Florida Senate - 2016 COMMITTEE AMENDMENT
Bill No. SB 1142
Ì681578UÎ681578
LEGISLATIVE ACTION
Senate . House
Comm: RCS .
02/01/2016 .
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The Committee on Banking and Insurance (Richter) recommended the
following:
1 Senate Amendment (with title amendment)
2
3 Delete everything after the enacting clause
4 and insert:
5 Section 1. Section 627.42392, Florida Statutes, is created
6 to read:
7 627.42392 Continuity of care for medically stable
8 patients.—
9 (1) As used in this section, the term:
10 (a) “Complex or chronic medical condition” means a
11 physical, behavioral, or developmental condition that does not
12 have a known cure or that can be severely debilitating or fatal
13 if left untreated or undertreated.
14 (b) “Rare disease” has the same meaning as in the Public
15 Health Service Act, 42 U.S.C. s. 287a-1.
16 (2) A pharmacy benefits manager or an individual or group
17 insurance policy that is delivered, issued for delivery,
18 renewed, amended, or continued in this state and that provides
19 medical, major medical, or similar comprehensive coverage must
20 continue to cover a drug for an insured with a complex or
21 chronic medical condition or a rare disease if:
22 (a) The drug was previously covered by the insurer for a
23 medical condition or disease of the insured; and
24 (b) The prescribing provider continues to prescribe the
25 drug for the medical condition or disease, provided that the
26 drug is appropriately prescribed and neither of the following
27 has occurred:
28 1. The United States Food and Drug Administration has
29 issued a notice, guidance, warning, announcement, or any other
30 statement about the drug which calls into question the clinical
31 safety of the drug; or
32 2. The manufacturer of the drug has notified the United
33 States Food and Drug Administration of any manufacturing
34 discontinuance or potential discontinuance as required by s.
35 506C of the Federal Food Drug and Cosmetic Act, 21 U.S.C. s.
36 356c.
37 (3) With respect to a drug for an insured with a complex or
38 chronic medical condition or a rare disease which meets the
39 conditions of paragraphs (2)(a) and (2)(b), except during open
40 enrollment periods, a pharmacy benefits manager or an individual
41 or group insurance policy may not:
42 (a) Set forth, by contract, limitations on maximum coverage
43 of prescription drug benefits;
44 (b) Subject the insured to increased out-of-pocket costs;
45 or
46 (c) Move a drug for an insured to a more restrictive tier,
47 if an individual or group insurance policy or a pharmacy
48 benefits manager uses a formulary with tiers.
49 (4) This section does not apply to a grandfathered health
50 plan as defined in s. 627.402, or to benefits set forth in s.
51 627.6561(5)(b), (c), (d), and (e).
52 Section 2. Paragraph (e) of subsection (5) of section
53 627.6699, Florida Statutes, is amended to read:
54 627.6699 Employee Health Care Access Act.—
55 (5) AVAILABILITY OF COVERAGE.—
56 (e) All health benefit plans issued under this section must
57 comply with the following conditions:
58 1. For employers who have fewer than two employees, a late
59 enrollee may be excluded from coverage for no longer than 24
60 months if he or she was not covered by creditable coverage
61 continually to a date not more than 63 days before the effective
62 date of his or her new coverage.
63 2. Any requirement used by a small employer carrier in
64 determining whether to provide coverage to a small employer
65 group, including requirements for minimum participation of
66 eligible employees and minimum employer contributions, must be
67 applied uniformly among all small employer groups having the
68 same number of eligible employees applying for coverage or
69 receiving coverage from the small employer carrier, except that
70 a small employer carrier that participates in, administers, or
71 issues health benefits pursuant to s. 381.0406 which do not
72 include a preexisting condition exclusion may require as a
73 condition of offering such benefits that the employer has had no
74 health insurance coverage for its employees for a period of at
75 least 6 months. A small employer carrier may vary application of
76 minimum participation requirements and minimum employer
77 contribution requirements only by the size of the small employer
78 group.
79 3. In applying minimum participation requirements with
80 respect to a small employer, a small employer carrier shall not
81 consider as an eligible employee employees or dependents who
82 have qualifying existing coverage in an employer-based group
83 insurance plan or an ERISA qualified self-insurance plan in
84 determining whether the applicable percentage of participation
85 is met. However, a small employer carrier may count eligible
86 employees and dependents who have coverage under another health
87 plan that is sponsored by that employer.
