AB50,1395,15131. A disclosure that artificial intelligence or algorithmic decision-making was 14used at any stage in reviewing the claim, even if a human later reviewed the 15outcome. AB50,1395,18162. A detailed explanation of how the artificial intelligence or algorithmic 17decision-making reached its decision, including any factors the artificial 18intelligence or algorithmic decision-making weighed. AB50,1395,20193. A contact point for requesting a human review of the claim if the claim was 20denied. AB50,1395,2321(3) Independent review of denials. In addition to an insured’s right to an 22independent review under s. 632.835, as applicable, insureds have the right to 23request a review by the office of the public intervenor of any claim denial. AB50,1396,2
1(4) Prohibited practices. An insurer may not do any of the following with 2respect to a disability insurance policy: AB50,1396,33(a) Use vague or misleading policy terms to justify a claim denial. AB50,1396,44(b) Fail to provide a specific and comprehensible reason for a claim denial. AB50,1396,65(c) Cancel coverage under the policy after a claim is submitted due to alleged 6misstatements on the policy application. AB50,1396,87(d) Deny a claim based on hidden or ambiguous exclusions in a disability 8insurance policy. AB50,1396,99(e) Stall review of a claim to avoid timely payment. AB50,1396,1110(f) Reject a claim without reviewing all relevant medical records or consulting 11qualified experts. AB50,1396,1312(g) Fail to properly review or respond to an insured’s appeal in a timely 13manner. AB50,1396,1514(h) Allow non-physician personnel to determine whether care is medically 15necessary. AB50,1396,1716(i) Apply different medical necessity criteria based on financial interests 17rather than patient needs. AB50,1396,1918(j) Disregard a treating health care provider’s medical assessment without a 19valid clinical reason. AB50,1396,2120(k) Mandate prior approval for routine or urgent procedures in a manner that 21causes harmful delays. AB50,1396,2422(L) For a disability insurance policy that provides coverage of emergency 23medical services, refuse to cover emergency medical services provided by out-of-24network providers. AB50,1397,2
1(m) List a health care provider as in-network on a provider directory and then 2deny a claim by stating the health care provider is out-of-network. AB50,1397,43(n) Deny coverage based on age, gender, disability, or a chronic condition 4rather than medical necessity. AB50,1397,65(o) Apply stricter standards in reviewing claims related to mental health 6conditions than claims related to physical health conditions. AB50,1397,87(p) Perform a blanket denial of claims for high-cost conditions without an 8individualized review of each claim. AB50,1397,99(r) Reclassify a claim to a lower-cost treatment to reduce insurer payout. AB50,1397,1110(s) Require an insured to fail a cheaper treatment before approving coverage 11for necessary care. AB50,1397,1212(t) Manipulate cost-sharing rules to shift higher costs to insureds. AB50,1397,1713(5) Transparency and reporting. (a) Beginning on January 1, 2027, an 14insurer shall annually publish a report detailing the insurer’s claim denial rates, 15reasons for claim denials, and the outcome of any appeal of a claim denial for the 16previous year for all disability insurance policies under which the insurer provides 17coverage. AB50,1397,1918(b) The commissioner shall maintain a public database of insurers’ claim 19denial rates and the outcomes of independent reviews under s. 632.835. AB50,1397,2320(c) Beginning on January 1, 2027, an insurer that uses artificial intelligence 21or algorithmic decision-making in claims processing shall annually publish a report 22detailing all of the following for the previous year for all disability insurance policies 23under which the insurer provides coverage: AB50,1398,2
11. The percentage of claims submitted to the insurer that were reviewed by 2artificial intelligence or algorithmic decision-making. AB50,1398,532. The claim denial rate of claims reviewed by artificial intelligence or 4algorithmic decision-making compared to the claim denial rate of claims reviewed 5by humans. AB50,1398,763. The steps the insurer takes to ensure fairness and accuracy in decisions 7made by artificial intelligence or algorithmic decision-making. AB50,1398,118(6) Claim denial rate audits. (a) The commissioner may conduct an audit 9of an insurer if the insurer’s claim denials are of such frequency as to indicate a 10general business practice. This paragraph is supplemental to and does not limit 11any other powers or duties of the commissioner. AB50,1398,1312(b) The commissioner may collect any relevant information from an insurer 13that is necessary to conduct an audit under par. (a). AB50,1398,1514(c) The commissioner may contract with a 3rd party to conduct an audit under 15par. (a). AB50,1398,2016(d) The commissioner may, based on the findings of an audit under par. (a), 17order the insurer who is the subject of the audit to comply with a corrective action 18plan approved by the commissioner. The commissioner shall specify in any 19corrective action plan under this paragraph the deadline by which an insurer must 20be in compliance with the corrective action plan. AB50,1398,2221(e) An insurer who is the subject of an audit under par. (a) shall provide a 22written response to any adverse findings of the audit. AB50,1399,223(f) If an insurer fails to comply with a corrective action plan under par. (d) by
