AB68: Bill Text

AB68,1524,13 (c) A group health benefit plan other than one described under par. (b) shall have a medical loss ratio of at least 85 percent.

AB68,1524,17 (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.

AB68,2936 Section 2936. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and amended to read:

AB68,1525,2 632.746 (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.

AB68,2937 Section 2937. 632.746 (1) (b) of the statutes is repealed.

AB68,2938 Section 2938. 632.746 (2) (a) of the statutes is amended to read:

AB68,1525,8 632.746 (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.

AB68,2939 Section 2939. 632.746 (2) (c), (d) and (e) of the statutes are repealed.

AB68,2940 Section 2940. 632.746 (3) (a) of the statutes is repealed.

AB68,2941 Section 2941 . 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).

AB68,2942 Section 2942 . 632.746 (3) (d) 2. and 3. of the statutes are repealed.

AB68,2943 Section 2943 . 632.746 (5) of the statutes is repealed.

AB68,2944 Section 2944. 632.746 (8) (a) (intro.) of the statutes is amended to read:

AB68,1525,18 632.746 (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:

AB68,2945 Section 2945 . 632.748 (2) of the statutes is amended to read:

AB68,1526,2 632.748 (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 similarly situated individual enrolled under the plan.

AB68,2946 Section 2946. 632.7495 (4) (b) of the statutes is amended to read:

AB68,1526,4 632.7495 (4) (b) The coverage has a term of not more than 12 3 months.

AB68,2947 Section 2947. 632.7495 (4) (c) of the statutes is amended to read:

AB68,1526,10 632.7495 (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.

AB68,2948 Section 2948 . 632.7496 of the statutes is created to read:

AB68,1526,14 632.7496 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) that an insurer is not required to renew.

AB68,1526,17 (2) Guaranteed issue. Every short-term, limited duration plan shall accept every individual in this state who applies for coverage whether or not any individual has a preexisting condition.

AB68,1526,22 (3) Prohibiting discrimination based on health status. (a) 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 the plan based on any of the following health status-related factors in relation to the individual or a dependent of the individual:

AB68,1526,23 1. Health status.

AB68,1526,24 2. Medical condition, including both physical and mental illnesses.

AB68,1526,25 3. Claims experience.

AB68,1527,1 4. Receipt of health care.

AB68,1527,2 5. Medical history.

AB68,1527,3 6. Genetic information.

AB68,1527,5 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

AB68,1527,6 8. Disability.

AB68,1527,13 (b) A short-term, limited duration 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 a similarly situated individual enrolled under the plan.

AB68,1527,15 (4) Premium rate variation. A short-term, limited duration plan may vary premium rates for a specific plan based only on the following considerations:

AB68,1527,16 (a) Whether the policy or plan covers an individual or a family.

AB68,1527,17 (b) Rating area in the state, as established by the commissioner.

AB68,1527,20 (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.

AB68,1527,21 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

AB68,1527,23 (5) Annual and lifetime limits. A short-term, limited duration plan may not establish any of the following:

AB68,1527,25 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

AB68,1528,2 (b) Limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan for the initial or cumulative duration of the plan.

AB68,2949 Section 2949. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to read:

AB68,1528,12 632.76 (2) (a) No claim for loss incurred or disability commencing after 2 years from the date of issue of the policy may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of loss. This paragraph does not apply to a group health benefit plan, as defined in s. 632.745 (9), which is subject to s. 632.746 , a disability insurance policy, as defined in s. 632.895 (1) (a), or a self-insured health plan, as defined in s. 632.85 (1) (c).

AB68,1528,18 (ac) 1. Notwithstanding par. (a), no No claim or loss incurred or disability commencing after 12 months from the date of issue of under an individual disability insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description by a provision effective on the date of the loss.

AB68,1528,25 2. Except as provided in subd. 3., an An individual disability insurance policy, as defined in s. 632.895 (1) (a), other than a short-term policy subject to s. 632.7495 (4) and (5), may not define a preexisting condition more restrictively than a condition that was present before the date of enrollment for the coverage, whether physical or mental, regardless of the cause of the condition, for which and regardless of whether medical advice, diagnosis, care, or treatment was recommended or received within 12 months before the effective date of coverage.

