Amendment AA3-SB70

SB70-AA3,31,2 632.865 (2m) Fiduciary duty and disclosures to health benefit plan sponsors. (a) A pharmacy benefit manager owes a fiduciary duty to the health benefit plan sponsor to act according to the health benefit plan sponsor's instructions and in the best interests of the health benefit plan sponsor.

SB70-AA3,31,5 (b) A pharmacy benefit manager shall annually provide, no later than the date and using the method prescribed by the commissioner by rule, the health benefit plan sponsor all of the following information from the previous calendar year:

SB70-AA3,31,7 1. The indirect profit received by the pharmacy benefit manager from owning any interest in a pharmacy or service provider.

SB70-AA3,31,9 2. Any payment made by the pharmacy benefit manager to a consultant or broker who works on behalf of the health benefit plan sponsor.

SB70-AA3,31,13 3. From the amounts received from all drug manufacturers, the amounts retained by the pharmacy benefit manager, and not passed through to the health benefit plan sponsor, that are related to the health benefit plan sponsor's claims or bona fide service fees.

SB70-AA3,31,18 4. The amounts, including pharmacy access and audit recovery fees, received from all pharmacies that are in the pharmacy benefit manager's network or have a contract to be in the network and, from these amounts, the amount retained by the pharmacy benefit manager and not passed through to the health benefit plan sponsor.”.

SB70-AA3,31,19 178. Page 374, line 11: after that line insert:

SB70-AA3,31,20 “ Section 3. 632.869 of the statutes is created to read:

SB70-AA3,31,22 632.869 Reimbursement to federal drug pricing program participants. (1) In this section:

SB70-AA3,32,2 (a) “Covered entity” means an entity described in 42 USC 256b (a) (4) (A), (D), (E), (J), or (N) that participates in the federal drug pricing program under 42 USC 256b, a pharmacy of the entity, or a pharmacy contracted with the entity to dispense drugs purchased through the federal drug pricing program under 42 USC 256b.

SB70-AA3,32,3 (b) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).

SB70-AA3,32,5 (2) No person, including a pharmacy benefit manager and 3rd-party payer, may do any of the following:

SB70-AA3,32,9 (a) Reimburse a covered entity for a drug that is subject to an agreement under 42 USC 256b at a rate lower than that paid for the same drug to pharmacies that are not covered entities and have a similar prescription volume to that of the covered entity.

SB70-AA3,32,12 (b) Assess a covered entity any fee, charge back, or other adjustment on the basis of the covered entity's participation in the federal drug pricing program under 42 USC 256b.

SB70-AA3,32,15 (3) The commissioner may promulgate rules to implement this section and to establish a minimum reimbursement rate for covered entities and any other entity described under 42 USC 256b (a) (4).”.

SB70-AA3,32,16 179. Page 374, line 11: after that line insert:

SB70-AA3,32,17 “ Section 4. 609.712 of the statutes is created to read:

SB70-AA3,32,19 609.712 Essential health benefits; preventive services. Defined network plans and preferred provider plans are subject to s. 632.895 (13m) and (14m).

SB70-AA3,5 Section 5. 609.847 of the statutes is created to read:

SB70-AA3,32,23 609.847 Preexisting condition discrimination and certain benefit limits prohibited. Limited service health organizations, preferred provider plans, and defined network plans are subject to s. 632.728.

SB70-AA3,6 Section 6. 625.12 (1) (a) of the statutes is amended to read:

SB70-AA3,33,2 625.12 (1) (a) Past and prospective loss and expense experience within and outside of this state, except as provided in s. 632.728.

SB70-AA3,7 Section 7. 625.12 (1) (e) of the statutes is amended to read:

SB70-AA3,33,5 625.12 (1) (e) Subject to s. ss. 632.365 and 632.728, all other relevant factors, including the judgment of technical personnel.

