Florida Senate - 2016 SENATOR AMENDMENT
Bill No. CS for CS for CS for SB 676
Ì5404769Î540476
LEGISLATIVE ACTION
Senate . House
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Floor: NC/2R .
03/09/2016 05:01 PM .
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Senator Hays moved the following:
1 Senate Substitute for Amendment (503040) (with title
2 amendment)
3
4 Between lines 960 and 961
5 insert:
6 Section 20. Effective January 1, 2018, section 627.42393,
7 Florida Statutes, is created to read:
8 627.42393 Continuity of care for medically stable
9 patients.—
10 (1) As used in this section, the term:
11 (a) “Complex or chronic medical condition” means a
12 physical, behavioral, or developmental condition that does not
13 have a known cure or that can be severely debilitating or fatal
14 if left untreated or undertreated.
15 (b) “Rare disease” has the same meaning as in the Public
16 Health Service Act, 42 U.S.C. s. 287a-1.
17 (2) A pharmacy benefits manager or an individual or group
18 insurance policy that is delivered, issued for delivery,
19 renewed, amended, or continued in this state and that provides
20 medical, major medical, or similar comprehensive coverage must
21 continue to cover a drug for an insured with a complex or
22 chronic medical condition or a rare disease if:
23 (a) The drug was previously covered by the insurer for a
24 medical condition or disease of the insured; and
25 (b) The prescribing provider continues to prescribe the
26 drug for the medical condition or disease, provided that the
27 drug is appropriately prescribed and neither of the following
28 has occurred:
29 1. The United States Food and Drug Administration has
30 issued a notice, guidance, warning, announcement, or any other
31 statement about the drug which calls into question the clinical
32 safety of the drug; or
33 2. The manufacturer of the drug has notified the United
34 States Food and Drug Administration of any manufacturing
35 discontinuance or potential discontinuance as required by s.
36 506C of the Federal Food Drug and Cosmetic Act, 21 U.S.C. s.
37 356c.
38 (3) With respect to a drug for an insured with a complex or
39 chronic medical condition or a rare disease which meets the
40 conditions of paragraphs (2)(a) and (2)(b), except during open
41 enrollment periods, a pharmacy benefits manager or an individual
42 or group insurance policy may not:
43 (a) Set forth, by contract, limitations on maximum coverage
44 of prescription drug benefits;
45 (b) Subject the insured to increased out-of-pocket costs;
46 or
47 (c) Move a drug for an insured to a more restrictive tier,
48 if an individual or group insurance policy or a pharmacy
49 benefits manager uses a formulary with tiers.
50 (4) This section does not apply to a grandfathered health
51 plan as defined in s. 627.402, or to benefits set forth in s.
52 627.6561(5)(b), (c), (d), and (e).
53 Section 21. Effective January 1, 2018, paragraph (e) of
54 subsection (5) of section 627.6699, Florida Statutes, is amended
55 to read:
56 627.6699 Employee Health Care Access Act.—
57 (5) AVAILABILITY OF COVERAGE.—
58 (e) All health benefit plans issued under this section must
59 comply with the following conditions:
60 1. For employers who have fewer than two employees, a late
61 enrollee may be excluded from coverage for no longer than 24
62 months if he or she was not covered by creditable coverage
63 continually to a date not more than 63 days before the effective
64 date of his or her new coverage.
65 2. Any requirement used by a small employer carrier in
66 determining whether to provide coverage to a small employer
67 group, including requirements for minimum participation of
68 eligible employees and minimum employer contributions, must be
69 applied uniformly among all small employer groups having the
70 same number of eligible employees applying for coverage or
71 receiving coverage from the small employer carrier, except that
72 a small employer carrier that participates in, administers, or
73 issues health benefits pursuant to s. 381.0406 which do not
74 include a preexisting condition exclusion may require as a
75 condition of offering such benefits that the employer has had no
76 health insurance coverage for its employees for a period of at
77 least 6 months. A small employer carrier may vary application of
78 minimum participation requirements and minimum employer
79 contribution requirements only by the size of the small employer
80 group.
81 3. In applying minimum participation requirements with
82 respect to a small employer, a small employer carrier shall not
83 consider as an eligible employee employees or dependents who
84 have qualifying existing coverage in an employer-based group
85 insurance plan or an ERISA qualified self-insurance plan in
86 determining whether the applicable percentage of participation
87 is met. However, a small employer carrier may count eligible
88 employees and dependents who have coverage under another health
89 plan that is sponsored by that employer.
