 6. Genetic information.