SB70-AA3,8 Section 8. 625.12 (2) of the statutes is amended to read:

SB70-AA3,33,15 625.12 (2) Classification. Except as provided in s. ss. 632.728 and 632.729, risks may be classified in any reasonable way for the establishment of rates and minimum premiums, except that no classifications may be based on race, color, creed or national origin, and classifications in automobile insurance may not be based on physical condition or developmental disability as defined in s. 51.01 (5). Subject to ss. 632.365, 632.728, and 632.729, rates thus produced may be modified for individual risks in accordance with rating plans or schedules that establish reasonable standards for measuring probable variations in hazards, expenses, or both. Rates may also be modified for individual risks under s. 625.13 (2).

SB70-AA3,9 Section 9. 625.15 (1) of the statutes is amended to read:

SB70-AA3,33,24 625.15 (1) Rate making. An Except as provided in s. 632.728, an insurer may itself establish rates and supplementary rate information for one or more market segments based on the factors in s. 625.12 and, if the rates are for motor vehicle liability insurance, subject to s. 632.365, or the insurer may use rates and supplementary rate information prepared by a rate service organization, with average expense factors determined by the rate service organization or with such modification for its own expense and loss experience as the credibility of that experience allows.

SB70-AA3,10 Section 10. 628.34 (3) (a) of the statutes is amended to read:

SB70-AA3,34,8 628.34 (3) (a) No insurer may unfairly discriminate among policyholders by charging different premiums or by offering different terms of coverage except on the basis of classifications related to the nature and the degree of the risk covered or the expenses involved, subject to ss. 632.365, 632.728, 632.729, 632.746 and, 632.748, and 632.7496. Rates are not unfairly discriminatory if they are averaged broadly among persons insured under a group, blanket or franchise policy, and terms are not unfairly discriminatory merely because they are more favorable than in a similar individual policy.

SB70-AA3,11 Section 11. 632.728 of the statutes is created to read:

SB70-AA3,34,11 632.728 Coverage of persons with preexisting conditions; guaranteed issue; benefit limits. (1) Definitions. In this section:

SB70-AA3,34,13 (a) “Cost sharing” includes deductibles, coinsurance, copayments, or similar charges.

SB70-AA3,34,14 (b) “Health benefit plan” has the meaning given in s. 632.745 (11).

SB70-AA3,34,15 (c) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

SB70-AA3,34,21 (2) Guaranteed issue. (a) Every individual health benefit plan shall accept every individual in this state who, and every group health benefit plan shall accept every employer in this state that, applies for coverage, regardless of sexual orientation, gender identity, or whether or not any employee or individual has a preexisting condition. A health benefit plan may restrict enrollment in coverage described in this paragraph to open or special enrollment periods.

SB70-AA3,34,24 (b) The commissioner shall establish a statewide open enrollment period of no shorter than 30 days for every individual health benefit plan to allow individuals, including individuals who do not have coverage, to enroll in coverage.

SB70-AA3,35,5 (3) Prohibiting discrimination based on health status. (a) An individual health benefit plan or a self-insured health 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:

SB70-AA3,35,6 1. Health status.

SB70-AA3,35,7 2. Medical condition, including both physical and mental illnesses.

SB70-AA3,35,8 3. Claims experience.

SB70-AA3,35,9 4. Receipt of health care.

SB70-AA3,35,10 5. Medical history.

SB70-AA3,35,11 6. Genetic information.

SB70-AA3,35,13 7. Evidence of insurability, including conditions arising out of acts of domestic violence.

SB70-AA3,35,14 8. Disability.

SB70-AA3,35,21 (b) An insurer offering an individual health benefit plan or a self-insured health 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.

SB70-AA3,35,25 (c) Nothing in this subsection prevents an insurer offering an individual health benefit plan or a self-insured health plan from establishing premium discounts or rebates or modifying otherwise applicable cost sharing in return for adherence to programs of health promotion and disease prevention.

SB70-AA3,36,3 (4) Premium rate variation. A health benefit plan offered on the individual or small employer market or a self-insured health plan may vary premium rates for a specific plan based only on the following considerations:

SB70-AA3,36,4 (a) Whether the policy or plan covers an individual or a family.

SB70-AA3,36,5 (b) Rating area in the state, as established by the commissioner.

SB70-AA3,36,8 (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.

