Wisconsin 2023-2024 Regular Session

Wisconsin Assembly Bill AB103 Compare Versions

Only one version of the bill is available at this time.

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3	3	2023 - 2024 LEGISLATURE
4	4	2023 ASSEMBLY BILL 103
5	5	March 14, 2023 - Introduced by Representatives TITTL, ARMSTRONG, SUBECK,
6	6	BEHNKE, KRUG, MURPHY, MURSAU, ROZAR, SCHRAA, C. ANDERSON, J. ANDERSON,
7	7	BALDEH, BARE, BROOKS, CABRERA, DRAKE, GREEN, GUNDRUM, JACOBSON, JOERS,
8	8	O'CONNOR, OHNSTAD, RATCLIFF, RODRIGUEZ, SCHMIDT, SCHUTT, SHANKLAND,
9	9	SINICKI, SPIROS, STUBBS, WICHGERS, CLANCY and MADISON, cosponsored by
10	10	Senators JACQUE, WANGGAARD, CARPENTER, JAMES, CABRAL-GUEVARA, L.
11	11	JOHNSON, LARSON, QUINN, ROYS and TAYLOR. Referred to Committee on Health,
12	12	Aging and Long-Term Care.
13	13	*AUTHORS SUBJECT TO CHANGE*
14	14	AN ACT to amend 40.51 (8), 40.51 (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1)
15	15	(intro.) and 609.83; and to create 632.862 of the statutes; relating to:
16	16	application of prescription drug payments to health insurance cost-sharing
17	17	requirements.
18	18	Analysis by the Legislative Reference Bureau
19	19	Health insurance policies and plans often apply deductibles and out-of-pocket
20	20	maximum amounts to the benefits covered by the policy or plan. A deductible is an
21	21	amount that an enrollee in a policy or plan must pay out of pocket before attaining
22	22	the full benefits of the policy or plan. An out-of-pocket maximum amount is a limit
23	23	specified by a policy or plan on the amount that an enrollee pays, and, once that limit
24	24	is reached, the policy or plan covers the benefit entirely. This bill generally requires
25	25	health insurance policies that offer prescription drug benefits, self-insured health
26	26	plans, and pharmacy benefit managers acting on behalf of policies or plans to apply
27	27	amounts paid by or on behalf of an individual covered under the policy or plan for
28	28	brand name prescription drugs to any cost-sharing requirement or to any
29	29	calculation of an out-of-pocket maximum amount of the policy or plan. Health
30	30	insurance policies are referred to in the bill as disability insurance policies.
31	31	The people of the state of Wisconsin, represented in senate and assembly, do
32	32	enact as follows:
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38	38	SECTION 1 ASSEMBLY BILL 103
39	39	SECTION 1. 40.51 (8) of the statutes is amended to read:
40	40	40.51 (8) Every health care coverage plan offered by the state under sub. (6)
41	41	shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.729, 632.746
42	42	(1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853,
43	43	632.855, 632.861, 632.862, 632.867, 632.87 (3) to (6), 632.885, 632.89, 632.895 (5m)
44	44	and (8) to (17), and 632.896.
45	45	SECTION 2. 40.51 (8m) of the statutes is amended to read:
46	46	40.51 (8m) Every health care coverage plan offered by the group insurance
47	47	board under sub. (7) shall comply with ss. 631.95, 632.729, 632.746 (1) to (8) and (10),
48	48	632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.861,
49	49	632.862, 632.867, 632.885, 632.89, and 632.895 (11) to (17).
50	50	SECTION 3. 66.0137 (4) of the statutes is amended to read:
51	51	66.0137 (4) SELF-INSURED HEALTH PLANS. If a city, including a 1st class city, or
52	52	a village provides health care benefits under its home rule power, or if a town
53	53	provides health care benefits, to its officers and employees on a self-insured basis,
54	54	the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
55	55	632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855,
56	56	632.861, 632.862, 632.867, 632.87 (4) to (6), 632.885, 632.89, 632.895 (9) to (17),
57	57	632.896, and 767.513 (4).
58	58	SECTION 4. 120.13 (2) (g) of the statutes is amended to read:
59	59	120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss.
60	60	49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.729, 632.746 (10) (a) 2. and (b) 2.,
61	61	632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (4)
62	62	to (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).
63	63	SECTION 5. 185.983 (1) (intro.) of the statutes is amended to read:
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91	91	SECTION 5
92	92	ASSEMBLY BILL 103
93	93	185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a
94	94	cooperative association organized under s. 185.981 shall be exempt from chs. 600 to
95	95	646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44,
96	96	601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93,
97	97	631.95, 632.72 (2), 632.729, 632.745 to 632.749, 632.775, 632.79, 632.795, 632.798,
98	98	632.85, 632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (2) to (6), 632.885,
99	99	632.89, 632.895 (5) and (8) to (17), 632.896, and 632.897 (10) and chs. 609, 620, 630,
100	100	635, 645, and 646, but the sponsoring association shall:
101	101	SECTION 6. 609.83 of the statutes is amended to read:
102	102	609.83 Coverage of drugs and devices; application of payments .
103	103	Limited service health organizations, preferred provider plans, and defined network
104	104	plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (16t) and (16v).
