Florida Senate - 2017                        COMMITTEE AMENDMENT
       Bill No. CS for CS for SB 182
       
       
       
       
       
       
                                Ì220914ÇÎ220914                         
       
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
                   Comm: WD            .                                
                  04/19/2017           .                                
                                       .                                
                                       .                                
                                       .                                
       —————————————————————————————————————————————————————————————————




       —————————————————————————————————————————————————————————————————
       The Committee on Rules (Lee) recommended the following:
       
    1         Senate Amendment (with title amendment)
    2  
    3         Delete lines 20 - 165
    4  and insert:
    5         Section 1. Effective January 1, 2018, section 627.42393,
    6  Florida Statutes, is created to read:
    7         627.42393Insurance policies; limiting changes to
    8  prescription drug formularies.—
    9         (1)Other than at the time of coverage renewal, an
   10  individual or group insurance policy that is delivered, issued
   11  for delivery, renewed, amended, or continued in this state and
   12  that provides medical, major medical, or similar comprehensive
   13  coverage may not:
   14         (a)Remove a covered prescription drug from its list of
   15  covered drugs during the policy year unless the United States
   16  Food and Drug Administration has issued a statement about the
   17  drug which calls into question the clinical safety of the drug,
   18  or the manufacturer of the drug has notified the United States
   19  Food and Drug Administration of a manufacturing discontinuance
   20  or potential discontinuance of the drug as required by s. 506C
   21  of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. s. 356c.
   22         (b)Reclassify a drug to a more restrictive drug tier or
   23  increase the amount that an insured must pay for a copayment,
   24  coinsurance, or deductible for prescription drug benefits, or
   25  reclassify a drug to a higher cost-sharing tier during the
   26  policy year.
   27         (2)This section does not prohibit the addition of
   28  prescription drugs to the list of drugs covered under the policy
   29  during the policy year.
   30         (3)This section does not apply to a grandfathered health
   31  plan as defined in s. 627.402 or to benefits set forth in s.
   32  627.6513(1)-(14).
   33         (4)This section does not alter or amend s. 465.025, which
   34  provides conditions under which a pharmacist may substitute a
   35  generically equivalent drug product for a brand name drug
   36  product.
   37         (5)This section does not alter or amend s. 465.0252, which
   38  provides conditions under which a pharmacist may dispense a
   39  substitute biological product for the prescribed biological
   40  product.
   41         Section 2. Effective January 1, 2018, paragraph (e) of
   42  subsection (5) of section 627.6699, Florida Statutes, is amended
   43  to read:
   44         627.6699 Employee Health Care Access Act.—
   45         (5) AVAILABILITY OF COVERAGE.—
   46         (e) All health benefit plans issued under this section must
   47  comply with the following conditions:
   48         1. For employers who have fewer than two employees, a late
   49  enrollee may be excluded from coverage for no longer than 24
   50  months if he or she was not covered by creditable coverage
   51  continually to a date not more than 63 days before the effective
   52  date of his or her new coverage.
   53         2. Any requirement used by a small employer carrier in
   54  determining whether to provide coverage to a small employer
   55  group, including requirements for minimum participation of
   56  eligible employees and minimum employer contributions, must be
   57  applied uniformly among all small employer groups having the
   58  same number of eligible employees applying for coverage or
   59  receiving coverage from the small employer carrier, except that
   60  a small employer carrier that participates in, administers, or
   61  issues health benefits pursuant to s. 381.0406 which do not
   62  include a preexisting condition exclusion may require as a
   63  condition of offering such benefits that the employer has had no
   64  health insurance coverage for its employees for a period of at
   65  least 6 months. A small employer carrier may vary application of
   66  minimum participation requirements and minimum employer
   67  contribution requirements only by the size of the small employer
   68  group.
   69         3. In applying minimum participation requirements with
   70  respect to a small employer, a small employer carrier shall not
   71  consider as an eligible employee employees or dependents who
   72  have qualifying existing coverage in an employer-based group
   73  insurance plan or an ERISA qualified self-insurance plan in
   74  determining whether the applicable percentage of participation
   75  is met. However, a small employer carrier may count eligible
   76  employees and dependents who have coverage under another health
   77  plan that is sponsored by that employer.
   78         4. A small employer carrier shall not increase any
   79  requirement for minimum employee participation or any
   80  requirement for minimum employer contribution applicable to a
   81  small employer at any time after the small employer has been
   82  accepted for coverage, unless the employer size has changed, in
   83  which case the small employer carrier may apply the requirements
   84  that are applicable to the new group size.
   85         5. If a small employer carrier offers coverage to a small
   86  employer, it must offer coverage to all the small employer’s
   87  eligible employees and their dependents. A small employer
   88  carrier may not offer coverage limited to certain persons in a
   89  group or to part of a group, except with respect to late
   90  enrollees.
