Florida Senate - 2024                                     SB 228
       
       
        
       By Senator Wright
       
       
       
       
       
       8-00104-24                                             2024228__
    1                        A bill to be entitled                      
    2         An act relating to health insurance cost sharing;
    3         creating s. 627.6383, F.S.; defining the term “cost
    4         sharing requirement”; requiring specified individual
    5         health insurers and their pharmacy benefit managers to
    6         apply payments by or on behalf of insureds toward the
    7         total contributions of the insureds’ cost-sharing
    8         requirements; providing construction; providing
    9         applicability; amending s. 627.6385, F.S.; providing
   10         disclosure requirements for specified health insurers
   11         and their pharmacy benefit managers; providing
   12         applicability; amending s. 627.64741, F.S.; requiring
   13         that specified contracts require pharmacy benefit
   14         managers to apply payments by or on behalf of insureds
   15         toward the insureds’ total contributions to cost
   16         sharing requirements; providing applicability;
   17         providing disclosure requirements for such pharmacy
   18         benefit managers; creating s. 627.65715, F.S.;
   19         defining the term “cost-sharing requirement”;
   20         requiring specified group health insurers and their
   21         pharmacy benefit managers to apply payments by or on
   22         behalf of insureds toward the total contributions of
   23         the insureds’ cost-sharing requirements; providing
   24         construction; providing disclosure requirements for
   25         specified group health insurers and their pharmacy
   26         benefit managers; providing applicability; amending s.
   27         627.6572, F.S.; requiring that specified contracts
   28         require pharmacy benefit managers to apply payments by
   29         or on behalf of insureds toward the insureds’ total
   30         contributions to cost-sharing requirements; providing
   31         applicability; providing disclosure requirements for
   32         such pharmacy benefit managers; amending s. 627.6699,
   33         F.S.; requiring small employer carriers to comply with
   34         certain cost-sharing requirements; making technical
   35         changes; amending s. 641.31, F.S.; defining the term
   36         “cost-sharing requirement”; requiring specified health
   37         maintenance organizations and their pharmacy benefit
   38         managers to apply payments by or on behalf of
   39         subscribers toward the total contributions of the
   40         subscribers’ cost-sharing requirements; providing
   41         construction; providing disclosure requirements for
   42         such health maintenance organizations and pharmacy
   43         benefit managers; providing applicability; amending s.
   44         641.314, F.S.; requiring specified contracts to
   45         require pharmacy benefit managers to apply payments by
   46         or on behalf of subscribers toward the subscribers’
   47         total contributions to cost-sharing requirements;
   48         providing applicability; providing disclosure
   49         requirements for such pharmacy benefit managers;
   50         amending s. 409.967, F.S.; conforming a cross
   51         reference; amending s. 641.185, F.S.; conforming a
   52         provision to changes made by the act; providing a
   53         declaration of important state interest; providing an
   54         effective date.
   55          
   56  Be It Enacted by the Legislature of the State of Florida:
   57  
   58         Section 1. Section 627.6383, Florida Statutes, is created
   59  to read:
   60         627.6383Cost-sharing requirements.—
   61         (1)As used in this section, the term “cost-sharing
   62  requirement” means a dollar limit, a deductible, a copayment,
   63  coinsurance, or any other out-of-pocket expense imposed on an
   64  insured, including, but not limited to, the annual limitation on
   65  cost sharing subject to 42 U.S.C. s. 18022.
   66         (2)(a)Each health insurer issuing, delivering, or renewing
   67  a policy that provides prescription drug coverage in this state,
   68  or each pharmacy benefit manager on behalf of such health
   69  insurer, shall apply any amount paid by an insured or by another
   70  person on behalf of the insured toward the insured’s total
   71  contribution to any cost-sharing requirement.
   72         (b)The amount paid by or on behalf of the insured which is
   73  applied toward the insured’s total contribution to any cost
   74  sharing requirement under paragraph (a) includes, but is not
   75  limited to, any payment with or any discount through financial
   76  assistance, a manufacturer copay card, a product voucher, or any
   77  other reduction in out-of-pocket expenses made by or on behalf
   78  of the insured for a prescription drug.
   79         (3)This section applies to any health insurance policy
   80  issued, delivered, or renewed in this state on or after January
   81  1, 2025.
