SB 2508                                          First Engrossed
    1                        A bill to be entitled                      
    2         An act relating to the Division of State Group
    3         Insurance; amending s. 110.12301, F.S.; removing a
    4         requirement that a contract for dependent eligibility
    5         verification services for the state group insurance
    6         program be a contingency-based contract; requiring the
    7         division to notify subscribers of dependent
    8         eligibility rules by a certain date; requiring the
    9         division to hold a subscriber harmless for past claims
   10         of ineligible dependents for a specified timeframe;
   11         providing for applicability; removing a requirement
   12         that the Department of Management Services submit
   13         budget amendments pursuant to ch. 216, F.S., regarding
   14         vendor payments for dependent eligibility verification
   15         services; authorizing the contractor providing
   16         dependent eligibility verification services to request
   17         certain information from subscribers; requiring the
   18         division and the contractor to disclose to subscribers
   19         that dependent eligibility verification information
   20         may be subject to disclosure and inspection under
   21         public records requirements under certain
   22         circumstances; specifying requirements for marriage
   23         licenses or certificates or birth certificates
   24         submitted for dependent eligibility verification;
   25         authorizing foreign-born subscribers to submit an
   26         affidavit in lieu of documentation under certain
   27         circumstances; specifying that original or photocopied
   28         documentation may be submitted; authorizing a
   29         subscriber to redact unnecessary information before
   30         submitting documentation; requiring the contractor to
   31         retain documentation obtained for dependent
   32         eligibility verification services for a specified
   33         timeframe; requiring the department and the contractor
   34         to destroy such documentation after a specified date;
   35         amending s. 110.12315, F.S.; providing that retail,
   36         mail order, and specialty pharmacies participating in
   37         the state employees’ prescription drug program shall
   38         be reimbursed as established by contract; revising
   39         supply limitations under the program; requiring that
   40         the pharmacy dispensing fee be negotiated by the
   41         department; revising provisions governing the
   42         reimbursement schedule for prescription drugs and
   43         supplies dispensed under the program; requiring the
   44         department to maintain certain lists; establishing
   45         supply limitations for maintenance drugs and supplies;
   46         specifying pricing of certain copayments by health
   47         plan members; deleting a provision requiring the
   48         department to implement additional cost-saving
   49         measures and adjustments; revising copayment and
   50         coinsurance amounts for the State Group Health
   51         Insurance Standard Plan and the State Group Health
   52         Insurance High Deductible Plan; providing an effective
   53         date.
   55  Be It Enacted by the Legislature of the State of Florida:
   57         Section 1. Section 110.12301, Florida Statutes, is amended
   58  to read:
   59         110.12301 Competitive procurement of postpayment claims
   60  review services and dependent eligibility verification
   61  services.—The Division of State Group Insurance is directed to
   62  competitively procure:
   63         (1) Postpayment claims review services for the state group
   64  health insurance plans established pursuant to s. 110.123.
   65  Compensation under the contract shall be paid from amounts
   66  identified as claim overpayments that are made by or on behalf
   67  of the health plans and that are recovered by the vendor. The
   68  vendor may retain that portion of the amount recovered as
   69  provided in the contract. The contract must require the vendor
   70  to maintain all necessary documentation supporting the amounts
   71  recovered, retained, and remitted to the division; and
   72         (2) A contingency-based contract for dependent eligibility
   73  verification services for the state group insurance program;
   74  however, compensation under the contract may not exceed
   75  historical claim costs for the prior 12 months for the dependent
   76  populations disenrolled as a result of the contractor’s vendor’s
   77  services.
   78         (a)1. By September 1, 2017, the division shall notify all
   79  subscribers regarding the eligibility rules for dependents.
   80  Through November 30, 2017, the division must may establish a 3
   81  month grace period and hold subscribers harmless for past claims
   82  of ineligible dependents if such dependents are removed from
   83  plan membership before December 1, 2017.