AB68,2950 Section 2950. 632.76 (2) (ac) 3. (intro.) of the statutes is amended to read:

AB68,1529,4 632.76 (2) (ac) 3. (intro.) Except as the commissioner provides by rule under s. 632.7495 (5), all of the following apply to an individual disability insurance policy that is a short-term, limited duration policy subject to s. 632.7495 (4) and (5):

AB68,2951 Section 2951. 632.76 (2) (ac) 3. b. of the statutes is amended to read:

AB68,1529,11 632.76 (2) (ac) 3. b. The policy shall reduce the length of time during which a may not impose any preexisting condition exclusion may be imposed by the aggregate of the insured's consecutive periods of coverage under the insurer's individual disability insurance policies that are short-term policies subject to s. 632.7495 (4) and (5). For purposes of this subd. 3. b., coverage periods are consecutive if there are no more than 63 days between the coverage periods.

AB68,2952 Section 2952. 632.795 (4) (a) of the statutes is amended to read:

AB68,1529,24 632.795 (4) (a) An insurer subject to sub. (2) shall provide coverage under the same policy form and for the same premium as it originally offered in the most recent enrollment period, subject only to the medical underwriting used in that enrollment period. Unless otherwise prescribed by rule, the insurer may apply deductibles, preexisting condition limitations, waiting periods , or other limits only to the extent that they would have been applicable had coverage been extended at the time of the most recent enrollment period and with credit for the satisfaction or partial satisfaction of similar provisions under the liquidated insurer's policy or plan. The insurer may exclude coverage of claims that are payable by a solvent insurer under insolvency coverage required by the commissioner or by the insurance regulator of another jurisdiction. Coverage shall be effective on the date that the liquidated insurer's coverage terminates.

AB68,2953 Section 2953. 632.796 of the statutes is created to read:

AB68,1530,2 632.796 Drug cost report. (1) Definition. In this section, “disability insurance policy” has the meaning given in s. 632.895 (1) (a).

AB68,1530,8 (2) Report required. Annually, at the time the insurer files its rate request with the commissioner, each insurer that offers a disability insurance policy that covers prescription drugs shall submit to the commissioner a report that identifies the 25 prescription drugs that are the highest cost to the insurer and the 25 prescription drugs that have the highest cost increases over the 12 months before the submission of the report.

AB68,2954 Section 2954 . 632.86 of the statutes is repealed.

AB68,2955 Section 2955 . 632.861 of the statutes is created to read:

AB68,1530,11 632.861 Prescription drug charges. (1) Definitions. In this section:

AB68,1530,12 (a) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

AB68,1530,14 (b) “Enrollee” means an individual who is covered under a disability insurance policy or a self-insured health plan.

AB68,1530,15 (c) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).

AB68,1530,16 (d) “Prescription drug” has the meaning given in s. 450.01 (20).

AB68,1530,17 (e) “Prescription drug benefit” has the meaning given in s. 632.865 (1) (e).

AB68,1530,18 (f) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB68,1531,2 (2) Allowing disclosures. (a) A disability insurance policy or self-insured health plan that provides a prescription drug benefit may not restrict, directly or indirectly, any pharmacy that dispenses a prescription drug to an enrollee in the policy or plan from informing, or penalize such pharmacy for informing, an enrollee of any differential between the out-of-pocket cost to the enrollee under the policy or plan with respect to acquisition of the drug and the amount an individual would pay for acquisition of the drug without using any health plan or health insurance coverage.

AB68,1531,11 (b) A disability insurance policy or self-insured health plan that provides a prescription drug benefit shall ensure that any pharmacy benefit manager that provides services under a contract with the policy or plan does not, with respect to such policy or plan, restrict, directly or indirectly, any pharmacy that dispenses a prescription drug to an enrollee in the policy or plan from informing, or penalize such pharmacy for informing, an enrollee of any differential between the out-of-pocket cost to the enrollee under the policy or plan with respect to acquisition of the drug and the amount an individual would pay for acquisition of the drug without using any health plan or health insurance coverage.

AB68,1531,16 (3) Cost-sharing limitation. A disability insurance policy or self-insured health plan that provides a prescription drug benefit or a pharmacy benefit manager that provides services under a contract with a policy or plan may not require an enrollee to pay at the point of sale for a covered prescription drug an amount that is greater than the lowest of all of the following amounts:

AB68,1531,18 (a) The cost-sharing amount for the prescription drug for the enrollee under the policy or plan.