   91         6. A small employer carrier may not modify any health
   92  benefit plan issued to a small employer with respect to a small
   93  employer or any eligible employee or dependent through riders,
   94  endorsements, or otherwise to restrict or exclude coverage for
   95  certain diseases or medical conditions otherwise covered by the
   96  health benefit plan.
   97         7. An initial enrollment period of at least 30 days must be
   98  provided. An annual 30-day open enrollment period must be
   99  offered to each small employer’s eligible employees and their
  100  dependents. A small employer carrier must provide special
  101  enrollment periods as required by s. 627.65615.
  102         8. A small employer carrier must limit changes to
  103  prescription drug formularies as required by s. 627.42393.
  104         Section 3. Effective January 1, 2018, subsection (36) of
  105  section 641.31, Florida Statutes, is amended to read:
  106         641.31 Health maintenance contracts.—
  107         (36) A health maintenance organization may increase the
  108  copayment for any benefit, or delete, amend, or limit any of the
  109  benefits to which a subscriber is entitled under the group
  110  contract only, upon written notice to the contract holder at
  111  least 45 days in advance of the time of coverage renewal. The
  112  health maintenance organization may amend the contract with the
  113  contract holder, with such amendment to be effective immediately
  114  at the time of coverage renewal. The written notice to the
  115  contract holder must shall specifically identify any deletions,
  116  amendments, or limitations to any of the benefits provided in
  117  the group contract during the current contract period which will
  118  be included in the group contract upon renewal. This subsection
  119  does not apply to any increases in benefits. The 45-day notice
  120  requirement does shall not apply if benefits are amended,
  121  deleted, or limited at the request of the contract holder.
  122         (a) Other than at the time of coverage renewal, a health
  123  maintenance organization that provides medical, major medical,
  124  or similar comprehensive coverage may not:
  125         1. Remove a covered prescription drug from its list of
  126  covered drugs during the contract year unless the United States
  127  Food and Drug Administration has issued a statement about the
  128  drug which calls into question the clinical safety of the drug,
  129  or the manufacturer of the drug has notified the United States
  130  Food and Drug Administration of a manufacturing discontinuance
  131  or potential discontinuance of the drug as required by s. 506C
  132  of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. s. 356c.
  133         2. Reclassify a drug to a more restrictive drug tier or
  134  increase the amount that an insured must pay for a copayment,
  135  coinsurance, or deductible for prescription drug benefits, or
  136  reclassify a drug to a higher cost-sharing tier during the
  137  contract year.
  138         (b) This subsection does not:
  139         1. Prohibit the addition of prescription drugs to the list
  140  of drugs covered during the contract year.
  141         2. Apply to a grandfathered health plan as defined in s.
  142  627.402 or to benefits set forth in s. 627.6513(1)-(14).
  143         3. Alter or amend s. 465.025, which provides conditions
  144  under which a pharmacist may substitute a generically equivalent
  145  drug product for a brand name drug product.
  146         4. Alter or amend s. 465.0252, which provides conditions
  147  under which a pharmacist may dispense a substitute biological
  148  product for the prescribed biological product.
  149         Section 4. The Legislature finds that the creation of
  150  section 627.42393, Florida Statutes, and the amendments made by
  151  this act to sections 627.6699 and 641.31, Florida Statutes,
  152  fulfill an important state interest.
  153         Section 5. Subsection (4) of section 409.977, Florida
  154  Statutes, is amended to read:
  155         409.977 Enrollment.—
  156         (4) The agency shall:
  157         (a) Develop a process to enable a recipient with access to
  158  employer-sponsored health care coverage to opt out of all
  159  managed care plans and to use Medicaid financial assistance to
  160  pay for the recipient’s share of the cost in such employer
  161  sponsored coverage.
  162         (b) Contingent upon federal approval, the agency shall also
  163  enable recipients with access to other insurance or related
  164  products providing access to health care services created
  165  pursuant to state law, including any product available under the
  166  Florida Health Choices Program, or any health exchange, to opt
  167  out.
  168         (c) Provide The amount of financial assistance provided for
  169  each recipient in an amount may not to exceed the amount of the
  170  Medicaid premium which that would have been paid to a managed
  171  care plan for that recipient opting to receive services under
  172  this subsection.
  173         (d)The agency shall Seek federal approval to require
  174  Medicaid recipients with access to employer-sponsored health
  175  care coverage to enroll in that coverage and use Medicaid
  176  financial assistance to pay for the recipient’s share of the
  177  cost for such coverage. The amount of financial assistance
  178  provided for each recipient may not exceed the amount of the
  179  Medicaid premium that would have been paid to a managed care
  180  plan for that recipient.
  181         (e) By January 1, 2018, resubmit an appropriate federal
  182  waiver or waiver amendment to the Centers for Medicare and
  183  Medicaid Services, the United States Department of Health and
  184  Human Services, or any other designated federal entity to
  185  incorporate the election by a recipient for a direct primary
  186  care agreement, as defined in s. 456.0625, within the Statewide
  187  Medicaid Managed Care program.
  188         Section 6. Section 456.0625, Florida Statutes, is created
  189  to read:
  190         456.0625 Direct primary care agreements.—