   82         Section 2. Present subsections (2) and (3) of section
   83  627.6385, Florida Statutes, are redesignated as subsections (3)
   84  and (4), respectively, a new subsection (2) is added to that
   85  section, and present subsection (2) of that section is amended,
   86  to read:
   87         627.6385 Disclosures to policyholders; calculations of cost
   88  sharing.—
   89         (2)Each health insurer issuing, delivering, or renewing a
   90  policy that provides prescription drug coverage in this state,
   91  regardless of whether the prescription drug benefits are
   92  administered or managed by the health insurer or by a pharmacy
   93  benefit manager on behalf of the health insurer, shall disclose
   94  on its website that any amount paid by a policyholder or by
   95  another person on behalf of the policyholder must be applied
   96  toward the policyholder’s total contribution to any cost-sharing
   97  requirement pursuant to s. 627.6383. This subsection applies to
   98  any policy issued, delivered, or renewed in this state on or
   99  after January 1, 2025.
  100         (3)(2) Each health insurer shall include in every policy
  101  delivered or issued for delivery to any person in this the state
  102  or in materials provided as required by s. 627.64725 a notice
  103  that the information required by this section is available
  104  electronically and the website address of the website where the
  105  information can be accessed. In addition, each health insurer
  106  issuing, delivering, or renewing a policy that provides
  107  prescription drug coverage in this state, regardless of whether
  108  the prescription drug benefits are administered or managed by
  109  the health insurer or by a pharmacy benefit manager on behalf of
  110  the health insurer, shall include in every policy issued,
  111  delivered, or renewed to any person in this state on or after
  112  January 1, 2025, the disclosure that any amount paid by a
  113  policyholder or by another person on behalf of the policyholder
  114  must be applied toward the policyholder’s total contribution to
  115  any cost-sharing requirement pursuant to s. 627.6383.
  116         Section 3. Paragraph (c) is added to subsection (2) of
  117  section 627.64741, Florida Statutes, to read:
  118         627.64741 Pharmacy benefit manager contracts.—
  119         (2) In addition to the requirements of part VII of chapter
  120  626, a contract between a health insurer and a pharmacy benefit
  121  manager must require that the pharmacy benefit manager:
  122         (c)1.Apply any amount paid by an insured or by another
  123  person on behalf of the insured toward the insured’s total
  124  contribution to any cost-sharing requirement pursuant to s.
  125  627.6383. This subparagraph applies to any insured whose
  126  insurance policy is issued, delivered, or renewed in this state
  127  on or after January 1, 2025.
  128         2.Disclose to every insured whose insurance policy is
  129  issued, delivered, or renewed in this state on or after January
  130  1, 2025, that the pharmacy benefit manager shall apply any
  131  amount paid by the insured or by another person on behalf of the
  132  insured toward the insured’s total contribution to any cost
  133  sharing requirement pursuant to s. 627.6383.
  134         Section 4. Section 627.65715, Florida Statutes, is created
  135  to read:
  136         627.65715Cost-sharing requirements.—
  137         (1)As used in this section, the term “cost-sharing
  138  requirement” means a dollar limit, a deductible, a copayment,
  139  coinsurance, or any other out-of-pocket expense imposed on an
  140  insured, including, but not limited to, the annual limitation on
  141  cost sharing subject to 42 U.S.C. s. 18022.
  142         (2)(a)Each insurer issuing, delivering, or renewing a
  143  policy that provides prescription drug coverage in this state,
  144  or each pharmacy benefit manager on behalf of such insurer,
  145  shall apply any amount paid by an insured or by another person
  146  on behalf of the insured toward the insured’s total contribution
  147  to any cost-sharing requirement.
  148         (b)The amount paid by or on behalf of the insured which is
  149  applied toward the insured’s total contribution to any cost
  150  sharing requirement under paragraph (a) includes, but is not
  151  limited to, any payment with or any discount through financial
  152  assistance, a manufacturer copay card, a product voucher, or any
  153  other reduction in out-of-pocket expenses made by or on behalf
  154  of the insured for a prescription drug.
  155         (3)Each insurer issuing, delivering, or renewing a policy
  156  that provides prescription drug coverage in this state,
  157  regardless of whether the prescription drug benefits are
  158  administered or managed by the insurer or by a pharmacy benefit
  159  manager on behalf of the insurer, shall disclose on its website
  160  and in every policy issued, delivered, or renewed in this state
  161  on or after January 1, 2025, that any amount paid by an insured
  162  or by another person on behalf of the insured must be applied
  163  toward the insured’s total contribution to any cost-sharing
  164  requirement.
