Florida Senate - 2022 SB 1480 By Senator Wright 14-00657-22 20221480__ 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 s. 627.64741, F.S.; 15 requiring that contracts require pharmacy benefits 16 managers to apply payments by or on behalf of insureds 17 toward the insureds total contributions to cost 18 sharing requirements; providing applicability; 19 providing disclosure requirements; creating s. 20 627.65715, F.S.; defining the term cost-sharing 21 requirement; requiring specified group health 22 insurers and their pharmacy benefits managers to apply 23 payments by or on behalf of insureds toward the total 24 contributions of the insureds cost-sharing 25 requirements; providing disclosure requirements; 26 providing applicability; amending s. 627.6572, F.S.; 27 requiring that contracts require pharmacy benefits 28 managers to apply payments by or on behalf of insureds 29 toward the insureds total contributions to cost 30 sharing requirements; providing applicability; 31 providing disclosure requirements; amending s. 32 627.6699, F.S.; providing contribution to cost-sharing 33 requirements for small employer carriers; amending s. 34 641.31, F.S.; defining the term cost-sharing 35 requirement; requiring specified health maintenance 36 organizations and their pharmacy benefits managers to 37 apply payments by or on behalf of subscribers toward 38 the total contributions of the subscribers cost 39 sharing requirements; providing disclosure 40 requirements; providing applicability; amending s. 41 641.314, F.S.; requiring that contracts require 42 pharmacy benefits managers to apply payments by or on 43 behalf of subscribers toward the subscribers total 44 contributions to cost-sharing requirements; providing 45 applicability; providing disclosure requirements; 46 amending s. 409.967, F.S.; conforming a cross 47 reference; amending s. 641.185, F.S.; conforming a 48 provision to changes made by the act; providing a 49 declaration of important state interest; providing an 50 effective date. 51 52 Be It Enacted by the Legislature of the State of Florida: 53 54 Section 1.Section 627.6383, Florida Statutes, is created 55 to read: 56 627.6383Cost-sharing requirements. 57 (1)As used in this section, the term cost-sharing 58 requirement means a dollar limit, deductible, copayment, 59 coinsurance, or any other out-of-pocket expense imposed on an 60 insured, including, but not limited to, the annual limitation on 61 cost sharing subject to 42 U.S.C. s. 18022. 62 (2)(a)Each health insurer issuing, delivering, or renewing 63 a policy in this state which provides prescription drug 64 coverage, or each pharmacy benefits manager on behalf of such 65 health insurer, shall apply any amount paid by an insured or by 66 another person on behalf of the insured toward the insureds 67 total contribution to any cost-sharing requirement. 68 (b)The amount paid by or on behalf of the insured which is 69 applied toward the insureds total contribution to any cost 70 sharing requirement under paragraph (a) includes, but is not 71 limited to, any payment with, or any discount through, financial 72 assistance, a manufacturer copay card, a product voucher, or any 73 other reduction in out-of-pocket expenses made by or on behalf 74 of the insured for a prescription drug. 75 (3)This section applies to any health insurance policy 76 issued, delivered, or renewed in this state on or after January 77 1, 2023. 78 Section 2.Present subsections (2) and (3) of section 79 627.6385, Florida Statutes, are redesignated as subsections (3) 80 and (4), respectively, a new subsection (2) is added to that 81 section, and present subsection (2) of that section is amended, 82 to read: 83 627.6385Disclosures to policyholders; calculations of cost 84 sharing. 85 (2)Each health insurer issuing, delivering, or renewing a 86 policy in this state which provides prescription drug coverage, 87 regardless of whether the prescription drug benefits are 88 administered or managed by the health insurer or by a pharmacy 89 benefits manager on behalf of the health insurer, shall disclose 90 on its website that any amount paid by a policyholder or by 91 another person on behalf of the policyholder must be applied 92 toward the policyholders total contribution to any cost-sharing 93 requirement pursuant to s. 627.6383. This subsection applies to 94 any policy issued, delivered, or renewed in this state on or 95 after January 1, 2023. 