1the deadline specified by the commissioner, the commissioner may order the 2insurer to pay a forfeiture pursuant to s. 601.64 (3). AB50,1399,63(7) Forfeitures. A violation of this section that results in a harmful delay in 4an insured’s care or an adverse health outcome for an insured shall be subject to a 5civil forfeiture of $10,000 per occurrence, in addition to any other penalties provided 6in s. 601.64 (3) or other law. AB50,28887Section 2888. 601.575 of the statutes is created to read: AB50,1399,138601.575 Prescription drug importation program. (1) Importation 9program requirements. The commissioner, in consultation with persons 10interested in the sale and pricing of prescription drugs and appropriate officials 11and agencies of the federal government, shall design and implement a prescription 12drug importation program for the benefit of residents of this state, that generates 13savings for residents, and that satisfies all of the following: AB50,1399,1614(a) The commissioner shall designate a state agency to become a licensed 15wholesale distributor or to contract with a licensed wholesale distributor and shall 16seek federal certification and approval to import prescription drugs. AB50,1399,1817(b) The program shall comply with relevant requirements of 21 USC 384, 18including safety and cost savings requirements. AB50,1399,2019(c) The program shall import prescription drugs from Canadian suppliers 20regulated under any appropriate Canadian or provincial laws. AB50,1399,2221(d) The program shall have a process to sample the purity, chemical 22composition, and potency of imported prescription drugs. AB50,1400,223(e) The program shall import only those prescription drugs for which 24importation creates substantial savings for residents of this state and only those
1prescription drugs that are not brand-name drugs and that have fewer than 4 2competitor prescription drugs in the United States. AB50,1400,43(f) The commissioner shall ensure that prescription drugs imported under the 4program are not distributed, dispensed, or sold outside of this state. AB50,1400,55(g) The program shall ensure all of the following: AB50,1400,761. Participation by any pharmacy or health care provider in the program is 7voluntary. AB50,1400,982. Any pharmacy or health care provider participating in the program has the 9appropriate license or other credential in this state. AB50,1400,12103. Any pharmacy or health care provider participating in the program charges 11a consumer or health plan the actual acquisition cost of the imported prescription 12drug that is dispensed. AB50,1400,1613(h) The program shall ensure that a payment by a health plan or health 14insurance policy for a prescription drug imported under the program reimburses no 15more than the actual acquisition cost of the imported prescription drug that is 16dispensed. AB50,1400,1817(i) The program shall ensure that any health plan or health insurance policy 18participating in the program does all of the following: AB50,1400,20191. Maintains a formulary and claims payment system with current 20information on prescription drugs imported under the program. AB50,1400,23212. Bases cost-sharing amounts for participants or insureds under the plan or 22policy on no more than the actual acquisition cost of the prescription drug imported 23under the program that is dispensed to the participant or insured. AB50,1401,3
13. Demonstrates to the commissioner or a state agency designated by the 2commissioner how premiums under the plan or policy are affected by savings on 3prescription drugs imported under the program. AB50,1401,64(j) Any wholesale distributor importing prescription drugs under the program 5shall limit its profit margin to the amount established by the commissioner or a 6state agency designated by the commissioner. AB50,1401,87(k) The program may not import any generic prescription drug that would 8violate federal patent laws on branded products in the United States. AB50,1401,139(L) The program shall comply with tracking and tracing requirements of 21 10USC 360eee and 360eee-1, to the extent practical and feasible, before the 11prescription drug to be imported comes into the possession of this state’s wholesale 12distributor and fully after the prescription drug to be imported is in the possession 13of this state’s wholesale distributor. AB50,1401,1514(m) The program shall establish a fee or other mechanism to finance the 15program that does not jeopardize significant savings to residents of this state. AB50,1401,1616(n) The program shall have an audit function that ensures all of the following: AB50,1401,18171. The commissioner has a sound methodology to determine the most cost-18effective prescription drugs to include in the program. AB50,1401,20192. The commissioner has a process in place to select Canadian suppliers that 20are high quality, high performing, and in full compliance with Canadian laws. AB50,1401,22213. Prescription drugs imported under the program are pure, unadulterated, 22potent, and safe. AB50,1401,23234. The program is complying with the requirements of this subsection. AB50,1402,2
