Florida Senate - 2021 SB 1078
By Senator Brodeur
9-00583A-21 20211078__
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 benefits managers
6 to apply payments by or on behalf of insureds toward
7 the total contributions of the insureds’ cost-sharing
8 requirements; providing applicability; amending s.
9 627.6385, F.S.; requiring specified individual health
10 insurers to disclose on their websites and in their
11 policies their applications of payments by or on
12 behalf of policyholders toward the policyholders’
13 total contributions to cost-sharing requirements;
14 providing applicability; amending ss. 627.64741,
15 627.6572, and 641.314, F.S.; requiring pharmacy
16 benefits managers to apply payments by or on behalf of
17 insureds and subscribers toward the insureds’ and
18 subscribers’ total contributions to cost-sharing
19 requirements; providing applicability; providing
20 disclosure requirements; creating s. 627.65715, F.S.,
21 and amending s. 641.31, F.S.; defining the term “cost
22 sharing requirement”; requiring specified group health
23 insurers and health maintenance organizations and
24 their pharmacy benefits managers to apply payments by
25 or on behalf of insureds and subscribers toward the
26 total contributions of the insureds’ and subscribers’
27 cost-sharing requirements, respectively; providing
28 disclosure requirements; providing applicability;
29 amending s. 627.6699, F.S.; providing requirements for
30 small employer carriers; amending s. 409.967, F.S.;
31 conforming a cross-reference; amending s. 641.185,
32 F.S.; conforming a provision to changes made by the
33 act; providing a declaration of important state
34 interest; providing an effective date.
35
36 Be It Enacted by the Legislature of the State of Florida:
37
38 Section 1. Section 627.6383, Florida Statutes, is created
39 to read:
40 627.6383 Cost-sharing requirements.—
41 (1) As used in this section, the term “cost-sharing
42 requirement” means a dollar limit, deductible, copayment,
43 coinsurance, or any other out-of-pocket expense imposed on an
44 insured, including, but not limited to, the annual limitation on
45 cost sharing subject to 42 U.S.C. s. 18022.
46 (2)(a) Each health insurer issuing, delivering, or renewing
47 a policy in this state which provides prescription drug coverage
48 or each pharmacy benefits manager on behalf of such health
49 insurer must apply any amount paid by an insured or by another
50 person on behalf of the insured toward the insured’s total
51 contribution to any cost-sharing requirement.
52 (b) The amount paid by or on behalf of the insured which is
53 applied toward the insured’s total contribution to any cost
54 sharing requirement under paragraph (a) includes, but is not
55 limited to, any payment with, or any discount through, financial
56 assistance, a manufacturer copay card, a product voucher, or any
57 other reduction in out-of-pocket expenses made by or on behalf
58 of the insured for a prescription drug.
59 (3) This section applies to any health insurance policy
60 issued, delivered, or renewed in this state on or after January
61 1, 2022.
62 Section 2. Present subsections (2) and (3) of section
63 627.6385, Florida Statutes, are redesignated as subsections (3)
64 and (4), respectively, a new subsection (2) is added to that
65 section, and present subsection (2) of that section is amended,
66 to read:
67 627.6385 Disclosures to policyholders; calculations of cost
68 sharing.—
69 (2) Each health insurer issuing, delivering, or renewing a
70 policy in this state which provides prescription drug coverage,
71 regardless of whether the prescription drug benefits are
72 administered or managed by the health insurer or by a pharmacy
73 benefits manager on behalf of the health insurer, shall disclose
74 on its website that any amount paid by a policyholder or by
75 another person on behalf of the policyholder shall be applied
76 toward the policyholder’s total contribution to any cost-sharing
77 requirement pursuant to s. 627.6383. This subsection applies to
78 any policy issued, delivered, or renewed in this state on or
79 after January 1, 2022.
