SB70-AA3,31,223 632.865 (2m) Fiduciary duty and disclosures to health benefit plan
24sponsors
. (a) A pharmacy benefit manager owes a fiduciary duty to the health

1benefit plan sponsor to act according to the health benefit plan sponsor's instructions
2and in the best interests of the health benefit plan sponsor.
SB70-AA3,31,53 (b) A pharmacy benefit manager shall annually provide, no later than the date
4and using the method prescribed by the commissioner by rule, the health benefit plan
5sponsor all of the following information from the previous calendar year:
SB70-AA3,31,76 1. The indirect profit received by the pharmacy benefit manager from owning
7any interest in a pharmacy or service provider.
SB70-AA3,31,98 2. Any payment made by the pharmacy benefit manager to a consultant or
9broker who works on behalf of the health benefit plan sponsor.
SB70-AA3,31,1310 3. From the amounts received from all drug manufacturers, the amounts
11retained by the pharmacy benefit manager, and not passed through to the health
12benefit plan sponsor, that are related to the health benefit plan sponsor's claims or
13bona fide service fees.
SB70-AA3,31,1814 4. The amounts, including pharmacy access and audit recovery fees, received
15from all pharmacies that are in the pharmacy benefit manager's network or have a
16contract to be in the network and, from these amounts, the amount retained by the
17pharmacy benefit manager and not passed through to the health benefit plan
18sponsor.”.
SB70-AA3,31,19 19178. Page 374, line 11: after that line insert:
SB70-AA3,31,20 20 Section 3. 632.869 of the statutes is created to read:
SB70-AA3,31,22 21632.869 Reimbursement to federal drug pricing program participants.
22 (1) In this section:
SB70-AA3,32,223 (a) “Covered entity” means an entity described in 42 USC 256b (a) (4) (A), (D),
24(E), (J), or (N) that participates in the federal drug pricing program under 42 USC

1256b, a pharmacy of the entity, or a pharmacy contracted with the entity to dispense
2drugs purchased through the federal drug pricing program under 42 USC 256b.
SB70-AA3,32,33 (b) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).
SB70-AA3,32,5 4(2) No person, including a pharmacy benefit manager and 3rd-party payer,
5may do any of the following:
SB70-AA3,32,96 (a) Reimburse a covered entity for a drug that is subject to an agreement under
742 USC 256b at a rate lower than that paid for the same drug to pharmacies that are
8not covered entities and have a similar prescription volume to that of the covered
9entity.
SB70-AA3,32,1210 (b) Assess a covered entity any fee, charge back, or other adjustment on the
11basis of the covered entity's participation in the federal drug pricing program under
1242 USC 256b.
SB70-AA3,32,15 13(3) The commissioner may promulgate rules to implement this section and to
14establish a minimum reimbursement rate for covered entities and any other entity
15described under 42 USC 256b (a) (4).”.
SB70-AA3,32,16 16179. Page 374, line 11: after that line insert:
SB70-AA3,32,17 17 Section 4. 609.712 of the statutes is created to read:
SB70-AA3,32,19 18609.712 Essential health benefits; preventive services. Defined network
19plans and preferred provider plans are subject to s. 632.895 (13m) and (14m).
SB70-AA3,5 20Section 5. 609.847 of the statutes is created to read:
SB70-AA3,32,23 21609.847 Preexisting condition discrimination and certain benefit
22limits prohibited.
Limited service health organizations, preferred provider plans,
23and defined network plans are subject to s. 632.728.
SB70-AA3,6 24Section 6. 625.12 (1) (a) of the statutes is amended to read:
SB70-AA3,33,2
1625.12 (1) (a) Past and prospective loss and expense experience within and
2outside of this state, except as provided in s. 632.728.
SB70-AA3,7 3Section 7. 625.12 (1) (e) of the statutes is amended to read:
SB70-AA3,33,54 625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors,
5including the judgment of technical personnel.