  165         (4)This section applies to any group health insurance
  166  policy issued, delivered, or renewed in this state on or after
  167  January 1, 2025.
  168         Section 5. Paragraph (c) is added to subsection (2) of
  169  section 627.6572, Florida Statutes, to read:
  170         627.6572 Pharmacy benefit manager contracts.—
  171         (2) In addition to the requirements of part VII of chapter
  172  626, a contract between a health insurer and a pharmacy benefit
  173  manager must require that the pharmacy benefit manager:
  174         (c)1.Apply any amount paid by an insured or by another
  175  person on behalf of the insured toward the insured’s total
  176  contribution to any cost-sharing requirement pursuant to s.
  177  627.65715. This subparagraph applies to any insured whose
  178  insurance policy is issued, delivered, or renewed in this state
  179  on or after January 1, 2025.
  180         2.Disclose to every insured whose insurance policy is
  181  issued, delivered, or renewed in this state on or after January
  182  1, 2025, that the pharmacy benefit manager shall apply any
  183  amount paid by the insured or by another person on behalf of the
  184  insured toward the insured’s total contribution to any cost
  185  sharing requirement pursuant to s. 627.65715.
  186         Section 6. Paragraph (e) of subsection (5) of section
  187  627.6699, Florida Statutes, is amended to read:
  188         627.6699 Employee Health Care Access Act.—
  189         (5) AVAILABILITY OF COVERAGE.—
  190         (e) All health benefit plans issued under this section must
  191  comply with the following conditions:
  192         1. For employers who have fewer than two employees, a late
  193  enrollee may be excluded from coverage for no longer than 24
  194  months if he or she was not covered by creditable coverage
  195  continually to a date not more than 63 days before the effective
  196  date of his or her new coverage.
  197         2. Any requirement used by a small employer carrier in
  198  determining whether to provide coverage to a small employer
  199  group, including requirements for minimum participation of
  200  eligible employees and minimum employer contributions, must be
  201  applied uniformly among all small employer groups having the
  202  same number of eligible employees applying for coverage or
  203  receiving coverage from the small employer carrier, except that
  204  a small employer carrier that participates in, administers, or
  205  issues health benefits pursuant to s. 381.0406 which do not
  206  include a preexisting condition exclusion may require as a
  207  condition of offering such benefits that the employer has had no
  208  health insurance coverage for its employees for a period of at
  209  least 6 months. A small employer carrier may vary application of
  210  minimum participation requirements and minimum employer
  211  contribution requirements only by the size of the small employer
  212  group.
  213         3. In applying minimum participation requirements with
  214  respect to a small employer, a small employer carrier may shall
  215  not consider as an eligible employee employees or dependents who
  216  have qualifying existing coverage in an employer-based group
  217  insurance plan or an ERISA qualified self-insurance plan in
  218  determining whether the applicable percentage of participation
  219  is met. However, a small employer carrier may count eligible
  220  employees and dependents who have coverage under another health
  221  plan that is sponsored by that employer.
  222         4. A small employer carrier may shall not increase any
  223  requirement for minimum employee participation or any
  224  requirement for minimum employer contribution applicable to a
  225  small employer at any time after the small employer has been
  226  accepted for coverage, unless the employer size has changed, in
  227  which case the small employer carrier may apply the requirements
  228  that are applicable to the new group size.
  229         5. If a small employer carrier offers coverage to a small
  230  employer, it must offer coverage to all the small employer’s
  231  eligible employees and their dependents. A small employer
  232  carrier may not offer coverage limited to certain persons in a
  233  group or to part of a group, except with respect to late
  234  enrollees.
  235         6. A small employer carrier may not modify any health
  236  benefit plan issued to a small employer with respect to a small
  237  employer or any eligible employee or dependent through riders,
  238  endorsements, or otherwise to restrict or exclude coverage for
  239  certain diseases or medical conditions otherwise covered by the
  240  health benefit plan.
  241         7. An initial enrollment period of at least 30 days must be
  242  provided. An annual 30-day open enrollment period must be
  243  offered to each small employer’s eligible employees and their
  244  dependents. A small employer carrier must provide special
  245  enrollment periods as required by s. 627.65615.
  246         8.A small employer carrier shall comply with s. 627.65715
  247  with respect to contribution to cost-sharing requirements, as
  248  defined in that section.
  249         Section 7. Subsection (48) is added to section 641.31,
  250  Florida Statutes, to read:
  251         641.31 Health maintenance contracts.—
  252         (48)(a)As used in this subsection, the term “cost-sharing
  253  requirement” means a dollar limit, a deductible, a copayment,
  254  coinsurance, or any other out-of-pocket expense imposed on a
  255  subscriber, including, but not limited to, the annual limitation
  256  on cost sharing subject to 42 U.S.C. s. 18022.