80 (3)(2) Each health insurer shall include in every policy
81 delivered or issued for delivery to any person in the state or
82 in materials provided as required by s. 627.64725 notice that
83 the information required by this section is available
84 electronically and the address of the website where the
85 information can be accessed. In addition, each health insurer
86 issuing, delivering, or renewing a policy in this state which
87 provides prescription drug coverage, regardless of whether the
88 prescription drug benefits are administered or managed by the
89 health insurer or by a pharmacy benefits manager on behalf of
90 the health insurer, shall include in every policy that is
91 issued, delivered, or renewed to any person in this state on or
92 after January 1, 2022, the disclosure that any amount paid by a
93 policyholder or by another person on behalf of the policyholder
94 shall be applied toward the policyholder’s total contribution to
95 any cost-sharing requirement pursuant to s. 627.6383.
96 Section 3. Paragraph (c) is added to subsection (2) of
97 section 627.64741, Florida Statutes, to read:
98 627.64741 Pharmacy benefit manager contracts.—
99 (2) A contract between a health insurer and a pharmacy
100 benefit manager must require that the pharmacy benefit manager:
101 (c)1. Apply any amount paid by an insured or by another
102 person on behalf of the insured toward the insured’s total
103 contribution to any cost-sharing requirement pursuant to s.
104 627.6383. This subparagraph applies to any insured whose
105 insurance policy is issued, delivered, or renewed in this state
106 on or after January 1, 2022.
107 2. Disclose to every insured whose insurance policy is
108 issued, delivered, or renewed in this state on or after January
109 1, 2022, that the pharmacy benefits manager shall apply any
110 amount paid by the insured or by another person on behalf of the
111 insured toward the insured’s total contribution to any cost
112 sharing requirement pursuant to s. 627.6383.
113 Section 4. Section 627.65715, Florida Statutes, is created
114 to read:
115 627.65715 Cost-sharing requirements.—
116 (1) As used in this section, the term “cost-sharing
117 requirement” means a dollar limit, deductible, copayment,
118 coinsurance, or any other out-of-pocket expense imposed on an
119 insured, including, but not limited to, the annual limitation on
120 cost sharing subject to 42 U.S.C. s. 18022.
121 (2)(a) Each insurer issuing, delivering, or renewing a
122 policy in this state which provides prescription drug coverage
123 or each pharmacy benefits manager on behalf of such insurer must
124 apply any amount paid by an insured or by another person on
125 behalf of the insured toward the insured’s total contribution to
126 any cost-sharing requirement.
127 (b) The amount paid by or on behalf of the insured which is
128 applied toward the insured’s total contribution to any cost
129 sharing requirement under paragraph (a) includes, but is not
130 limited to, any payment with, or any discount through, financial
131 assistance, a manufacturer copay card, a product voucher, or any
132 other reduction in out-of-pocket expenses made by or on behalf
133 of the insured for a prescription drug.
134 (3) Each insurer issuing, delivering, or renewing a policy
135 in this state which provides prescription drug coverage,
136 regardless of whether the prescription drug benefits are
137 administered or managed by the insurer or by a pharmacy benefits
138 manager on behalf of the insurer, shall disclose, on its website
139 and in every policy issued, delivered, or renewed in this state
140 on or after January 1, 2022, that any amount paid by an insured
141 or by another person on behalf of the insured shall be applied
142 toward the insured’s total contribution to any cost-sharing
143 requirement.
144 (4) This section applies to any group health insurance
145 policy issued, delivered, or renewed in this state on or after
146 January 1, 2022.
147 Section 5. Paragraph (c) is added to subsection (2) of
148 section 627.6572, Florida Statutes, to read:
149 627.6572 Pharmacy benefit manager contracts.—
150 (2) A contract between a health insurer and a pharmacy
151 benefit manager must require that the pharmacy benefit manager:
152 (c)1. Apply any amount paid by an insured or by another
153 person on behalf of the insured toward the insured’s total
154 contribution to any cost-sharing requirement pursuant to s.
155 627.65715. This subparagraph applies to any insured whose
156 insurance policy is issued, delivered, or renewed in this state
157 on or after January 1, 2022.
