SB45,2881 Section 2881. 601.25 of the statutes is created to read:

SB45,1392,19 601.25 Office of the public intervenor. (1) The office of the public intervenor shall assist individuals with insurance claims, policies, appeals, and other legal actions to pursue insurance coverage for medical procedures, prescription medications, and other health care services.

SB45,1392,24 (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.

SB45,1393,2 (3) The commissioner may provide by rule for the governance, duties, and administration of the office of the public intervenor.

SB45,2882 Section 2882. 601.31 (1) (mv) of the statutes is created to read:

SB45,1393,6 601.31 (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.

SB45,2883 Section 2883. 601.31 (1) (nv) of the statutes is created to read:

SB45,1393,9 601.31 (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.

SB45,2884 Section 2884. 601.31 (1) (nw) of the statutes is created to read:

SB45,1393,13 601.31 (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.

SB45,2885 Section 2885. 601.41 (14) of the statutes is created to read:

SB45,1393,20 601.41 (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.

SB45,2886 Section 2886. 601.45 (1) of the statutes is amended to read:

SB45,1394,6 601.45 (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.

SB45,2887 Section 2887. 601.455 of the statutes is created to read:

SB45,1394,9 601.455 Fair claims processing, health insurance transparency, and claim denial rate audits. (1) Definitions. In this section:

SB45,1394,15 (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.

SB45,1394,16 (b) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

SB45,1394,17 (c) “Health care provider” has the meaning given in s. 146.81 (1) (a) to (p).

SB45,1394,20 (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.

SB45,1394,24 (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.

SB45,1395,1 (c) All claim denials shall include all of the following:

SB45,1395,3 1. A specific and detailed explanation of the reason for the denial that cites the exact medical or policy basis for the denial.

SB45,1395,6 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.

SB45,1395,9 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.

SB45,1395,12 (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:

SB45,1395,15 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.

SB45,1395,18 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.

SB45,1395,20 3. A contact point for requesting a human review of the claim if the claim was denied.