SB70-AA3,8 6Section 8. 625.12 (2) of the statutes is amended to read:
SB70-AA3,33,157 625.12 (2) Classification. Except as provided in s. ss. 632.728 and 632.729,
8risks may be classified in any reasonable way for the establishment of rates and
9minimum premiums, except that no classifications may be based on race, color, creed
10or national origin, and classifications in automobile insurance may not be based on
11physical condition or developmental disability as defined in s. 51.01 (5). Subject to
12ss. 632.365, 632.728, and 632.729, rates thus produced may be modified for
13individual risks in accordance with rating plans or schedules that establish
14reasonable standards for measuring probable variations in hazards, expenses, or
15both. Rates may also be modified for individual risks under s. 625.13 (2).
SB70-AA3,9 16Section 9. 625.15 (1) of the statutes is amended to read:
SB70-AA3,33,2417 625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may
18itself establish rates and supplementary rate information for one or more market
19segments based on the factors in s. 625.12 and, if the rates are for motor vehicle
20liability insurance, subject to s. 632.365, or the insurer may use rates and
21supplementary rate information prepared by a rate service organization, with
22average expense factors determined by the rate service organization or with such
23modification for its own expense and loss experience as the credibility of that
24experience allows.
SB70-AA3,10 25Section 10. 628.34 (3) (a) of the statutes is amended to read:
SB70-AA3,34,8
1628.34 (3) (a) No insurer may unfairly discriminate among policyholders by
2charging different premiums or by offering different terms of coverage except on the
3basis of classifications related to the nature and the degree of the risk covered or the
4expenses involved, subject to ss. 632.365, 632.728, 632.729, 632.746 and, 632.748,
5and 632.7496
. Rates are not unfairly discriminatory if they are averaged broadly
6among persons insured under a group, blanket or franchise policy, and terms are not
7unfairly discriminatory merely because they are more favorable than in a similar
8individual policy.
SB70-AA3,11 9Section 11. 632.728 of the statutes is created to read:
SB70-AA3,34,11 10632.728 Coverage of persons with preexisting conditions; guaranteed
11issue; benefit limits.
(1) Definitions. In this section:
SB70-AA3,34,1312 (a) “Cost sharing” includes deductibles, coinsurance, copayments, or similar
13charges.
SB70-AA3,34,1414 (b) “Health benefit plan” has the meaning given in s. 632.745 (11).
SB70-AA3,34,1515 (c) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).
SB70-AA3,34,21 16(2) Guaranteed issue. (a) Every individual health benefit plan shall accept
17every individual in this state who, and every group health benefit plan shall accept
18every employer in this state that, applies for coverage, regardless of sexual
19orientation, gender identity, or whether or not any employee or individual has a
20preexisting condition. A health benefit plan may restrict enrollment in coverage
21described in this paragraph to open or special enrollment periods.
SB70-AA3,34,2422 (b) The commissioner shall establish a statewide open enrollment period of no
23shorter than 30 days for every individual health benefit plan to allow individuals,
24including individuals who do not have coverage, to enroll in coverage.
SB70-AA3,35,5
1(3) Prohibiting discrimination based on health status. (a) An individual
2health benefit plan or a self-insured health plan may not establish rules for the
3eligibility of any individual to enroll, or for the continued eligibility of any individual
4to remain enrolled, under the plan based on any of the following health
5status-related factors in relation to the individual or a dependent of the individual:
SB70-AA3,35,66 1. Health status.
SB70-AA3,35,77 2. Medical condition, including both physical and mental illnesses.
SB70-AA3,35,88 3. Claims experience.
SB70-AA3,35,99 4. Receipt of health care.
SB70-AA3,35,1010 5. Medical history.
SB70-AA3,35,1111 6. Genetic information.
SB70-AA3,35,1312 7. Evidence of insurability, including conditions arising out of acts of domestic
13violence.
SB70-AA3,35,1414 8. Disability.
SB70-AA3,35,2115 (b) An insurer offering an individual health benefit plan or a self-insured
16health plan may not require any individual, as a condition of enrollment or continued
17enrollment under the plan, to pay, on the basis of any health status-related factor
18under par. (a) with respect to the individual or a dependent of the individual, a
19premium or contribution or a deductible, copayment, or coinsurance amount that is
20greater than the premium or contribution or deductible, copayment, or coinsurance
21amount respectively for a similarly situated individual enrolled under the plan.
SB70-AA3,35,2522 (c) Nothing in this subsection prevents an insurer offering an individual health
23benefit plan or a self-insured health plan from establishing premium discounts or
24rebates or modifying otherwise applicable cost sharing in return for adherence to
25programs of health promotion and disease prevention.