88 4. A small employer carrier shall not increase any
89 requirement for minimum employee participation or any
90 requirement for minimum employer contribution applicable to a
91 small employer at any time after the small employer has been
92 accepted for coverage, unless the employer size has changed, in
93 which case the small employer carrier may apply the requirements
94 that are applicable to the new group size.
95 5. If a small employer carrier offers coverage to a small
96 employer, it must offer coverage to all the small employer’s
97 eligible employees and their dependents. A small employer
98 carrier may not offer coverage limited to certain persons in a
99 group or to part of a group, except with respect to late
100 enrollees.
101 6. A small employer carrier may not modify any health
102 benefit plan issued to a small employer with respect to a small
103 employer or any eligible employee or dependent through riders,
104 endorsements, or otherwise to restrict or exclude coverage for
105 certain diseases or medical conditions otherwise covered by the
106 health benefit plan.
107 7. An initial enrollment period of at least 30 days must be
108 provided. An annual 30-day open enrollment period must be
109 offered to each small employer’s eligible employees and their
110 dependents. A small employer carrier must provide special
111 enrollment periods as required by s. 627.65615.
112 8. A small employer carrier must provide continuity of care
113 for medically stable patients as required by s. 627.42392.
114 Section 3. Subsection (44) is added to section 641.31,
115 Florida Statutes, to read:
116 641.31 Health maintenance contracts.—
117 (44)(a) As used in this subsection, the term:
118 1. “Complex or chronic medical condition” means a physical,
119 behavioral, or developmental condition that does not have a
120 known cure or that can be severely debilitating or fatal if left
121 untreated or undertreated.
122 2. “Rare disease” has the same meaning as in the Public
123 Health Service Act, 42 U.S.C. s. 287a-1.
124 (b) A pharmacy benefits manager or a health maintenance
125 contract that is delivered, issued for delivery, renewed,
126 amended, or continued in this state and that provides medical,
127 major medical, or similar comprehensive coverage must continue
128 to cover a drug for a subscriber with a complex or chronic
129 medical condition or a rare disease if:
130 1. The drug was previously covered by the health
131 maintenance organization for a medical condition or disease of
132 the subscriber; and
133 2. The prescribing provider continues to prescribe the drug
134 for the medical condition or disease, provided that the drug is
135 appropriately prescribed and neither of the following has
136 occurred:
137 a. The United States Food and Drug Administration has
138 issued a notice, guidance, warning, announcement, or any other
139 statement about the drug which calls into question the clinical
140 safety of the drug; or
141 b. The manufacturer of the drug has notified the United
142 States Food and Drug Administration of any manufacturing
143 discontinuance or potential discontinuance as required by s.
144 506C of the Federal Food Drug and Cosmetic Act, 21 U.S.C. s.
145 356c.
146 (c) With respect to a drug for a subscriber with a complex
147 or chronic medical condition or a rare disease which meets the
148 conditions of subparagraphs (b)1. and (b)2., except during open
149 enrollment periods, a pharmacy benefits manager or a health
150 maintenance contract may not:
151 1. Set forth, by contract, limitations on maximum coverage
152 of prescription drug benefits;
153 2. Subject the subscriber to increased out-of-pocket costs;
154 or
155 3. Move a drug for a subscriber to a more restrictive tier,
156 if a health maintenance contract or a pharmacy benefits manager
157 uses a formulary with tiers.
158 (d) This section does not apply to a grandfathered health
159 plan as defined in s. 627.402.
160 Section 4. This act shall take effect January 1, 2018.
161
162 ================= T I T L E A M E N D M E N T ================
163 And the title is amended as follows:
164 Delete everything before the enacting clause
165 and insert:
166 A bill to be entitled
167 An act relating to treatments for stable patients;
168 creating s. 627.42392, F.S.; defining terms; requiring
169 a pharmacy benefits manager or a specified individual
170 or group insurance policy to continue to cover a drug
171 for specified insureds under certain circumstances;
172 prohibiting certain actions by a pharmacy benefits
173 manager or an individual or group policy with respect
174 to a drug for a certain insured except under certain
175 circumstances; providing applicability; amending s.
176 627.6699, F.S.; expanding a list of conditions that
177 certain health benefit plans must comply with;
178 amending s. 641.31, F.S.; defining terms; requiring a
179 pharmacy benefits manager or a specified health
180 maintenance contract to continue to cover a drug for
181 specified subscribers under certain circumstances;
182 prohibiting certain actions by a pharmacy benefits
183 manager or a health maintenance contract with respect
184 to a drug for a certain subscriber except under
185 certain circumstances; providing applicability;
186 providing an effective date.