96 (3)(2)Each health insurer shall include in every policy 97 delivered or issued for delivery to any person in this the state 98 or in materials provided as required by s. 627.64725 a notice 99 that the information required by this section is available 100 electronically and the website address of the website where the 101 information can be accessed. In addition, each health insurer 102 issuing, delivering, or renewing a policy in this state which 103 provides prescription drug coverage, regardless of whether the 104 prescription drug benefits are administered or managed by the 105 health insurer or by a pharmacy benefits manager on behalf of 106 the health insurer, shall include in every policy that is 107 issued, delivered, or renewed to any person in this state on or 108 after January 1, 2023, the disclosure that any amount paid by a 109 policyholder or by another person on behalf of the policyholder 110 must be applied toward the policyholders total contribution to 111 any cost-sharing requirement pursuant to s. 627.6383. 112 Section 3.Paragraph (c) is added to subsection (2) of 113 section 627.64741, Florida Statutes, to read: 114 627.64741Pharmacy benefit manager contracts. 115 (2)A contract between a health insurer and a pharmacy 116 benefit manager must require that the pharmacy benefit manager: 117 (c)1.Apply any amount paid by an insured or by another 118 person on behalf of the insured toward the insureds total 119 contribution to any cost-sharing requirement pursuant to s. 120 627.6383. This subparagraph applies to any insured whose 121 insurance policy is issued, delivered, or renewed in this state 122 on or after January 1, 2023. 123 2.Disclose to every insured whose insurance policy is 124 issued, delivered, or renewed in this state on or after January 125 1, 2023, that the pharmacy benefits manager shall apply any 126 amount paid by the insured or by another person on behalf of the 127 insured toward the insureds total contribution to any cost 128 sharing requirement pursuant to s. 627.6383. 129 Section 4.Section 627.65715, Florida Statutes, is created 130 to read: 131 627.65715Cost-sharing requirements. 132 (1)As used in this section, the term cost-sharing 133 requirement means a dollar limit, deductible, copayment, 134 coinsurance, or any other out-of-pocket expense imposed on an 135 insured, including, but not limited to, the annual limitation on 136 cost sharing subject to 42 U.S.C. s. 18022. 137 (2)(a)Each insurer issuing, delivering, or renewing a 138 policy in this state which provides prescription drug coverage, 139 or each pharmacy benefits manager on behalf of such insurer, 140 shall apply any amount paid by an insured or by another person 141 on behalf of the insured toward the insureds total contribution 142 to any cost-sharing requirement. 143 (b)The amount paid by or on behalf of the insured which is 144 applied toward the insureds total contribution to any cost 145 sharing requirement under paragraph (a) includes, but is not 146 limited to, any payment with, or any discount through, financial 147 assistance, a manufacturer copay card, a product voucher, or any 148 other reduction in out-of-pocket expenses made by or on behalf 149 of the insured for a prescription drug. 150 (3)Each insurer issuing, delivering, or renewing a policy 151 in this state which provides prescription drug coverage, 152 regardless of whether the prescription drug benefits are 153 administered or managed by the insurer or by a pharmacy benefits 154 manager on behalf of the insurer, shall disclose, on its website 155 and in every policy issued, delivered, or renewed in this state 156 on or after January 1, 2023, that any amount paid by an insured 157 or by another person on behalf of the insured must be applied 158 toward the insureds total contribution to any cost-sharing 159 requirement. 160 (4)This section applies to any group health insurance 161 policy issued, delivered, or renewed in this state on or after 162 January 1, 2023. 163 Section 5.Paragraph (c) is added to subsection (2) of 164 section 627.6572, Florida Statutes, to read: 165 627.6572Pharmacy benefit manager contracts. 166 (2)A contract between a health insurer and a pharmacy 167 benefit manager must require that the pharmacy benefit manager: 168 (c)1.Apply any amount paid by an insured or by another 169 person on behalf of the insured toward the insureds total 170 contribution to any cost-sharing requirement pursuant to s. 171 627.65715. This subparagraph applies to any insured whose 172 insurance policy is issued, delivered, or renewed in this state 173 on or after January 1, 2023. 