SB70-AA3,36,3
1(4) Premium rate variation. A health benefit plan offered on the individual or
2small employer market or a self-insured health plan may vary premium rates for a
3specific plan based only on the following considerations:
SB70-AA3,36,44 (a) Whether the policy or plan covers an individual or a family.
SB70-AA3,36,55 (b) Rating area in the state, as established by the commissioner.
SB70-AA3,36,86 (c) Age, except that the rate may not vary by more than 3 to 1 for adults over
7the age groups and the age bands shall be consistent with recommendations of the
8National Association of Insurance Commissioners.
SB70-AA3,36,99 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.
SB70-AA3,36,14 10(5) Statewide risk pool. An insurer offering a health benefit plan may not
11segregate enrollees into risk pools other than a single statewide risk pool for the
12individual market and a single statewide risk pool for the small employer market or
13a single statewide risk pool that combines the individual and small employer
14markets.
SB70-AA3,36,16 15(6) Annual and lifetime limits. An individual or group health benefit plan or
16a self-insured health plan may not establish any of the following:
SB70-AA3,36,1817 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent
18of an enrollee under the plan.
SB70-AA3,36,2019 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent
20of an enrollee under the plan.
SB70-AA3,36,24 21(7) Cost sharing maximum. A health benefit plan offered on the individual or
22small employer market may not require an enrollee under the plan to pay more in
23cost sharing than the maximum amount calculated under 42 USC 18022 (c),
24including the annual indexing of the limits.
SB70-AA3,37,3
1(8) Medical loss ratio. (a) In this subsection, “medical loss ratio” means the
2proportion, expressed as a percentage, of premium revenues spent by a health
3benefit plan on clinical services and quality improvement.
SB70-AA3,37,54 (b) A health benefit plan on the individual or small employer market shall have
5a medical loss ratio of at least 80 percent.
SB70-AA3,37,76 (c) A group health benefit plan other than one described under par. (b) shall
7have a medical loss ratio of at least 85 percent.
SB70-AA3,37,11 8(9) Actuarial values of plan tiers. Any health benefit plan offered on the
9individual or small employer market shall provide a level of coverage that is designed
10to provide benefits that are actuarially equivalent to at least 60 percent of the full
11actuarial value of the benefits provided under the plan.
SB70-AA3,12 12Section 12. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and
13amended to read:
SB70-AA3,37,2014 632.746 (1) Subject to subs. (2) and (3), an An insurer that offers a group health
15benefit plan may, with respect to a participant or beneficiary under the plan, not
16impose a preexisting condition exclusion only if the exclusion relates to a condition,
17whether physical or mental, regardless of the cause of the condition, for which
18medical advice, diagnosis, care or treatment was recommended or received within
19the 6-month period ending on the participant's or beneficiary's enrollment date
20under the plan
on a participant or beneficiary under the plan.
SB70-AA3,13 21Section 13. 632.746 (1) (b) of the statutes is repealed.
SB70-AA3,14 22Section 14. 632.746 (2) (a) of the statutes is amended to read:
SB70-AA3,38,223 632.746 (2) (a) An insurer offering a group health benefit plan may not treat
24impose a preexisting condition exclusion based on genetic information as a

1preexisting condition under sub. (1) without a diagnosis of a condition related to the
2information
.
SB70-AA3,15 3Section 15. 632.746 (2) (c), (d) and (e) of the statutes are repealed.
SB70-AA3,16 4Section 16. 632.746 (3) (a) of the statutes is repealed.
SB70-AA3,17 5Section 17. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).
SB70-AA3,18 6Section 18. 632.746 (3) (d) 2. and 3. of the statutes are repealed.
SB70-AA3,19 7Section 19. 632.746 (5) of the statutes is repealed.