105	105	SECTION 7. 632.862 of the statutes is created to read:
106	106	632.862 Application of prescription drug payments. (1) DEFINITIONS. In
107	107	this section:
108	108	(a) “Brand name” has the meaning given in s. 450.12 (1) (a).
109	109	(b) “Brand name drug” means any of the following:
110	110	1. A prescription drug that contains a brand name and that has no medically
111	111	appropriate generic equivalent.
112	112	2. A prescription drug that contains a brand name and that has a medically
113	113	appropriate generic equivalent but to which the enrollee or other covered individual
114	114	has obtained access through any of the following:
115	115	a. Prior authorization.
116	116	b. A step therapy protocol.
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142	142	SECTION 7 ASSEMBLY BILL 103
143	143	c. The exceptions and appeals process of the disability insurance policy,
144	144	self-insured health plan, or pharmacy benefit manager.
145	145	(c) “Cost-sharing requirement” means a deductible, copayment, or
146	146	coinsurance.
147	147	(d) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).
148	148	(e) “Generic equivalent” means a drug product equivalent, as defined in s.
149	149	450.13 (1e), that is nationally available.
150	150	(f) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).
151	151	(g) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).
152	152	(2) APPLICATION OF PAYMENTS. Except as provided in sub. (4), a disability
153	153	insurance policy that offers a prescription drug benefit, a self-insured health plan,
154	154	or a pharmacy benefit manager acting on behalf of a disability insurance policy or
155	155	self-insured health plan shall apply to any cost-sharing requirement or to any
156	156	calculation of an out-of-pocket maximum amount of the disability insurance policy
157	157	or self-insured health plan, including the annual limitations on cost sharing
158	158	established under 42 USC 18022 (c) and 42 USC 300gg-6 (b), any amounts paid by
159	159	an enrollee or other individual covered under the disability insurance policy or
160	160	self-insured health plan, or by any person on behalf of the enrollee or individual, for
161	161	brand name drugs that are covered under the disability insurance policy or
162	162	self-insured health plan.
163	163	(3) CALCULATION OF COST-SHARING ANNUAL LIMITATIONS. For purposes of
164	164	calculating an enrollee's contribution to the annual limitation on cost sharing under
165	165	42 USC 18022 (c) and 42 USC 300gg-6 (b), a disability insurance policy that offers
166	166	a prescription drug benefit, a self-insured health plan, or a pharmacy benefit
167	167	manager acting on behalf of a disability insurance policy or self-insured health plan
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195	195	SECTION 7
196	196	ASSEMBLY BILL 103
197	197	shall include expenditures for any item or service covered under the disability
198	198	insurance policy or self-insured health plan if the item or service is included within
199	199	a category of essential health benefits, as described in 42 USC 18022 (b) (1), and
200	200	regardless of whether the disability insurance policy, self-insured health plan, or
201	201	pharmacy benefit manager classifies the item or service as an essential health
202	202	benefit.
203	203	(4) EXCEPTION; HIGH DEDUCTIBLE HEALTH PLANS. If applying the requirement
204	204	under sub. (2) to payments made by or on behalf of an enrollee or other individual
205	205	covered under a high deductible health plan, as defined under 26 USC 223 (c) (2),
206	206	would result in the enrollee failing to meet the definition of an eligible individual
207	207	under 26 USC 223 (c) (1), the disability insurance policy, self-insured health plan,
208	208	or pharmacy benefit manager shall begin applying the requirement under sub. (2)
209	209	to the disability insurance policy or self-insured health plan's deductible after the
210	210	enrollee has satisfied the minimum deductible requirement under 26 USC 223 (c) (2)
211	211	(A) (i). This subsection does not apply to any amounts paid for items or services that
212	212	are preventive care, as described in 26 USC 223 (c) (2) (C).
213	213	SECTION 8.0Initial applicability.
214	214	(1) (a) For policies and plans containing provisions inconsistent with this act,
215	215	the act first applies to policy or plan years beginning on January 1 of the year
216	216	following the year in which this paragraph takes effect, except as provided in par. (b).
217	217	(b) For policies or plans that are affected by a collective bargaining agreement
218	218	containing provisions inconsistent with this act, this act first applies to policy or plan
219	219	years beginning on the effective date of this paragraph or on the day on which the
220	220	collective bargaining agreement is newly established, extended, modified, or
221	221	renewed, whichever is later.
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248	248	SECTION 9 ASSEMBLY BILL 103
249	249	SECTION 9.0Effective date.
250	250	(1) This act takes effect on the first day of the 4th month beginning after
251	251	publication.
252	252	(END)
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