  257         (b)1. Each health maintenance organization issuing,
  258  delivering, or renewing a health maintenance contract or
  259  certificate that provides prescription drug coverage in this
  260  state, or each pharmacy benefit manager on behalf of such health
  261  maintenance organization, shall apply any amount paid by a
  262  subscriber or by another person on behalf of the subscriber
  263  toward the subscriber’s total contribution to any cost-sharing
  264  requirement.
  265         2. The amount paid by or on behalf of the subscriber which
  266  is applied toward the subscriber’s total contribution to any
  267  cost-sharing requirement under subparagraph 1. includes, but is
  268  not limited to, any payment with or any discount through
  269  financial assistance, a manufacturer copay card, a product
  270  voucher, or any other reduction in out-of-pocket expenses made
  271  by or on behalf of the subscriber for a prescription drug.
  272         (c) Each health maintenance organization issuing,
  273  delivering, or renewing a health maintenance contract or
  274  certificate that provides prescription drug coverage in this
  275  state, regardless of whether the prescription drug benefits are
  276  administered or managed by the health maintenance organization
  277  or by a pharmacy benefit manager on behalf of the health
  278  maintenance organization, shall disclose on its website and in
  279  every subscriber’s health maintenance contract, certificate, or
  280  member handbook issued, delivered, or renewed in this state on
  281  or after January 1, 2025, that any amount paid by a subscriber
  282  or by another person on behalf of the subscriber must be applied
  283  toward the subscriber’s total contribution to any cost-sharing
  284  requirement.
  285         (d) This subsection applies to any health maintenance
  286  contract or certificate issued, delivered, or renewed in this
  287  state on or after January 1, 2025.
  288         Section 8. Paragraph (c) is added to subsection (2) of
  289  section 641.314, Florida Statutes, to read:
  290         641.314 Pharmacy benefit manager contracts.—
  291         (2) In addition to the requirements of part VII of chapter
  292  626, a contract between a health maintenance organization and a
  293  pharmacy benefit manager must require that the pharmacy benefit
  294  manager:
  295         (c)1. Apply any amount paid by a subscriber or by another
  296  person on behalf of the subscriber toward the subscriber’s total
  297  contribution to any cost-sharing requirement pursuant to s.
  298  641.31(48). This subparagraph applies to any subscriber whose
  299  health maintenance contract or certificate is issued, delivered,
  300  or renewed in this state on or after January 1, 2025.
  301         2. Disclose to every subscriber whose health maintenance
  302  contract or certificate is issued, delivered, or renewed in this
  303  state on or after January 1, 2025, that the pharmacy benefit
  304  manager shall apply any amount paid by the subscriber or by
  305  another person on behalf of the subscriber toward the
  306  subscriber’s total contribution to any cost-sharing requirement
  307  pursuant to s. 641.31(48).
  308         Section 9. Paragraph (o) of subsection (2) of section
  309  409.967, Florida Statutes, is amended to read:
  310         409.967 Managed care plan accountability.—
  311         (2) The agency shall establish such contract requirements
  312  as are necessary for the operation of the statewide managed care
  313  program. In addition to any other provisions the agency may deem
  314  necessary, the contract must require:
  315         (o) Transparency.—Managed care plans shall comply with ss.
  316  627.6385(4) and 641.54(7) ss. 627.6385(3) and 641.54(7).
  317         Section 10. Paragraph (k) of subsection (1) of section
  318  641.185, Florida Statutes, is amended to read:
  319         641.185 Health maintenance organization subscriber
  320  protections.—
  321         (1) With respect to the provisions of this part and part
  322  III, the principles expressed in the following statements serve
  323  as standards to be followed by the commission, the office, the
  324  department, and the Agency for Health Care Administration in
  325  exercising their powers and duties, in exercising administrative
  326  discretion, in administrative interpretations of the law, in
  327  enforcing its provisions, and in adopting rules:
  328         (k) A health maintenance organization subscriber shall be
  329  given a copy of the applicable health maintenance contract,
  330  certificate, or member handbook specifying: all the provisions,
  331  disclosure, and limitations required pursuant to s. 641.31(1),
  332  and (4), and (48); the covered services, including those
  333  services, medical conditions, and provider types specified in
  334  ss. 641.31, 641.31094, 641.31095, 641.31096, 641.51(11), and
  335  641.513; and where and in what manner services may be obtained
  336  pursuant to s. 641.31(4).
  337         Section 11. The Legislature finds that this act fulfills an
  338  important state interest.
  339         Section 12. This act shall take effect July 1, 2024.