Wisconsin 2023-2024 Regular Session

Wisconsin Senate Bill SB100 Compare Versions

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

Old	New	Differences
1	1	LRB-0164/1
2	2	KRP:klm
3	3	2023 - 2024 LEGISLATURE
4	4	2023 SENATE BILL 100
5	5	March 1, 2023 - Introduced by Senators JACQUE, WANGGAARD, CARPENTER, JAMES,
6	6	CABRAL-GUEVARA, L. JOHNSON, LARSON, QUINN, ROYS and TAYLOR, cosponsored
7	7	by Representatives TITTL, ARMSTRONG, SUBECK, BEHNKE, KRUG, MURPHY,
8	8	MURSAU, ROZAR, SCHRAA, C. ANDERSON, J. ANDERSON, BALDEH, BARE, BROOKS,
9	9	CABRERA, DRAKE, GREEN, GUNDRUM, JACOBSON, JOERS, O'CONNOR, OHNSTAD,
10	10	RATCLIFF, RODRIGUEZ, SCHMIDT, SCHUTT, SHANKLAND, SINICKI, SPIROS, STUBBS
11	11	and WICHGERS. Referred to Committee on Insurance and Small Business.
12	12	AN ACT to amend 40.51 (8), 40.51 (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1)
13	13	(intro.) and 609.83; and to create 632.862 of the statutes; relating to:
14	14	application of prescription drug payments to health insurance cost-sharing
15	15	requirements.
16	16	Analysis by the Legislative Reference Bureau
17	17	Health insurance policies and plans often apply deductibles and out-of-pocket
18	18	maximum amounts to the benefits covered by the policy or plan. A deductible is an
19	19	amount that an enrollee in a policy or plan must pay out of pocket before attaining
20	20	the full benefits of the policy or plan. An out-of-pocket maximum amount is a limit
21	21	specified by a policy or plan on the amount that an enrollee pays, and, once that limit
22	22	is reached, the policy or plan covers the benefit entirely. This bill generally requires
23	23	health insurance policies that offer prescription drug benefits, self-insured health
24	24	plans, and pharmacy benefit managers acting on behalf of policies or plans to apply
25	25	amounts paid by or on behalf of an individual covered under the policy or plan for
26	26	brand name prescription drugs to any cost-sharing requirement or to any
27	27	calculation of an out-of-pocket maximum amount of the policy or plan. Health
28	28	insurance policies are referred to in the bill as disability insurance policies.
29	29	The people of the state of Wisconsin, represented in senate and assembly, do
30	30	enact as follows:
31	31	1
32	32	2
33	33	3
34	34	4 - 2 -2023 - 2024 Legislature LRB-0164/1
35	35	KRP:klm
36	36	SECTION 1 SENATE BILL 100
37	37	SECTION 1. 40.51 (8) of the statutes is amended to read:
38	38	40.51 (8) Every health care coverage plan offered by the state under sub. (6)
39	39	shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.729, 632.746
40	40	(1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853,
41	41	632.855, 632.861, 632.862, 632.867, 632.87 (3) to (6), 632.885, 632.89, 632.895 (5m)
42	42	and (8) to (17), and 632.896.
43	43	SECTION 2. 40.51 (8m) of the statutes is amended to read:
44	44	40.51 (8m) Every health care coverage plan offered by the group insurance
45	45	board under sub. (7) shall comply with ss. 631.95, 632.729, 632.746 (1) to (8) and (10),
46	46	632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.861,
47	47	632.862, 632.867, 632.885, 632.89, and 632.895 (11) to (17).
48	48	SECTION 3. 66.0137 (4) of the statutes is amended to read:
49	49	66.0137 (4) SELF-INSURED HEALTH PLANS. If a city, including a 1st class city, or
50	50	a village provides health care benefits under its home rule power, or if a town
51	51	provides health care benefits, to its officers and employees on a self-insured basis,
52	52	the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
53	53	632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855,
54	54	632.861, 632.862, 632.867, 632.87 (4) to (6), 632.885, 632.89, 632.895 (9) to (17),
55	55	632.896, and 767.513 (4).
