Florida Senate - 2016                          SENATOR AMENDMENT
       Bill No. CS for CS for CS for SB 676
       
       
       
       
       
       
                                Ì5404769Î540476                         
       
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
                                       .                                
                                       .                                
                                       .                                
                 Floor: NC/2R          .                                
             03/09/2016 05:01 PM       .                                
       —————————————————————————————————————————————————————————————————




       —————————————————————————————————————————————————————————————————
       Senator Hays moved the following:
       
    1         Senate Substitute for Amendment (503040) (with title
    2  amendment)
    3  
    4         Between lines 960 and 961
    5  insert:
    6         Section 20. Effective January 1, 2018, section 627.42393,
    7  Florida Statutes, is created to read:
    8         627.42393Continuity of care for medically stable
    9  patients.—
   10         (1) As used in this section, the term:
   11         (a) “Complex or chronic medical condition” means a
   12  physical, behavioral, or developmental condition that does not
   13  have a known cure or that can be severely debilitating or fatal
   14  if left untreated or undertreated.
   15         (b) “Rare diseasehas the same meaning as in the Public
   16  Health Service Act, 42 U.S.C. s. 287a-1.
   17         (2) A pharmacy benefits manager or an individual or group
   18  insurance policy that is delivered, issued for delivery,
   19  renewed, amended, or continued in this state and that provides
   20  medical, major medical, or similar comprehensive coverage must
   21  continue to cover a drug for an insured with a complex or
   22  chronic medical condition or a rare disease if:
   23         (a) The drug was previously covered by the insurer for a
   24  medical condition or disease of the insured; and
   25         (b) The prescribing provider continues to prescribe the
   26  drug for the medical condition or disease, provided that the
   27  drug is appropriately prescribed and neither of the following
   28  has occurred:
   29         1. The United States Food and Drug Administration has
   30  issued a notice, guidance, warning, announcement, or any other
   31  statement about the drug which calls into question the clinical
   32  safety of the drug; or
   33         2. The manufacturer of the drug has notified the United
   34  States Food and Drug Administration of any manufacturing
   35  discontinuance or potential discontinuance as required by s.
   36  506C of the Federal Food Drug and Cosmetic Act, 21 U.S.C. s.
   37  356c.
   38         (3) With respect to a drug for an insured with a complex or
   39  chronic medical condition or a rare disease which meets the
   40  conditions of paragraphs (2)(a) and (2)(b), except during open
   41  enrollment periods, a pharmacy benefits manager or an individual
   42  or group insurance policy may not:
   43         (a) Set forth, by contract, limitations on maximum coverage
   44  of prescription drug benefits;
   45         (b) Subject the insured to increased out-of-pocket costs;
   46  or
   47         (c) Move a drug for an insured to a more restrictive tier,
   48  if an individual or group insurance policy or a pharmacy
   49  benefits manager uses a formulary with tiers.
   50         (4) This section does not apply to a grandfathered health
   51  plan as defined in s. 627.402, or to benefits set forth in s.
   52  627.6561(5)(b), (c), (d), and (e).
   53         Section 21. Effective January 1, 2018, paragraph (e) of
   54  subsection (5) of section 627.6699, Florida Statutes, is amended
   55  to read:
   56         627.6699 Employee Health Care Access Act.—
   57         (5) AVAILABILITY OF COVERAGE.—
   58         (e) All health benefit plans issued under this section must
   59  comply with the following conditions:
   60         1. For employers who have fewer than two employees, a late
   61  enrollee may be excluded from coverage for no longer than 24
   62  months if he or she was not covered by creditable coverage
   63  continually to a date not more than 63 days before the effective
   64  date of his or her new coverage.
   65         2. Any requirement used by a small employer carrier in
   66  determining whether to provide coverage to a small employer
   67  group, including requirements for minimum participation of
   68  eligible employees and minimum employer contributions, must be
   69  applied uniformly among all small employer groups having the
   70  same number of eligible employees applying for coverage or
   71  receiving coverage from the small employer carrier, except that
   72  a small employer carrier that participates in, administers, or
   73  issues health benefits pursuant to s. 381.0406 which do not
   74  include a preexisting condition exclusion may require as a
   75  condition of offering such benefits that the employer has had no
   76  health insurance coverage for its employees for a period of at
   77  least 6 months. A small employer carrier may vary application of
   78  minimum participation requirements and minimum employer
   79  contribution requirements only by the size of the small employer
   80  group.
   81         3. In applying minimum participation requirements with
   82  respect to a small employer, a small employer carrier shall not
   83  consider as an eligible employee employees or dependents who
   84  have qualifying existing coverage in an employer-based group
   85  insurance plan or an ERISA qualified self-insurance plan in
   86  determining whether the applicable percentage of participation