SB70-AA3,20 8Section 20. 632.746 (8) (a) (intro.) of the statutes is amended to read:
SB70-AA3,38,129 632.746 (8) (a) (intro.) A health maintenance organization that offers a group
10health benefit plan and that does not impose any preexisting condition exclusion
11under sub. (1)
with respect to a particular coverage option may impose an affiliation
12period for that coverage option, but only if all of the following apply:
SB70-AA3,21 13Section 21. 632.748 (2) of the statutes is amended to read:
SB70-AA3,38,2014 632.748 (2) An insurer offering a group health benefit plan may not require any
15individual, as a condition of enrollment or continued enrollment under the plan, to
16pay, on the basis of any health status-related factor with respect to the individual
17or a dependent of the individual, a premium or contribution or a deductible,
18copayment, or coinsurance amount
that is greater than the premium or contribution
19or deductible, copayment, or coinsurance amount respectively for a similarly
20situated individual enrolled under the plan.
SB70-AA3,22 21Section 22. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to read:
SB70-AA3,39,422 632.76 (2) (a) No claim for loss incurred or disability commencing after 2 years
23from the date of issue of the policy may be reduced or denied on the ground that a
24disease or physical condition existed prior to the effective date of coverage, unless the
25condition was excluded from coverage by name or specific description by a provision

1effective on the date of loss. This paragraph does not apply to a group health benefit
2plan, as defined in s. 632.745 (9), which is subject to s. 632.746 , a disability insurance
3policy, as defined in s. 632.895 (1) (a), or a self-insured health plan, as defined in s.
4632.85 (1) (c)
.
SB70-AA3,39,105 (ac) 1. Notwithstanding par. (a), no No claim or loss incurred or disability
6commencing after 12 months from the date of issue of under an individual disability
7insurance policy, as defined in s. 632.895 (1) (a), may be reduced or denied on the
8ground that a disease or physical condition existed prior to the effective date of
9coverage, unless the condition was excluded from coverage by name or specific
10description by a provision effective on the date of the loss
.
SB70-AA3,39,1711 2. Except as provided in subd. 3., an An individual disability insurance policy,
12as defined in s. 632.895 (1) (a), other than a short-term policy subject to s. 632.7495
13(4) and (5), may not define a preexisting condition more restrictively than a condition
14that was present before the date of enrollment for the coverage, whether physical or
15mental, regardless of the cause of the condition, for which and regardless of whether
16medical advice, diagnosis, care, or treatment was recommended or received within
1712 months before the effective date of coverage
.
SB70-AA3,23 18Section 23. 632.795 (4) (a) of the statutes is amended to read:
SB70-AA3,40,519 632.795 (4) (a) An insurer subject to sub. (2) shall provide coverage under the
20same policy form and for the same premium as it originally offered in the most recent
21enrollment period, subject only to the medical underwriting used in that enrollment
22period. Unless otherwise prescribed by rule, the insurer may apply deductibles,
23preexisting condition limitations, waiting periods , or other limits only to the extent
24that they would have been applicable had coverage been extended at the time of the
25most recent enrollment period and with credit for the satisfaction or partial

1satisfaction of similar provisions under the liquidated insurer's policy or plan. The
2insurer may exclude coverage of claims that are payable by a solvent insurer under
3insolvency coverage required by the commissioner or by the insurance regulator of
4another jurisdiction. Coverage shall be effective on the date that the liquidated
5insurer's coverage terminates.
SB70-AA3,24 6Section 24. 632.895 (8) (d) of the statutes is amended to read:
SB70-AA3,40,137 632.895 (8) (d) Coverage is required under this subsection despite whether the
8woman shows any symptoms of breast cancer. Except as provided in pars. (b), (c), and
9(e), coverage under this subsection may only be subject to exclusions and limitations,
10including deductibles, copayments and restrictions on excessive charges, that are
11applied to other radiological examinations covered under the disability insurance
12policy. Coverage under this subsection may not be subject to any deductibles,
13copayments, or coinsurance.
SB70-AA3,25 14Section 25. 632.895 (13m) of the statutes is created to read:
SB70-AA3,40,1615 632.895 (13m) Preventive services. (a) In this section, “self-insured health
16plan” has the meaning given in s. 632.85 (1) (c).
SB70-AA3,40,1917 (b) Every disability insurance policy, except any disability insurance policy that
18is described in s. 632.745 (11) (b) 1. to 12., and every self-insured health plan shall
19provide coverage for all of the following preventive services:
SB70-AA3,40,2020 1. Mammography in accordance with sub. (8).
SB70-AA3,40,2221 2. Genetic breast cancer screening and counseling and preventive medication
22for adult women at high risk for breast cancer.
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