  191         (1) As used in this section, the term:
  192         (a) “Direct primary care agreement” means a contract
  193  between a primary care provider and a patient, the patient’s
  194  legal representative, or an employer which meets the
  195  requirements specified under subsection (3) and which does not
  196  indemnify for services provided by a third party.
  197         (b) “Primary care provider” means a health care
  198  practitioner licensed under chapter 458, chapter 459, chapter
  199  460, or chapter 464 or a primary care group practice that
  200  provides medical services to patients which are commonly
  201  provided without referral from another health care provider.
  202         (c) “Primary care service” means the screening, assessment,
  203  diagnosis, and treatment of a patient for the purpose of
  204  promoting health or detecting and managing disease or injury
  205  within the competency and training of the primary care provider.
  206         (2) A primary care provider or an agent of the primary care
  207  provider may enter into a direct primary care agreement for
  208  providing primary care services. Section 624.27 applies to a
  209  direct primary care agreement.
  210         (3)A direct primary care agreement must:
  211         (a) Be in writing.
  212         (b) Be signed by the primary care provider or an agent of
  213  the primary care provider and the patient, the patient’s legal
  214  representative, or an employer.
  215         (c) Allow a party to terminate the agreement by giving the
  216  other party at least 30 days’ advance written notice. The
  217  agreement may provide for immediate termination due to a
  218  violation of the physician-patient relationship or a breach of
  219  the terms of the agreement.
  220         (d) Describe the scope of primary care services that are
  221  covered by the monthly fee.
  222         (e) Specify the monthly fee and any fees for primary care
  223  services not covered by the monthly fee.
  224         (f) Specify the duration of the agreement and any automatic
  225  renewal provisions.
  226         (g) Offer a refund to the patient of monthly fees paid in
  227  advance if the primary care provider ceases to offer primary
  228  care services for any reason.
  229         (h) Contain, in contrasting color and in not less than 12
  230  point type, the following statements on the same page as the
  231  applicant’s signature:
  232         1. This agreement is not health insurance, and the primary
  233  care provider will not file any claims against the patient’s
  234  health insurance policy or plan for reimbursement of any primary
  235  care services covered by this agreement.
  236         2. This agreement does not qualify as minimum essential
  237  coverage to satisfy the individual shared responsibility
  238  provision of the federal Patient Protection and Affordable Care
  239  Act, Pub. L. No. 111-148.
  240         3. This agreement is not workers’ compensation insurance
  241  and may not replace the employer’s obligations under chapter
  242  440, Florida Statutes.
  243         Section 7. Section 624.27, Florida Statutes, is created to
  244  read:
  245         624.27 Application of code as to direct primary care
  246  agreements.—
  247         (1) A direct primary care agreement, as defined in s.
  248  456.0625, does not constitute insurance and is not subject to
  249  any chapter of the Florida Insurance Code. The act of entering
  250  into a direct primary care agreement does not constitute the
  251  business of insurance and is not subject to any chapter of the
  252  Florida Insurance Code.
  253         (2) A primary care provider or an agent of a primary care
  254  provider is not required to obtain a certificate of authority or
  255  license under any chapter of the Florida Insurance Code to
  256  market, sell, or offer to sell a direct primary care agreement
  257  pursuant to s. 456.0625.
  258         Section 8. Except as otherwise expressly provided in this
  259  act, this act shall take effect July 1, 2017.
  260  
  261  ================= T I T L E  A M E N D M E N T ================
  262  And the title is amended as follows:
  263         Delete lines 2 - 16
  264  and insert:
  265         An act relating to health care; creating s. 627.42393,
  266         F.S.; limiting, under specified circumstances, changes
  267         to a health insurance policy prescription drug
  268         formulary during a policy year; providing construction
  269         and applicability; amending s. 627.6699, F.S.;
  270         requiring small employer carriers to limit changes to
  271         prescription drug formularies under certain
  272         circumstances; amending s. 641.31, F.S.; limiting,
  273         under specified circumstances, changes to a health
  274         maintenance contract prescription drug formulary
  275         during a contract year; providing construction and
  276         applicability; providing a declaration of important
  277         state interest; amending s. 409.977, F.S.; requiring
  278         the Agency for Health Care Administration to provide
  279         specified financial assistance to certain Medicaid
  280         recipients; requiring the agency to resubmit, by a
  281         specified date, certain federal waivers or waiver
  282         amendments to specified federal entities to
  283         incorporate recipient elections of certain direct
  284         primary care agreements; creating s. 456.0625, F.S.;
  285         defining terms; authorizing primary care providers or
  286         their agents to enter into direct primary care
  287         agreements for providing primary care services;
  288         providing applicability; specifying requirements for
  289         direct primary care agreements; creating s. 624.27,
  290         F.S.; providing construction and applicability of the
  291         Florida Insurance Code as to direct primary care
  292         agreements; providing an exception for primary care
  293         providers or their agents from certain requirements
  294         under the code under certain circumstances; providing
  295         effective dates.