SB45,1396,1716(i) Apply different medical necessity criteria based on financial interests 17rather than patient needs. SB45,1396,1918(j) Disregard a treating health care provider’s medical assessment without a 19valid clinical reason. SB45,1396,2120(k) Mandate prior approval for routine or urgent procedures in a manner that 21causes harmful delays. SB45,1396,2422(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. SB45,1397,2
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. SB45,1397,43(n) Deny coverage based on age, gender, disability, or a chronic condition 4rather than medical necessity. SB45,1397,65(o) Apply stricter standards in reviewing claims related to mental health 6conditions than claims related to physical health conditions. SB45,1397,87(p) Perform a blanket denial of claims for high-cost conditions without an 8individualized review of each claim. SB45,1397,99(r) Reclassify a claim to a lower-cost treatment to reduce insurer payout. SB45,1397,1110(s) Require an insured to fail a cheaper treatment before approving coverage 11for necessary care. SB45,1397,1212(t) Manipulate cost-sharing rules to shift higher costs to insureds. SB45,1397,1713(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. SB45,1397,1918(b) The commissioner shall maintain a public database of insurers’ claim 19denial rates and the outcomes of independent reviews under s. 632.835. SB45,1397,2320(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: SB45,1398,2
11. The percentage of claims submitted to the insurer that were reviewed by 2artificial intelligence or algorithmic decision-making. SB45,1398,532. 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. SB45,1398,763. The steps the insurer takes to ensure fairness and accuracy in decisions 7made by artificial intelligence or algorithmic decision-making. SB45,1398,118(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. SB45,1398,1312(b) The commissioner may collect any relevant information from an insurer 13that is necessary to conduct an audit under par. (a). SB45,1398,1514(c) The commissioner may contract with a 3rd party to conduct an audit under 15par. (a). SB45,1398,2016(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. SB45,1398,2221(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. SB45,1399,223(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). SB45,1399,63(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. SB45,28887Section 2888. 601.575 of the statutes is created to read: SB45,1399,138601.575 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: SB45,1399,1614(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. SB45,1399,1817(b) The program shall comply with relevant requirements of 21 USC 384, 18including safety and cost savings requirements. SB45,1399,2019(c) The program shall import prescription drugs from Canadian suppliers 20regulated under any appropriate Canadian or provincial laws.