AB68,1531,21 (b) The amount a person would pay for the prescription drug if the enrollee purchased the prescription drug at the dispensing pharmacy without using any health plan or health insurance coverage.

AB68,1532,10 (4) Drug substitution. (a) Except as provided in par. (b), a disability insurance policy that offers a prescription drug benefit, a self-insured health plan that offers a prescription drug benefit, or a pharmacy benefit manager acting on behalf of a disability insurance policy or self-insured health plan shall provide to an enrollee advanced written notice of a formulary change that removes a prescription drug from the formulary of the policy or plan or that reassigns a prescription drug to a benefit tier for the policy or plan that has a higher deductible, copayment, or coinsurance. The advanced written notice of a formulary change under this paragraph shall be provided no fewer than 30 days before the expected date of the removal or reassignment and shall include information on the procedure for the enrollee to request an exception to the formulary change. The policy, plan, or pharmacy benefit manager is required to provide the advanced written notice under this paragraph only to those enrollees in the policy or plan who are using the drug at the time the notification must be sent according to available claims history.

AB68,1532,13 (b) 1. A disability insurance policy, self-insured health plan, or pharmacy benefit manager is not required to provide advanced written notice under par. (a) if the prescription drug that is to be removed or reassigned is any of the following:

AB68,1532,14 a. No longer approved by the federal food and drug administration.

AB68,1532,17 b. The subject of a notice, guidance, warning, announcement, or other statement from the federal food and drug administration relating to concerns about the safety of the prescription drug.

AB68,1532,19 c. Approved by the federal food and drug administration for use without a prescription.

AB68,1533,2 2. A disability insurance policy, self-insured health plan, or pharmacy benefit manager is not required to provide advanced written notice under par. (a) if, for the prescription drug that is being removed from the formulary or reassigned to a benefit tier that has a higher deductible, copayment, or coinsurance, the policy, plan, or pharmacy benefit manager adds to the formulary a generic prescription drug that is approved by the federal food and drug administration for use as an alternative to the prescription drug or a prescription drug in the same pharmacologic class or with the same mechanism of action at any of the following benefit tiers:

AB68,1533,4 a. The same benefit tier from which the prescription drug is being removed or reassigned.

AB68,1533,6 b. A benefit tier that has a lower deductible, copayment, or coinsurance than the benefit tier from which the prescription drug is being removed or reassigned.

AB68,1533,14 (c) A pharmacist or pharmacy shall notify an enrollee in a disability insurance policy or self-insured health plan if a prescription drug for which an enrollee is filling or refilling a prescription is removed from the formulary and the policy or plan or a pharmacy benefit manager acting on behalf of a policy or plan adds to the formulary a generic prescription drug that is approved by the federal food and drug administration for use as an alternative to the prescription drug or a prescription drug in the same pharmacologic class or with the same mechanism of action at any of the following benefit tiers:

AB68,1533,16 1. The same benefit tier from which the prescription drug is being removed or reassigned.

AB68,1533,18 2. A benefit tier that has a lower deductible, copayment, or coinsurance than the benefit tier from which the prescription drug is being removed or reassigned.

AB68,1533,25 (d) If an enrollee has had an adverse reaction to the generic prescription drug or the prescription drug in the same pharmacologic class or with the same mechanism of action that is being substituted for an originally prescribed drug, the pharmacist or pharmacy may extend the prescription order for the originally prescribed drug to fill one 30-day supply of the originally prescribed drug for the cost-sharing amount that applies to the prescription drug at the time of the substitution.

AB68,2956 Section 2956. 632.862 of the statutes is created to read:

AB68,1534,3 632.862 Application of prescription drug payments. (1) Definitions. In this section:

AB68,1534,4 (a) “Brand name” has the meaning given in s. 450.12 (1) (a).

AB68,1534,5 (b) “Brand name drug” means any of the following:

AB68,1534,7 1. A prescription drug that contains a brand name and that has no generic equivalent.

AB68,1534,11 2. A prescription drug that contains a brand name and has a generic equivalent but for which the enrollee has received prior authorization from the insurer offering the disability insurance policy or the self-insured health plan or authorization from a physician to obtain the prescription drug under the policy or plan.

AB68,1534,12 (c) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

AB68,1534,13 (d) “Prescription drug” has the meaning given in s. 450.01 (20)

AB68,1534,14 (e) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).