56	56	SECTION 4. 120.13 (2) (g) of the statutes is amended to read:
57	57	120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss.
58	58	49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.729, 632.746 (10) (a) 2. and (b) 2.,
59	59	632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (4)
60	60	to (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).
61	61	SECTION 5. 185.983 (1) (intro.) of the statutes is amended to read:
62	62	1
63	63	2
64	64	3
65	65	4
66	66	5
67	67	6
68	68	7
69	69	8
70	70	9
71	71	10
72	72	11
73	73	12
74	74	13
75	75	14
76	76	15
77	77	16
78	78	17
79	79	18
80	80	19
81	81	20
82	82	21
83	83	22
84	84	23
85	85	24
86	86	25 - 3 -2023 - 2024 Legislature
87	87	LRB-0164/1
88	88	KRP:klm
89	89	SECTION 5
90	90	SENATE BILL 100
91	91	185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a
92	92	cooperative association organized under s. 185.981 shall be exempt from chs. 600 to
93	93	646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44,
94	94	601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93,
95	95	631.95, 632.72 (2), 632.729, 632.745 to 632.749, 632.775, 632.79, 632.795, 632.798,
96	96	632.85, 632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (2) to (6), 632.885,
97	97	632.89, 632.895 (5) and (8) to (17), 632.896, and 632.897 (10) and chs. 609, 620, 630,
98	98	635, 645, and 646, but the sponsoring association shall:
99	99	SECTION 6. 609.83 of the statutes is amended to read:
100	100	609.83 Coverage of drugs and devices; application of payments .
101	101	Limited service health organizations, preferred provider plans, and defined network
102	102	plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (16t) and (16v).
103	103	SECTION 7. 632.862 of the statutes is created to read:
104	104	632.862 Application of prescription drug payments. (1) DEFINITIONS. In
105	105	this section:
106	106	(a) “Brand name” has the meaning given in s. 450.12 (1) (a).
107	107	(b) “Brand name drug” means any of the following:
108	108	1. A prescription drug that contains a brand name and that has no medically
109	109	appropriate generic equivalent.
110	110	2. A prescription drug that contains a brand name and that has a medically
111	111	appropriate generic equivalent but to which the enrollee or other covered individual
112	112	has obtained access through any of the following:
113	113	a. Prior authorization.
114	114	b. A step therapy protocol.
115	115	1
116	116	2
117	117	3
118	118	4
119	119	5
120	120	6
121	121	7
122	122	8
123	123	9
124	124	10
125	125	11
126	126	12
127	127	13
128	128	14
129	129	15
130	130	16
131	131	17
132	132	18
133	133	19
134	134	20
135	135	21
136	136	22
137	137	23
138	138	24 - 4 -2023 - 2024 Legislature LRB-0164/1
139	139	KRP:klm
140	140	SECTION 7 SENATE BILL 100
141	141	c. The exceptions and appeals process of the disability insurance policy,
142	142	self-insured health plan, or pharmacy benefit manager.
143	143	(c) “Cost-sharing requirement” means a deductible, copayment, or
144	144	coinsurance.
145	145	(d) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).
146	146	(e) “Generic equivalent” means a drug product equivalent, as defined in s.
147	147	450.13 (1e), that is nationally available.
148	148	(f) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).
149	149	(g) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).
150	150	(2) APPLICATION OF PAYMENTS. Except as provided in sub. (4), a disability
151	151	insurance policy that offers a prescription drug benefit, a self-insured health plan,
152	152	or a pharmacy benefit manager acting on behalf of a disability insurance policy or
153	153	self-insured health plan shall apply to any cost-sharing requirement or to any
154	154	calculation of an out-of-pocket maximum amount of the disability insurance policy
155	155	or self-insured health plan, including the annual limitations on cost sharing
156	156	established under 42 USC 18022 (c) and 42 USC 300gg-6 (b), any amounts paid by
157	157	an enrollee or other individual covered under the disability insurance policy or
158	158	self-insured health plan, or by any person on behalf of the enrollee or individual, for
159	159	brand name drugs that are covered under the disability insurance policy or
160	160	self-insured health plan.
