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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
A bill to be entitled 1
An act relating to health insurance cost sharing; 2
creating s. 627.6383, F.S.; defining the term "cost -3
sharing requirement"; requiring specified individual 4
health insurers and their pharmacy benefit managers to 5
apply payments by or on behalf of insureds tow ard the 6
total contributions of the insureds' cost -sharing 7
requirements; providing construction; providing 8
applicability; amending s. 627.6385, F.S.; providing 9
disclosure requirements; providing applicability; 10
amending s. 627.64741, F.S.; requiring specifie d 11
contracts to require pharmacy benefit managers to 12
apply payments by or on behalf of insureds toward the 13
insureds' total contributions to cost -sharing 14
requirements; providing applicability; providing 15
disclosure requirements; creating s. 627.65715, F.S.; 16
defining the term "cost -sharing requirement"; 17
requiring specified group health insurers and their 18
pharmacy benefit managers to apply payments by or on 19
behalf of insureds toward the total contributions of 20
the insureds' cost-sharing requirements; providing 21
construction; providing disclosure requirements; 22
providing applicability; amending s. 627.6572, F.S.; 23
requiring specified contracts to require pharmacy 24
benefit managers to apply payments by or on behalf of 25
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insureds toward the insureds' total contributions to 26
cost-sharing requirements; providing applicability; 27
providing disclosure requirements; amending s. 28
627.6699, F.S.; requiring small employer carriers to 29
comply with certain cost -sharing requirements; making 30
technical changes; amending s. 641.31, F.S.; defi ning 31
the term "cost-sharing requirement"; requiring 32
specified health maintenance organizations and their 33
pharmacy benefit managers to apply payments by or on 34
behalf of subscribers toward the total contributions 35
of the subscribers' cost -sharing requirements ; 36
providing construction; providing disclosure 37
requirements; providing applicability; amending s. 38
641.314, F.S.; requiring specified contracts to 39
require pharmacy benefit managers to apply payments by 40
or on behalf of subscribers toward the subscribers' 41
total contributions to cost -sharing requirements; 42
providing applicability; providing disclosure 43
requirements; amending s. 409.967, F.S.; conforming a 44
cross-reference; amending s. 641.185, F.S.; conforming 45
a provision to changes made by the act; providing a 46
declaration of important state interest; providing an 47
effective date. 48
49
Be It Enacted by the Legislature of the State of Florida: 50
HB 1063 2023
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51
Section 1. Section 627.6383, Florida Statutes, is created 52
to read: 53
627.6383 Cost-sharing requirements. — 54
(1) As used in this section, the term "cost -sharing 55
requirement" means a dollar limit, a deductible, a copayment, 56
coinsurance, or any other out -of-pocket expense imposed on an 57
insured, including, but not limited to, the annual limitation on 58
cost sharing subject to 42 U.S.C. s. 18022. 59
(2)(a) Each health insurer issuing, delivering, or 60
renewing a policy in this state which provides prescription drug 61
coverage, or each pharmacy benefit manager on behalf of such 62
health insurer, shall apply any amount paid by an insured or by 63
another person on behalf of the insured toward the insured's 64
total contribution to any cost -sharing requirement. 65
(b) The amount paid by or on behalf of the insured which 66
is applied toward the insured's total contribution to any cost -67
sharing requirement under paragraph (a) includes, but is not 68
limited to, any payment with or any discount through financial 69
assistance, a manufacturer copay card, a product voucher, or any 70
other reduction in out -of-pocket expenses made by or on behalf 71
of the insured for a prescription drug. 72
(3) This section applies to any health insurance policy 73
issued, delivered, or renewed in this state on or after January 74
1, 2024. 75
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Section 2. Present subsections (2) and (3) of section 76
627.6385, Florida Statutes, are redesignated as subsections (3) 77
and (4), respectively, a new subsection (2) is added to that 78
section, and present subsection (2) of that section is amended, 79
to read: 80
627.6385 Disclosures to policyholders; calculations of 81
cost sharing.— 82
(2) Each health insurer issuing, delivering, or renewing a 83
policy in this state which provides prescription drug coverage, 84
regardless of whether the prescription drug benefits are 85
administered or managed by the health insurer or by a pharmacy 86
benefit manager on behalf of the health insur er, shall disclose 87
on its website that any amount paid by a policyholder or by 88