158 2. Disclose to every insured whose insurance policy is
159 issued, delivered, or renewed in this state on or after January
160 1, 2022, that the pharmacy benefits manager shall apply any
161 amount paid by the insured or by another person on behalf of the
162 insured toward the insured’s total contribution to any cost
163 sharing requirement pursuant to s. 627.65715.
164 Section 6. Paragraph (e) of subsection (5) of section
165 627.6699, Florida Statutes, is amended to read:
166 627.6699 Employee Health Care Access Act.—
167 (5) AVAILABILITY OF COVERAGE.—
168 (e) All health benefit plans issued under this section must
169 comply with the following conditions:
170 1. For employers who have fewer than two employees, a late
171 enrollee may be excluded from coverage for no longer than 24
172 months if he or she was not covered by creditable coverage
173 continually to a date not more than 63 days before the effective
174 date of his or her new coverage.
175 2. Any requirement used by a small employer carrier in
176 determining whether to provide coverage to a small employer
177 group, including requirements for minimum participation of
178 eligible employees and minimum employer contributions, must be
179 applied uniformly among all small employer groups having the
180 same number of eligible employees applying for coverage or
181 receiving coverage from the small employer carrier, except that
182 a small employer carrier that participates in, administers, or
183 issues health benefits pursuant to s. 381.0406 which do not
184 include a preexisting condition exclusion may require as a
185 condition of offering such benefits that the employer has had no
186 health insurance coverage for its employees for a period of at
187 least 6 months. A small employer carrier may vary application of
188 minimum participation requirements and minimum employer
189 contribution requirements only by the size of the small employer
190 group.
191 3. In applying minimum participation requirements with
192 respect to a small employer, a small employer carrier shall not
193 consider as an eligible employee employees or dependents who
194 have qualifying existing coverage in an employer-based group
195 insurance plan or an ERISA qualified self-insurance plan in
196 determining whether the applicable percentage of participation
197 is met. However, a small employer carrier may count eligible
198 employees and dependents who have coverage under another health
199 plan that is sponsored by that employer.
200 4. A small employer carrier shall not increase any
201 requirement for minimum employee participation or any
202 requirement for minimum employer contribution applicable to a
203 small employer at any time after the small employer has been
204 accepted for coverage, unless the employer size has changed, in
205 which case the small employer carrier may apply the requirements
206 that are applicable to the new group size.
207 5. If a small employer carrier offers coverage to a small
208 employer, it must offer coverage to all the small employer’s
209 eligible employees and their dependents. A small employer
210 carrier may not offer coverage limited to certain persons in a
211 group or to part of a group, except with respect to late
212 enrollees.
213 6. A small employer carrier may not modify any health
214 benefit plan issued to a small employer with respect to a small
215 employer or any eligible employee or dependent through riders,
216 endorsements, or otherwise to restrict or exclude coverage for
217 certain diseases or medical conditions otherwise covered by the
218 health benefit plan.
219 7. An initial enrollment period of at least 30 days must be
220 provided. An annual 30-day open enrollment period must be
221 offered to each small employer’s eligible employees and their
222 dependents. A small employer carrier must provide special
223 enrollment periods as required by s. 627.65615.
224 8. A small employer carrier shall comply with s. 627.65715
225 with respect to contribution to cost-sharing requirements, as
226 defined in that section.
227 Section 7. Subsection (48) is added to section 641.31,
228 Florida Statutes, to read:
229 641.31 Health maintenance contracts.—
230 (48)(a) As used in this subsection, the term “cost-sharing
231 requirement” means a dollar limit, deductible, copayment,
232 coinsurance, or any other out-of-pocket expense imposed on a
233 subscriber, including, but not limited to, the annual limitation
234 on cost sharing subject to 42 U.S.C. s. 18022.
235 (b)1. Each health maintenance organization issuing,
236 delivering, or renewing a health maintenance contract or
237 certificate in this state which provides prescription drug
238 coverage or each pharmacy benefits manager on behalf of such
239 health maintenance organization must apply any amount paid by a
240 subscriber or by another person on behalf of the subscriber
241 toward the subscriber’s total contribution to any cost-sharing
242 requirement.