   87  is met. However, a small employer carrier may count eligible
   88  employees and dependents who have coverage under another health
   89  plan that is sponsored by that employer.
   90         4. A small employer carrier shall not increase any
   91  requirement for minimum employee participation or any
   92  requirement for minimum employer contribution applicable to a
   93  small employer at any time after the small employer has been
   94  accepted for coverage, unless the employer size has changed, in
   95  which case the small employer carrier may apply the requirements
   96  that are applicable to the new group size.
   97         5. If a small employer carrier offers coverage to a small
   98  employer, it must offer coverage to all the small employer’s
   99  eligible employees and their dependents. A small employer
  100  carrier may not offer coverage limited to certain persons in a
  101  group or to part of a group, except with respect to late
  102  enrollees.
  103         6. A small employer carrier may not modify any health
  104  benefit plan issued to a small employer with respect to a small
  105  employer or any eligible employee or dependent through riders,
  106  endorsements, or otherwise to restrict or exclude coverage for
  107  certain diseases or medical conditions otherwise covered by the
  108  health benefit plan.
  109         7. An initial enrollment period of at least 30 days must be
  110  provided. An annual 30-day open enrollment period must be
  111  offered to each small employer’s eligible employees and their
  112  dependents. A small employer carrier must provide special
  113  enrollment periods as required by s. 627.65615.
  114         8. A small employer carrier must provide continuity of care
  115  for medically stable patients as required by s. 627.42392.
  116         Section 22. Effective January 1, 2018, subsection (44) is
  117  added to section 641.31, Florida Statutes, to read:
  118         641.31 Health maintenance contracts.—
  119         (44)(a) As used in this subsection, the term:
  120         1.“Complex or chronic medical condition” means a physical,
  121  behavioral, or developmental condition that does not have a
  122  known cure or that can be severely debilitating or fatal if left
  123  untreated or undertreated.
  124         2.“Rare disease” has the same meaning as in the Public
  125  Health Service Act, 42 U.S.C. s. 287a-1.
  126         (b) A pharmacy benefits manager or a health maintenance
  127  contract that is delivered, issued for delivery, renewed,
  128  amended, or continued in this state and that provides medical,
  129  major medical, or similar comprehensive coverage must continue
  130  to cover a drug for a subscriber with a complex or chronic
  131  medical condition or a rare disease if:
  132         1. The drug was previously covered by the health
  133  maintenance organization for a medical condition or disease of
  134  the subscriber; and
  135         2. The prescribing provider continues to prescribe the drug
  136  for the medical condition or disease, provided that the drug is
  137  appropriately prescribed and neither of the following has
  138  occurred:
  139         a. The United States Food and Drug Administration has
  140  issued a notice, guidance, warning, announcement, or any other
  141  statement about the drug which calls into question the clinical
  142  safety of the drug; or
  143         b. The manufacturer of the drug has notified the United
  144  States Food and Drug Administration of any manufacturing
  145  discontinuance or potential discontinuance as required by s.
  146  506C of the Federal Food Drug and Cosmetic Act, 21 U.S.C. s.
  147  356c.
  148         (c) With respect to a drug for a subscriber with a complex
  149  or chronic medical condition or a rare disease which meets the
  150  conditions of subparagraphs (b)1. and (b)2., except during open
  151  enrollment periods, a pharmacy benefits manager or a health
  152  maintenance contract may not:
  153         1.Set forth, by contract, limitations on maximum coverage
  154  of prescription drug benefits;
  155         2. Subject the subscriber to increased out-of-pocket costs;
  156  or
  157         3. Move a drug for a subscriber to a more restrictive tier,
  158  if a health maintenance contract or a pharmacy benefits manager
  159  uses a formulary with tiers.
  160         (d) This section does not apply to a grandfathered health
  161  plan as defined in s. 627.402.
  162  
  163  ================= T I T L E  A M E N D M E N T ================
  164  And the title is amended as follows:
  165         Between lines 71 and 72
  166  insert:
  167         creating s. 627.42392, F.S.; defining terms; requiring
  168         a pharmacy benefits manager or a specified individual
  169         or group insurance policy to continue to cover a drug
  170         for specified insureds under certain circumstances;
  171         prohibiting certain actions by a pharmacy benefits
  172         manager or an individual or group policy with respect
  173         to a drug for a certain insured except under certain
  174         circumstances; providing applicability; amending s.
  175         627.6699, F.S.; expanding a list of conditions that
  176         certain health benefit plans must comply with;
  177         amending s. 641.31, F.S.; defining terms; requiring a
  178         pharmacy benefits manager or a specified health
  179         maintenance contract to continue to cover a drug for
  180         specified subscribers under certain circumstances;
  181         prohibiting certain actions by a pharmacy benefits
  182         manager or a health maintenance contract with respect
  183         to a drug for a certain subscriber except under
  184         certain circumstances; providing applicability;