another person on behalf of the policyholder must be applied 89
toward the policyholder's total contribution to any cost -sharing 90
requirement pursuant to s. 627.6383. This subsectio n applies to 91
any policy issued, delivered, or renewed in this state on or 92
after January 1, 2024. 93
(3)(2) Each health insurer shall include in every policy 94
delivered or issued for delivery to any person in this the state 95
or in materials provided as require d by s. 627.64725 a notice 96
that the information required by this section is available 97
electronically and the website address of the website where the 98
information can be accessed. In addition, each health insurer 99
issuing, delivering, or renewing a policy in this state which 100
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provides prescription drug coverage, regardless of whether the 101
prescription drug benefits are administered or managed by the 102
health insurer or by a pharmacy benefit manager on behalf of the 103
health insurer, shall include in every policy th at is issued, 104
delivered, or renewed to any person in this state on or after 105
January 1, 2024, the disclosure that any amount paid by a 106
policyholder or by another person on behalf of the policyholder 107
must be applied toward the policyholder's total contributi on to 108
any cost-sharing requirement pursuant to s. 627.6383. 109
Section 3. Paragraph (c) is added to subsection (2) of 110
section 627.64741, Florida Statutes, to read: 111
627.64741 Pharmacy benefit manager contracts. — 112
(2) A contract between a health insurer and a pharmacy 113
benefit manager must require that the pharmacy benefit manager: 114
(c)1. Apply any amount paid by an insured or by another 115
person on behalf of the insured toward the insured's total 116
contribution to any cost -sharing requirement pursuant to s. 117
627.6383. This subparagraph applies to any insured whose 118
insurance policy is issued, delivered, or renewed in this state 119
on or after January 1, 2024. 120
2. Disclose to every insured whose insurance policy is 121
issued, delivered, or renewed in this state on or after January 122
1, 2024, that the pharmacy benefit manager shall apply any 123
amount paid by the insured or by another person on behalf of the 124
insured toward the insured's total contribution to any cost -125
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sharing requirement pursuant to s. 627.6383. 126
Section 4. Section 627.65715, Florida Statutes, is created 127
to read: 128
627.65715 Cost-sharing requirements. — 129
(1) As used in this section, the term "cost -sharing 130
requirement" means a dollar limit, a deductible, a copayment, 131
coinsurance, or any other out -of-pocket expense imposed on an 132
insured, including, but not limited to, the annual limitation on 133
cost sharing subject to 42 U.S.C. s. 18022. 134
(2)(a) Each insurer issuing, delivering, or renewing a 135
policy in this state which provides prescription drug coverage, 136
or each pharmacy benefit manager on behalf of such insurer, 137
shall apply any amount paid by an insured or by another person 138
on behalf of the insured toward the insured's total contribution 139
to any cost-sharing requirement. 140
(b) The amount paid by or on behalf o f the insured which 141
is applied toward the insured's total contribution to any cost -142
sharing requirement under paragraph (a) includes, but is not 143
limited to, any payment with or any discount through financial 144
assistance, a manufacturer copay card, a product voucher, or any 145
other reduction in out -of-pocket expenses made by or on behalf 146
of the insured for a prescription drug. 147
(3) Each insurer issuing, delivering, or renewing a policy 148
in this state which provides prescription drug coverage, 149
regardless of whether the prescription drug benefits are 150
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administered or managed by the insurer or by a pharmacy benefit 151
manager on behalf of the insurer, shall disclose on its website 152
and in every policy issued, delivered, or renewed in this state 153
on or after January 1, 202 4, that any amount paid by an insured 154
or by another person on behalf of the insured must be applied 155
toward the insured's total contribution to any cost -sharing 156
requirement. 157
(4) This section applies to any group health insurance 158
policy issued, delivered, or renewed in this state on or after 159
January 1, 2024. 160
Section 5. Paragraph (c) is added to subsection (2) of 161
section 627.6572, Florida Statutes, to read: 162
627.6572 Pharmacy benefit manager contracts. — 163
(2) A contract between a health insurer and a ph armacy 164
benefit manager must require that the pharmacy benefit manager: 165
(c)1. Apply any amount paid by an insured or by another 166
person on behalf of the insured toward the insured's total 167
contribution to any cost -sharing requirement pursuant to s. 168