SB70-AA3,36,9 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

SB70-AA3,36,14 (5) Statewide risk pool. An insurer offering a health benefit plan may not segregate enrollees into risk pools other than a single statewide risk pool for the individual market and a single statewide risk pool for the small employer market or a single statewide risk pool that combines the individual and small employer markets.

SB70-AA3,36,16 (6) Annual and lifetime limits. An individual or group health benefit plan or a self-insured health plan may not establish any of the following:

SB70-AA3,36,18 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

SB70-AA3,36,20 (b) Annual limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the plan.

SB70-AA3,36,24 (7) Cost sharing maximum. A health benefit plan offered on the individual or small employer market may not require an enrollee under the plan to pay more in cost sharing than the maximum amount calculated under 42 USC 18022 (c), including the annual indexing of the limits.

SB70-AA3,37,3 (8) Medical loss ratio. (a) In this subsection, “medical loss ratio” means the proportion, expressed as a percentage, of premium revenues spent by a health benefit plan on clinical services and quality improvement.

SB70-AA3,37,5 (b) A health benefit plan on the individual or small employer market shall have a medical loss ratio of at least 80 percent.

SB70-AA3,37,7 (c) A group health benefit plan other than one described under par. (b) shall have a medical loss ratio of at least 85 percent.

SB70-AA3,37,11 (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.

SB70-AA3,12 Section 12. 632.746 (1) (a) of the statutes is renumbered 632.746 (1) and amended to read:

SB70-AA3,37,20 632.746 (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.

SB70-AA3,13 Section 13. 632.746 (1) (b) of the statutes is repealed.

SB70-AA3,14 Section 14. 632.746 (2) (a) of the statutes is amended to read:

SB70-AA3,38,2 632.746 (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.

SB70-AA3,15 Section 15. 632.746 (2) (c), (d) and (e) of the statutes are repealed.

SB70-AA3,16 Section 16. 632.746 (3) (a) of the statutes is repealed.

SB70-AA3,17 Section 17. 632.746 (3) (d) 1. of the statutes is renumbered 632.746 (3) (d).

SB70-AA3,18 Section 18. 632.746 (3) (d) 2. and 3. of the statutes are repealed.

SB70-AA3,19 Section 19. 632.746 (5) of the statutes is repealed.

SB70-AA3,20 Section 20. 632.746 (8) (a) (intro.) of the statutes is amended to read:

SB70-AA3,38,12 632.746 (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:

SB70-AA3,21 Section 21. 632.748 (2) of the statutes is amended to read:

SB70-AA3,38,20 632.748 (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.

SB70-AA3,22 Section 22. 632.76 (2) (a) and (ac) 1. and 2. of the statutes are amended to read:

SB70-AA3,39,4 632.76 (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).

SB70-AA3,39,10 (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.

SB70-AA3,39,17 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.

SB70-AA3,23 Section 23. 632.795 (4) (a) of the statutes is amended to read:

SB70-AA3,40,5 632.795 (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.

SB70-AA3,24 Section 24. 632.895 (8) (d) of the statutes is amended to read:

SB70-AA3,40,13 632.895 (8) (d) Coverage is required under this subsection despite whether the woman shows any symptoms of breast cancer. Except as provided in pars. (b), (c), and (e), coverage under this subsection may only be subject to exclusions and limitations, including deductibles, copayments and restrictions on excessive charges, that are applied to other radiological examinations covered under the disability insurance policy. Coverage under this subsection may not be subject to any deductibles, copayments, or coinsurance.

SB70-AA3,25 Section 25. 632.895 (13m) of the statutes is created to read:

SB70-AA3,40,16 632.895 (13m) Preventive services. (a) In this section, “self-insured health plan” has the meaning given in s. 632.85 (1) (c).

SB70-AA3,40,19 (b) Every disability insurance policy, except any disability insurance policy that is described in s. 632.745 (11) (b) 1. to 12., and every self-insured health plan shall provide coverage for all of the following preventive services:

SB70-AA3,40,20 1. Mammography in accordance with sub. (8).

SB70-AA3,40,22 2. Genetic breast cancer screening and counseling and preventive medication for adult women at high risk for breast cancer.