174 2.Disclose to every insured whose insurance policy is 175 issued, delivered, or renewed in this state on or after January 176 1, 2023, that the pharmacy benefits manager shall apply any 177 amount paid by the insured or by another person on behalf of the 178 insured toward the insureds total contribution to any cost 179 sharing requirement pursuant to s. 627.65715. 180 Section 6.Paragraph (e) of subsection (5) of section 181 627.6699, Florida Statutes, is amended to read: 182 627.6699Employee Health Care Access Act. 183 (5)AVAILABILITY OF COVERAGE. 184 (e)All health benefit plans issued under this section must 185 comply with the following conditions: 186 1.For employers who have fewer than two employees, a late 187 enrollee may be excluded from coverage for no longer than 24 188 months if he or she was not covered by creditable coverage 189 continually to a date not more than 63 days before the effective 190 date of his or her new coverage. 191 2.Any requirement used by a small employer carrier in 192 determining whether to provide coverage to a small employer 193 group, including requirements for minimum participation of 194 eligible employees and minimum employer contributions, must be 195 applied uniformly among all small employer groups having the 196 same number of eligible employees applying for coverage or 197 receiving coverage from the small employer carrier, except that 198 a small employer carrier that participates in, administers, or 199 issues health benefits pursuant to s. 381.0406 which do not 200 include a preexisting condition exclusion may require as a 201 condition of offering such benefits that the employer has had no 202 health insurance coverage for its employees for a period of at 203 least 6 months. A small employer carrier may vary application of 204 minimum participation requirements and minimum employer 205 contribution requirements only by the size of the small employer 206 group. 207 3.In applying minimum participation requirements with 208 respect to a small employer, a small employer carrier may shall 209 not consider as an eligible employee employees or dependents who 210 have qualifying existing coverage in an employer-based group 211 insurance plan or an ERISA qualified self-insurance plan in 212 determining whether the applicable percentage of participation 213 is met. However, a small employer carrier may count eligible 214 employees and dependents who have coverage under another health 215 plan that is sponsored by that employer. 216 4.A small employer carrier may shall not increase any 217 requirement for minimum employee participation or any 218 requirement for minimum employer contribution applicable to a 219 small employer at any time after the small employer has been 220 accepted for coverage, unless the employer size has changed, in 221 which case the small employer carrier may apply the requirements 222 that are applicable to the new group size. 223 5.If a small employer carrier offers coverage to a small 224 employer, it must offer coverage to all the small employers 225 eligible employees and their dependents. A small employer 226 carrier may not offer coverage limited to certain persons in a 227 group or to part of a group, except with respect to late 228 enrollees. 229 6.A small employer carrier may not modify any health 230 benefit plan issued to a small employer with respect to a small 231 employer or any eligible employee or dependent through riders, 232 endorsements, or otherwise to restrict or exclude coverage for 233 certain diseases or medical conditions otherwise covered by the 234 health benefit plan. 235 7.An initial enrollment period of at least 30 days must be 236 provided. An annual 30-day open enrollment period must be 237 offered to each small employers eligible employees and their 238 dependents. A small employer carrier must provide special 239 enrollment periods as required by s. 627.65615. 240 8.A small employer carrier shall comply with s. 627.65715 241 with respect to contribution to cost-sharing requirements, as 242 defined in that section. 243 Section 7.Subsection (48) is added to section 641.31, 244 Florida Statutes, to read: 245 641.31Health maintenance contracts. 246 (48)(a)As used in this subsection, the term cost-sharing 247 requirement means a dollar limit, deductible, copayment, 248 coinsurance, or any other out-of-pocket expense imposed on a 249 subscriber, including, but not limited to, the annual limitation 250 on cost sharing subject to 42 U.S.C. s. 18022. 