161	161	(3) CALCULATION OF COST-SHARING ANNUAL LIMITATIONS. For purposes of
162	162	calculating an enrollee's contribution to the annual limitation on cost sharing under
163	163	42 USC 18022 (c) and 42 USC 300gg-6 (b), a disability insurance policy that offers
164	164	a prescription drug benefit, a self-insured health plan, or a pharmacy benefit
165	165	manager acting on behalf of a disability insurance policy or self-insured health plan
166	166	1
167	167	2
168	168	3
169	169	4
170	170	5
171	171	6
172	172	7
173	173	8
174	174	9
175	175	10
176	176	11
177	177	12
178	178	13
179	179	14
180	180	15
181	181	16
182	182	17
183	183	18
184	184	19
185	185	20
186	186	21
187	187	22
188	188	23
189	189	24
190	190	25 - 5 -2023 - 2024 Legislature
191	191	LRB-0164/1
192	192	KRP:klm
193	193	SECTION 7
194	194	SENATE BILL 100
195	195	shall include expenditures for any item or service covered under the disability
196	196	insurance policy or self-insured health plan if the item or service is included within
197	197	a category of essential health benefits, as described in 42 USC 18022 (b) (1), and
198	198	regardless of whether the disability insurance policy, self-insured health plan, or
199	199	pharmacy benefit manager classifies the item or service as an essential health
200	200	benefit.
201	201	(4) EXCEPTION; HIGH DEDUCTIBLE HEALTH PLANS. If applying the requirement
202	202	under sub. (2) to payments made by or on behalf of an enrollee or other individual
203	203	covered under a high deductible health plan, as defined under 26 USC 223 (c) (2),
204	204	would result in the enrollee failing to meet the definition of an eligible individual
205	205	under 26 USC 223 (c) (1), the disability insurance policy, self-insured health plan,
206	206	or pharmacy benefit manager shall begin applying the requirement under sub. (2)
207	207	to the disability insurance policy or self-insured health plan's deductible after the
208	208	enrollee has satisfied the minimum deductible requirement under 26 USC 223 (c) (2)
209	209	(A) (i). This subsection does not apply to any amounts paid for items or services that
210	210	are preventive care, as described in 26 USC 223 (c) (2) (C).
211	211	SECTION 8.0Initial applicability.
212	212	(1) (a) For policies and plans containing provisions inconsistent with this act,
213	213	the act first applies to policy or plan years beginning on January 1 of the year
214	214	following the year in which this paragraph takes effect, except as provided in par. (b).
215	215	(b) For policies or plans that are affected by a collective bargaining agreement
216	216	containing provisions inconsistent with this act, this act first applies to policy or plan
217	217	years beginning on the effective date of this paragraph or on the day on which the
218	218	collective bargaining agreement is newly established, extended, modified, or
219	219	renewed, whichever is later.
220	220	1
221	221	2
222	222	3
223	223	4
224	224	5
225	225	6
226	226	7
227	227	8
228	228	9
229	229	10
230	230	11
231	231	12
232	232	13
233	233	14
234	234	15
235	235	16
236	236	17
237	237	18
238	238	19
239	239	20
240	240	21
241	241	22
242	242	23
243	243	24
244	244	25 - 6 -2023 - 2024 Legislature LRB-0164/1
245	245	KRP:klm
246	246	SECTION 9 SENATE BILL 100
247	247	SECTION 9.0Effective date.
248	248	(1) This act takes effect on the first day of the 4th month beginning after
249	249	publication.
250	250	(END)
251	251	1
252	252	2
253	253	3
254	254	4