627.65715. This subparagraph applies to any insured whose 169
insurance policy is issued, delivered, or renewed in this state 170
on or after January 1, 2024. 171
2. Disclose to every insured whose insurance policy is 172
issued, delivered, or renewed in this state on or after January 173
1, 2024, that the pharmacy benefit manager shall apply any 174
amount paid by the insured or by another person on behalf of the 175
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insured toward the insured's total contribution to any cost -176
sharing requirement pursuant to s. 627.65715. 177
Section 6. Paragraph (e) of subsection (5) of section 178
627.6699, Florida Statutes, is amended to read: 179
627.6699 Employee Health Care Access Act. — 180
(5) AVAILABILITY OF COVERAGE. — 181
(e) All health benefit plans issued under this section 182
must comply with the following co nditions: 183
1. For employers who have fewer than two employees, a late 184
enrollee may be excluded from coverage for no longer than 24 185
months if he or she was not covered by creditable coverage 186
continually to a date not more than 63 days before the effective 187
date of his or her new coverage. 188
2. Any requirement used by a small employer carrier in 189
determining whether to provide coverage to a small employer 190
group, including requirements for minimum participation of 191
eligible employees and minimum employer contrib utions, must be 192
applied uniformly among all small employer groups having the 193
same number of eligible employees applying for coverage or 194
receiving coverage from the small employer carrier, except that 195
a small employer carrier that participates in, administe rs, or 196
issues health benefits pursuant to s. 381.0406 which do not 197
include a preexisting condition exclusion may require as a 198
condition of offering such benefits that the employer has had no 199
health insurance coverage for its employees for a period of at 200
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least 6 months. A small employer carrier may vary application of 201
minimum participation requirements and minimum employer 202
contribution requirements only by the size of the small employer 203
group. 204
3. In applying minimum participation requirements with 205
respect to a small employer, a small employer carrier may shall 206
not consider as an eligible employee employees or dependents who 207
have qualifying existing coverage in an employer -based group 208
insurance plan or an ERISA qualified self -insurance plan in 209
determining whether the applicable percentage of participation 210
is met. However, a small employer carrier may count eligible 211
employees and dependents who have coverage under another health 212
plan that is sponsored by that employer. 213
4. A small employer carrier may shall not increase any 214
requirement for minimum employee participation or any 215
requirement for minimum employer contribution applicable to a 216
small employer at any time after the small employer has been 217
accepted for coverage, unless the employer size has changed, in 218
which case the small employer carrier may apply the requirements 219
that are applicable to the new group size. 220
5. If a small employer carrier offers coverage to a small 221
employer, it must offer coverage to all the small employer's 222
eligible employees and the ir dependents. A small employer 223
carrier may not offer coverage limited to certain persons in a 224
group or to part of a group, except with respect to late 225
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enrollees. 226
6. A small employer carrier may not modify any health 227
benefit plan issued to a small employ er with respect to a small 228
employer or any eligible employee or dependent through riders, 229
endorsements, or otherwise to restrict or exclude coverage for 230
certain diseases or medical conditions otherwise covered by the 231
health benefit plan. 232
7. An initial enrollment period of at least 30 days must 233
be provided. An annual 30 -day open enrollment period must be 234
offered to each small employer's eligible employees and their 235
dependents. A small employer carrier must provide special 236
enrollment periods as required by s. 627.65615. 237
8. A small employer carrier shall comply with s. 627.65715 238
with respect to contribution to cost -sharing requirements, as 239
defined in that section. 240
Section 7. Subsection (48) is added to section 641.31, 241
Florida Statutes, to read: 242
641.31 Health maintenance contracts. — 243
(48)(a) As used in this subsection, the term "cost -sharing 244
requirement" means a dollar limit, a deductible, a copayment, 245
coinsurance, or any other out -of-pocket expense imposed on a 246
subscriber, including, but not limited t o, the annual limitation 247
on cost sharing subject to 42 U.S.C. s. 18022. 248
(b)1. Each health maintenance organization issuing, 249