243 2. The amount paid by or on behalf of the subscriber which
244 is applied toward the subscriber’s total contribution to any
245 cost-sharing requirement under subparagraph 1. includes, but is
246 not limited to, any payment with, or any discount through,
247 financial assistance, a manufacturer copay card, a product
248 voucher, or any other reduction in out-of-pocket expenses made
249 by or on behalf of the subscriber for a prescription drug.
250 (c) Each health maintenance organization issuing,
251 delivering, or renewing a health maintenance contract or
252 certificate in this state which provides prescription drug
253 coverage, regardless of whether the prescription drug benefits
254 are administered or managed by the health maintenance
255 organization or by a pharmacy benefits manager on behalf of the
256 health maintenance organization, shall disclose, on its website
257 and in every subscriber’s health maintenance contract,
258 certificate, or member handbook issued, delivered, or renewed in
259 this state on or after January 1, 2022, that any amount paid by
260 a subscriber or by another person on behalf of the subscriber
261 shall be applied toward the subscriber’s total contribution to
262 any cost-sharing requirement.
263 (d) This subsection applies to any health maintenance
264 contract or certificate issued, delivered, or renewed in this
265 state on or after January 1, 2022.
266 Section 8. Paragraph (c) is added to subsection (2) of
267 section 641.314, Florida Statutes, to read:
268 641.314 Pharmacy benefit manager contracts.—
269 (2) A contract between a health maintenance organization
270 and a pharmacy benefit manager must require that the pharmacy
271 benefit manager:
272 (c)1. Apply any amount paid by a subscriber or by another
273 person on behalf of the subscriber toward the subscriber’s total
274 contribution to any cost-sharing requirement pursuant to s.
275 641.31(48). This subparagraph applies to any subscriber whose
276 health maintenance contract or certificate is issued, delivered,
277 or renewed in this state on or after January 1, 2022.
278 2. Disclose to every subscriber whose health maintenance
279 contract or certificate is issued, delivered, or renewed in this
280 state on or after January 1, 2022, that the pharmacy benefits
281 manager shall apply any amount paid by the subscriber or by
282 another person on behalf of the subscriber toward the
283 subscriber’s total contribution to any cost-sharing requirement
284 pursuant to s. 641.31(48).
285 Section 9. Paragraph (o) of subsection (2) of section
286 409.967, Florida Statutes, is amended to read:
287 409.967 Managed care plan accountability.—
288 (2) The agency shall establish such contract requirements
289 as are necessary for the operation of the statewide managed care
290 program. In addition to any other provisions the agency may deem
291 necessary, the contract must require:
292 (o) Transparency.—Managed care plans shall comply with ss.
293 627.6385(4) ss. 627.6385(3) and 641.54(7).
294 Section 10. Paragraph (k) of subsection (1) of section
295 641.185, Florida Statutes, is amended to read:
296 641.185 Health maintenance organization subscriber
297 protections.—
298 (1) With respect to the provisions of this part and part
299 III, the principles expressed in the following statements serve
300 as standards to be followed by the commission, the office, the
301 department, and the Agency for Health Care Administration in
302 exercising their powers and duties, in exercising administrative
303 discretion, in administrative interpretations of the law, in
304 enforcing its provisions, and in adopting rules:
305 (k) A health maintenance organization subscriber shall be
306 given a copy of the applicable health maintenance contract,
307 certificate, or member handbook specifying: all the provisions,
308 disclosure, and limitations required pursuant to s. 641.31(1),
309 and (4), and (48); the covered services, including those
310 services, medical conditions, and provider types specified in
311 ss. 641.31, 641.31094, 641.31095, 641.31096, 641.51(11), and
312 641.513; and where and in what manner services may be obtained
313 pursuant to s. 641.31(4).
314 Section 11. The Legislature finds that this act fulfills an
315 important state interest.
316 Section 12. This act shall take effect July 1, 2021.