15. The program is adequately financed to support administrative functions of 2the program while generating significant cost savings to residents of this state. AB50,1402,436. The program does not put residents of this state at a higher risk than if the 4program did not exist. AB50,1402,657. The program provides and is projected to continue to provide substantial 6cost savings to residents of this state. AB50,1402,97(2) Anticompetitive behavior. The commissioner, in consultation with the 8attorney general, shall identify the potential for and monitor anticompetitive 9behavior in industries affected by a prescription drug importation program. AB50,1402,1910(3) Approval of program design; certification. No later than the first day 11of the 7th month beginning after the effective date of this subsection .... [LRB 12inserts date], the commissioner shall submit to the joint committee on finance a 13report that includes the design of the prescription drug importation program in 14accordance with this section. The commissioner may not submit the proposed 15program to the federal department of health and human services unless the joint 16committee on finance approves the proposed program. Within 14 days of the date of 17approval by the joint committee on finance of the proposed program, the 18commissioner shall submit to the federal department of health and human services 19a request for certification of the approved program. AB50,1403,420(4) Implementation of certified program. After the federal department of 21health and human services certifies the prescription drug importation program 22submitted under sub. (3), the commissioner shall begin implementation of the 23program, and the program shall be fully operational by 180 days after the date of
1certification by the federal department of health and human services. The 2commissioner shall do all of the following to implement the program to the extent 3the action is in accordance with other state laws and the certification by the federal 4department of health and human services: AB50,1403,75(a) Become a licensed wholesale distributor, designate another state agency to 6become a licensed wholesale distributor, or contract with a licensed wholesale 7distributor. AB50,1403,98(b) Contract with one or more Canadian suppliers that meet the criteria in 9sub. (1) (c) and (n). AB50,1403,1210(c) Create an outreach and marketing plan to communicate with and provide 11information to health plans and health insurance policies, employers, pharmacies, 12health care providers, and residents of this state on participating in the program. AB50,1403,1513(d) Develop and implement a registration process for health plans and health 14insurance policies, pharmacies, and health care providers interested in 15participating in the program. AB50,1403,1716(e) Create a publicly accessible source for listing prices of prescription drugs 17imported under the program. AB50,1403,2018(f) Create, publicize, and implement a method of communication to promptly 19answer questions from and address the needs of persons affected by the 20implementation of the program before the program is fully operational. AB50,1403,2221(g) Establish the audit functions under sub. (1) (n) with a timeline to complete 22each audit function every 2 years. AB50,1404,2
1(h) Conduct any other activities determined by the commissioner to be 2important to successful implementation of the program. AB50,1404,43(5) Report. By January 1 and July 1 of each year, the commissioner shall 4submit to the joint committee on finance a report including all of the following: AB50,1404,65(a) A list of prescription drugs included in the prescription drug importation 6program under this section. AB50,1404,97(b) The number of pharmacies, health care providers, and health plans and 8health insurance policies participating in the prescription drug importation 9program under this section. AB50,1404,1410(c) The estimated amount of savings to residents of this state, health plans 11and health insurance policies, and employers resulting from the implementation of 12the prescription drug importation program under this section reported from the 13date of the previous report under this subsection and from the date the program 14was fully operational. AB50,1404,1615(d) Findings of any audit functions under sub. (1) (n) completed since the date 16of the previous report under this subsection. AB50,1404,1817(6) Rule making. The commissioner may promulgate any rules necessary to 18implement this section. AB50,288919Section 2889. 601.59 of the statutes is created to read: AB50,1404,2020601.59 State-based exchange. (1) Definitions. In this section: AB50,1404,2121(a) “Exchange” has the meaning given in 45 CFR 155.20. AB50,1405,222(b) “State-based exchange on the federal platform” means an exchange that is
1described in and meets the requirements of 45 CFR 155.200 (f) and is approved by 2the federal secretary of health and human services under 45 CFR 155.106. AB50,1405,63(c) “State-based exchange without the federal platform” means an exchange, 4other than one described in 45 CFR 155.200 (f), that performs all the functions 5described in 45 CFR 155.200 (a) and is approved by the federal secretary of health 6and human services under 45 CFR 155.106. AB50,1405,137(2) Establishment and operation of state-based exchange. The 8commissioner shall establish and operate an exchange that at first is a state-based 9exchange on the federal platform and then subsequently transitions to a state-10based exchange without the federal platform. The commissioner shall develop 11procedures to address the transition from the state-based exchange on the federal 12platform to the state-based exchange without the federal platform, including the 13circumstances that shall be met in order for the transition to occur.
/2025/related/proposals/ab50
true
proposaltext
/2025/related/proposals/ab50/2887/_41
proposaltext/2025/REG/AB50,1398,7
proposaltext/2025/REG/AB50,1398,7
section
true