delivering, or renewing a health maintenance contract or 250
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certificate in this state which provides prescription drug 251
coverage, or each pharmacy benefit manager on behalf of such 252
health maintenance organization, shall apply any amount paid by 253
a subscriber or by another person on behalf of the subscriber 254
toward the subscriber's total contribution to any cost -sharing 255
requirement. 256
2. The amount paid by or on behalf of the subscriber which 257
is applied toward the subscriber's total contribution to any 258
cost-sharing requirement under subparagraph 1. includes, but is 259
not limited to, any payment with or any discount through 260
financial assistance, a manufacturer copay card, a product 261
voucher, or any other reduction in out -of-pocket expenses made 262
by or on behalf of the subscriber for a prescription drug. 263
(c) Each health maintenance organization issuing, 264
delivering, or renewing a health maintenan ce contract or 265
certificate in this state which provides prescription drug 266
coverage, regardless of whether the prescription drug benefits 267
are administered or managed by the health maintenance 268
organization or by a pharmacy benefit manager on behalf of the 269
health maintenance organization, shall disclose on its website 270
and in every subscriber's health maintenance contract, 271
certificate, or member handbook issued, delivered, or renewed in 272
this state on or after January 1, 2024, that any amount paid by 273
a subscriber or by another person on behalf of the subscriber 274
must be applied toward the subscriber's total contribution to 275
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any cost-sharing requirement. 276
(d) This subsection applies to any health maintenance 277
contract or certificate issued, delivered, or renewed in this 278
state on or after January 1, 2024. 279
Section 8. Paragraph (c) is added to subsection (2) of 280
section 641.314, Florida Statutes, to read: 281
641.314 Pharmacy benefit manager contracts. — 282
(2) A contract between a health maintenance organization 283
and a pharmacy benefit manager must require that the pharmacy 284
benefit manager: 285
(c)1. Apply any amount paid by a subscriber or by another 286
person on behalf of the subscriber toward the subscriber's total 287
contribution to any cost -sharing requirement pursuant to s. 288
641.31(48). This subparagraph applies to any subscriber whose 289
health maintenance contract or certificate is issued, delivered, 290
or renewed in this state on or after January 1, 2024. 291
2. Disclose to every subscriber whose health maintenance 292
contract or certificate is issued, delivered, or renewed in this 293
state on or after January 1, 2024, that the pharmacy benefit 294
manager shall apply any amount paid by the subscriber or by 295
another person on behalf of the subscriber toward the 296
subscriber's total contribution to any cost-sharing requirement 297
pursuant to s. 641.31(48). 298
Section 9. Paragraph (o) of subsection (2) of section 299
409.967, Florida Statutes, is amended to read: 300
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409.967 Managed care plan accountability. — 301
(2) The agency shall establish such contract requirements 302
as are necessary for the operation of the statewide managed care 303
program. In addition to any other provisions the agency may deem 304
necessary, the contract must require: 305
(o) Transparency.—Managed care plans shall comply with ss. 306
627.6385(4) and 641.54(7) ss. 627.6385(3) and 641.54(7) . 307
Section 10. Paragraph (k) of subsection (1) of section 308
641.185, Florida Statutes, is amended to read: 309
641.185 Health maintenance organization subscriber 310
protections.— 311
(1) With respect to the provisions of this part and part 312
III, the principles expressed in the following statements serve 313
as standards to be followed by the commission, the office, the 314
department, and the Agency for Health Care Administration in 315
exercising their powers and duties, in exercisin g administrative 316
discretion, in administrative interpretations of the law, in 317
enforcing its provisions, and in adopting rules: 318
(k) A health maintenance organization subscriber shall be 319
given a copy of the applicable health maintenance contract, 320
certificate, or member handbook specifying: all the provisions, 321
disclosure, and limitations required pursuant to s. 641.31(1) , 322
and (4), and (48); the covered services, including those 323
services, medical conditions, and provider types specified in 324
ss. 641.31, 641.31094, 641.31095, 641.31096, 641.51(11), and 325
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641.513; and where and in what manner services may be obtained 326
pursuant to s. 641.31(4). 327
Section 11. The Legislature finds that this act fulfills 328
an important state interest. 329
Section 12. This act shall take effect July 1, 2023. 330