251 (b)1.Each health maintenance organization issuing, 252 delivering, or renewing a health maintenance contract or 253 certificate in this state which provides prescription drug 254 coverage, or each pharmacy benefits manager on behalf of such 255 health maintenance organization, shall apply any amount paid by 256 a subscriber or by another person on behalf of the subscriber 257 toward the subscribers total contribution to any cost-sharing 258 requirement. 259 2.The amount paid by or on behalf of the subscriber which 260 is applied toward the subscribers total contribution to any 261 cost-sharing requirement under subparagraph 1. includes, but is 262 not limited to, any payment with, or any discount through, 263 financial assistance, a manufacturer copay card, a product 264 voucher, or any other reduction in out-of-pocket expenses made 265 by or on behalf of the subscriber for a prescription drug. 266 (c)Each health maintenance organization issuing, 267 delivering, or renewing a health maintenance contract or 268 certificate in this state which provides prescription drug 269 coverage, regardless of whether the prescription drug benefits 270 are administered or managed by the health maintenance 271 organization or by a pharmacy benefits manager on behalf of the 272 health maintenance organization, shall disclose, on its website 273 and in every subscribers health maintenance contract, 274 certificate, or member handbook issued, delivered, or renewed in 275 this state on or after January 1, 2023, that any amount paid by 276 a subscriber or by another person on behalf of the subscriber 277 must be applied toward the subscribers total contribution to 278 any cost-sharing requirement. 279 (d)This subsection applies to any health maintenance 280 contract or certificate issued, delivered, or renewed in this 281 state on or after January 1, 2023. 282 Section 8.Paragraph (c) is added to subsection (2) of 283 section 641.314, Florida Statutes, to read: 284 641.314Pharmacy benefit manager contracts. 285 (2)A contract between a health maintenance organization 286 and a pharmacy benefit manager must require that the pharmacy 287 benefit manager: 288 (c)1.Apply any amount paid by a subscriber or by another 289 person on behalf of the subscriber toward the subscribers total 290 contribution to any cost-sharing requirement pursuant to s. 291 641.31(48). This subparagraph applies to any subscriber whose 292 health maintenance contract or certificate is issued, delivered, 293 or renewed in this state on or after January 1, 2023. 294 2.Disclose to every subscriber whose health maintenance 295 contract or certificate is issued, delivered, or renewed in this 296 state on or after January 1, 2023, that the pharmacy benefits 297 manager shall apply any amount paid by the subscriber or by 298 another person on behalf of the subscriber toward the 299 subscribers total contribution to any cost-sharing requirement 300 pursuant to s. 641.31(48). 301 Section 9.Paragraph (o) of subsection (2) of section 302 409.967, Florida Statutes, is amended to read: 303 409.967Managed care plan accountability. 304 (2)The agency shall establish such contract requirements 305 as are necessary for the operation of the statewide managed care 306 program. In addition to any other provisions the agency may deem 307 necessary, the contract must require: 308 (o)Transparency.Managed care plans shall comply with ss. 309 627.6385(4) and 641.54(7) ss. 627.6385(3) and 641.54(7). 310 Section 10.Paragraph (k) of subsection (1) of section 311 641.185, Florida Statutes, is amended to read: 312 641.185Health maintenance organization subscriber 313 protections. 314 (1)With respect to the provisions of this part and part 315 III, the principles expressed in the following statements serve 316 as standards to be followed by the commission, the office, the 317 department, and the Agency for Health Care Administration in 318 exercising their powers and duties, in exercising administrative 319 discretion, in administrative interpretations of the law, in 320 enforcing its provisions, and in adopting rules: 321 (k)A health maintenance organization subscriber shall be 322 given a copy of the applicable health maintenance contract, 323 certificate, or member handbook specifying: all the provisions, 324 disclosure, and limitations required pursuant to s. 641.31(1), 325 and (4), and (48); the covered services, including those 326 services, medical conditions, and provider types specified in 327 ss. 641.31, 641.31094, 641.31095, 641.31096, 641.51(11), and 328 641.513; and where and in what manner services may be obtained 329 pursuant to s. 641.31(4). 330 Section 11.The Legislature finds that this act fulfills an 331 important state interest. 332 Section 12.This act shall take effect July 1, 2022.