90 4. A small employer carrier shall not increase any
91 requirement for minimum employee participation or any
92 requirement for minimum employer contribution applicable to a
93 small employer at any time after the small employer has been
94 accepted for coverage, unless the employer size has changed, in
95 which case the small employer carrier may apply the requirements
96 that are applicable to the new group size.
97 5. If a small employer carrier offers coverage to a small
98 employer, it must offer coverage to all the small employer’s
99 eligible employees and their dependents. A small employer
100 carrier may not offer coverage limited to certain persons in a
101 group or to part of a group, except with respect to late
102 enrollees.
103 6. A small employer carrier may not modify any health
104 benefit plan issued to a small employer with respect to a small
105 employer or any eligible employee or dependent through riders,
106 endorsements, or otherwise to restrict or exclude coverage for
107 certain diseases or medical conditions otherwise covered by the
108 health benefit plan.
109 7. An initial enrollment period of at least 30 days must be
110 provided. An annual 30-day open enrollment period must be
111 offered to each small employer’s eligible employees and their
112 dependents. A small employer carrier must provide special
113 enrollment periods as required by s. 627.65615.
114 8. A small employer carrier must provide continuity of care
115 for medically stable patients as required by s. 627.42392.
116 Section 22. Effective January 1, 2018, subsection (44) is
117 added to section 641.31, Florida Statutes, to read:
118 641.31 Health maintenance contracts.—
119 (44)(a) As used in this subsection, the term:
120 1. “Complex or chronic medical condition” means a physical,
121 behavioral, or developmental condition that does not have a
122 known cure or that can be severely debilitating or fatal if left
123 untreated or undertreated.
124 2. “Rare disease” has the same meaning as in the Public
125 Health Service Act, 42 U.S.C. s. 287a-1.
126 (b) A pharmacy benefits manager or a health maintenance
127 contract that is delivered, issued for delivery, renewed,
128 amended, or continued in this state and that provides medical,
129 major medical, or similar comprehensive coverage must continue
130 to cover a drug for a subscriber with a complex or chronic
131 medical condition or a rare disease if:
132 1. The drug was previously covered by the health
133 maintenance organization for a medical condition or disease of
134 the subscriber; and
135 2. The prescribing provider continues to prescribe the drug
136 for the medical condition or disease, provided that the drug is
137 appropriately prescribed and neither of the following has
138 occurred:
139 a. The United States Food and Drug Administration has
140 issued a notice, guidance, warning, announcement, or any other
141 statement about the drug which calls into question the clinical
142 safety of the drug; or
143 b. The manufacturer of the drug has notified the United
144 States Food and Drug Administration of any manufacturing
145 discontinuance or potential discontinuance as required by s.
146 506C of the Federal Food Drug and Cosmetic Act, 21 U.S.C. s.
147 356c.
148 (c) With respect to a drug for a subscriber with a complex
149 or chronic medical condition or a rare disease which meets the
150 conditions of subparagraphs (b)1. and (b)2., except during open
151 enrollment periods, a pharmacy benefits manager or a health
152 maintenance contract may not:
153 1. Set forth, by contract, limitations on maximum coverage
154 of prescription drug benefits;
155 2. Subject the subscriber to increased out-of-pocket costs;
156 or
157 3. Move a drug for a subscriber to a more restrictive tier,
158 if a health maintenance contract or a pharmacy benefits manager
159 uses a formulary with tiers.
160 (d) This section does not apply to a grandfathered health
161 plan as defined in s. 627.402.
162
163 ================= T I T L E A M E N D M E N T ================
164 And the title is amended as follows:
165 Between lines 71 and 72
166 insert:
167 creating s. 627.42392, F.S.; defining terms; requiring
168 a pharmacy benefits manager or a specified individual
169 or group insurance policy to continue to cover a drug
170 for specified insureds under certain circumstances;
171 prohibiting certain actions by a pharmacy benefits
172 manager or an individual or group policy with respect
173 to a drug for a certain insured except under certain
174 circumstances; providing applicability; amending s.
175 627.6699, F.S.; expanding a list of conditions that
176 certain health benefit plans must comply with;
177 amending s. 641.31, F.S.; defining terms; requiring a
178 pharmacy benefits manager or a specified health
179 maintenance contract to continue to cover a drug for
180 specified subscribers under certain circumstances;
181 prohibiting certain actions by a pharmacy benefits
182 manager or a health maintenance contract with respect
183 to a drug for a certain subscriber except under
184 certain circumstances; providing applicability;