Amendment SA4-SSA2-SB45

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.

SB45-SSA2-SA4,101,13 (6) Claim denial rate audits. (a) The commissioner may conduct an audit of an insurer if the insurer’s claim denials are of such frequency as to indicate a general business practice. This paragraph is supplemental to and does not limit any other powers or duties of the commissioner.

SB45-SSA2-SA4,101,15 (b) The commissioner may collect any relevant information from an insurer that is necessary to conduct an audit under par. (a).

SB45-SSA2-SA4,101,17 (c) The commissioner may contract with a 3rd party to conduct an audit under par. (a).

SB45-SSA2-SA4,101,22 (d) The commissioner may, based on the findings of an audit under par. (a), order the insurer who is the subject of the audit to comply with a corrective action plan approved by the commissioner. The commissioner shall specify in any corrective action plan under this paragraph the deadline by which an insurer must be in compliance with the corrective action plan.

SB45-SSA2-SA4,101,24 (e) An insurer who is the subject of an audit under par. (a) shall provide a written response to any adverse findings of the audit.

SB45-SSA2-SA4,102,3 (f) If an insurer fails to comply with a corrective action plan under par. (d) by the deadline specified by the commissioner, the commissioner may order the insurer to pay a forfeiture pursuant to s. 601.64 (3).

SB45-SSA2-SA4,102,7 (7) Forfeitures. A violation of this section that results in a harmful delay in an insured’s care or an adverse health outcome for an insured shall be subject to a civil forfeiture of $10,000 per occurrence, in addition to any other penalties provided in s. 601.64 (3) or other law.

SB45-SSA2-SA4,189 Section 189. 601.575 of the statutes is created to read:

SB45-SSA2-SA4,102,14 601.575 Prescription drug importation program. (1) Importation program requirements. The commissioner, in consultation with persons interested in the sale and pricing of prescription drugs and appropriate officials and agencies of the federal government, shall design and implement a prescription drug importation program for the benefit of residents of this state, that generates savings for residents, and that satisfies all of the following:

SB45-SSA2-SA4,102,17 (a) The commissioner shall designate a state agency to become a licensed wholesale distributor or to contract with a licensed wholesale distributor and shall seek federal certification and approval to import prescription drugs.

SB45-SSA2-SA4,102,19 (b) The program shall comply with relevant requirements of 21 USC 384, including safety and cost savings requirements.

SB45-SSA2-SA4,102,21 (c) The program shall import prescription drugs from Canadian suppliers regulated under any appropriate Canadian or provincial laws.

SB45-SSA2-SA4,102,23 (d) The program shall have a process to sample the purity, chemical composition, and potency of imported prescription drugs.

SB45-SSA2-SA4,103,3 (e) The program shall import only those prescription drugs for which importation creates substantial savings for residents of this state and only those prescription drugs that are not brand-name drugs and that have fewer than 4 competitor prescription drugs in the United States.

SB45-SSA2-SA4,103,5 (f) The commissioner shall ensure that prescription drugs imported under the program are not distributed, dispensed, or sold outside of this state.

SB45-SSA2-SA4,103,6 (g) The program shall ensure all of the following:

SB45-SSA2-SA4,103,8 1. Participation by any pharmacy or health care provider in the program is voluntary.

SB45-SSA2-SA4,103,10 2. Any pharmacy or health care provider participating in the program has the appropriate license or other credential in this state.

SB45-SSA2-SA4,103,13 3. Any pharmacy or health care provider participating in the program charges a consumer or health plan the actual acquisition cost of the imported prescription drug that is dispensed.

SB45-SSA2-SA4,103,17 (h) The program shall ensure that a payment by a health plan or health insurance policy for a prescription drug imported under the program reimburses no more than the actual acquisition cost of the imported prescription drug that is dispensed.

SB45-SSA2-SA4,103,19 (i) The program shall ensure that any health plan or health insurance policy participating in the program does all of the following:

SB45-SSA2-SA4,103,21 1. Maintains a formulary and claims payment system with current information on prescription drugs imported under the program.

SB45-SSA2-SA4,104,2 2. Bases cost-sharing amounts for participants or insureds under the plan or policy on no more than the actual acquisition cost of the prescription drug imported under the program that is dispensed to the participant or insured.

SB45-SSA2-SA4,104,5 3. Demonstrates to the commissioner or a state agency designated by the commissioner how premiums under the plan or policy are affected by savings on prescription drugs imported under the program.

SB45-SSA2-SA4,104,8 (j) Any wholesale distributor importing prescription drugs under the program shall limit its profit margin to the amount established by the commissioner or a state agency designated by the commissioner.

SB45-SSA2-SA4,104,10 (k) The program may not import any generic prescription drug that would violate federal patent laws on branded products in the United States.

SB45-SSA2-SA4,104,15 (L) The program shall comply with tracking and tracing requirements of 21 USC 360eee and 360eee-1, to the extent practical and feasible, before the prescription drug to be imported comes into the possession of this state’s wholesale distributor and fully after the prescription drug to be imported is in the possession of this state’s wholesale distributor.

SB45-SSA2-SA4,104,17 (m) The program shall establish a fee or other mechanism to finance the program that does not jeopardize significant savings to residents of this state.

SB45-SSA2-SA4,104,18 (n) The program shall have an audit function that ensures all of the following:

SB45-SSA2-SA4,104,20 1. The commissioner has a sound methodology to determine the most cost- effective prescription drugs to include in the program.

SB45-SSA2-SA4,104,22 2. The commissioner has a process in place to select Canadian suppliers that are high quality, high performing, and in full compliance with Canadian laws.

SB45-SSA2-SA4,105,2 3. Prescription drugs imported under the program are pure, unadulterated, potent, and safe.

SB45-SSA2-SA4,105,3 4. The program is complying with the requirements of this subsection.

SB45-SSA2-SA4,105,5 5. The program is adequately financed to support administrative functions of the program while generating significant cost savings to residents of this state.

SB45-SSA2-SA4,105,7 6. The program does not put residents of this state at a higher risk than if the program did not exist.