   84         2. Subparagraph 1. does not apply to any dependent
   85  identified as ineligible before July 1, 2017, for which the
   86  department has notified the state agency employing the
   87  associated subscriber The Department of Management Services
   88  shall submit budget amendments pursuant to chapter 216 in order
   89  to obtain budget authority necessary to expend funds from the
   90  State Employees’ Group Health Self-Insurance Trust Fund for
   91  payments to the vendor as provided in the contract.
   92         (b) The contractor providing dependent eligibility
   93  verification services may request the following information from
   94  subscribers:
   95         1. To prove a spouse’s eligibility:
   96         a. If married less than 12 months and the subscriber and
   97  his or her spouse have not filed a joint federal income tax
   98  return, a government-issued marriage certificate; or
   99         b. If married for 12 or more months, a transcript of the
  100  most recently filed federal income tax return.
  101         2. To prove a biological child’s or a newborn grandchild’s
  102  eligibility, a government-issued birth certificate.
  103         3. To prove an adopted child’s eligibility:
  104         a. An adoption certificate; or
  105         b. An adoption placement agreement and a petition for
  106  adoption.
  107         4. To prove a stepchild’s eligibility:
  108         a. A government-issued birth certificate for the stepchild;
  109  and
  110         b. The transcript of the subscriber’s most recently filed
  111  federal income tax return.
  112         5. Any other information necessary to verify the
  113  dependent’s eligibility for enrollment in the state group
  114  insurance program.
  115         (c) If a document requested from a subscriber is not
  116  confidential or exempt from public records requirements, the
  117  division and the contractor shall disclose to all subscribers
  118  that such information submitted to verify the eligibility of
  119  dependents may be subject to disclosure and inspection under
  120  chapter 119.
  121         (d) A government-issued marriage license or marriage
  122  certificate submitted for dependent eligibility verification
  123  must include the date of the marriage between the subscriber and
  124  the spouse.
  125         (e) A government-issued birth certificate submitted for
  126  dependent eligibility verification must list the parents’ names.
  127         (f) Foreign-born subscribers unable to obtain the necessary
  128  documentation within the specified time period of producing
  129  verification documentation may execute a signed affidavit
  130  attesting to eligibility requirements.
  131         (g) Documentation submitted to verify eligibility may be an
  132  original or a photocopy of an original document. Before
  133  submitting a document, the subscriber may redact any information
  134  on a document which is not necessary to verify the eligibility
  135  of the dependent.
  136         (h) All documentation obtained by the contractor to conduct
  137  the dependent eligibility verification services must be retained
  138  until June 30, 2019. The department or the contractor is not
  139  required to retain such documentation after June 30, 2019, and
  140  shall destroy such documentation as soon as practicable after
  141  such date.
  142         Section 2. Upon the expiration and reversion of the
  143  amendments made to section 110.12315, Florida Statutes, pursuant
  144  to section 123 of chapter 2016-62, Laws of Florida, section
  145  110.12315, Florida Statutes, is amended to read:
  146         110.12315 Prescription drug program.—The state employees’
  147  prescription drug program is established. This program shall be
  148  administered by the Department of Management Services, according
  149  to the terms and conditions of the plan as established by the
  150  relevant provisions of the annual General Appropriations Act and
  151  implementing legislation, subject to the following conditions:
  152         (1) The department shall allow prescriptions written by
  153  health care providers under the plan to be filled by any
  154  licensed pharmacy and reimbursed pursuant to subsection (2)
  155  contractual claims-processing provisions. Nothing in This
  156  section may not be construed as prohibiting a mail order
  157  prescription drug program distinct from the service provided by
  158  retail pharmacies.
  159         (2) In providing for reimbursement of pharmacies for
  160  prescription drugs and supplies medicines dispensed to members
  161  of the state group health insurance plan and their dependents
  162  under the state employees’ prescription drug program:
  163         (a) Retail, mail order, and specialty pharmacies
  164  participating in the program must be reimbursed as established
  165  by contract and at a uniform rate and subject to uniform
  166  conditions, according to the terms and conditions of the plan.
  167         (b) There is shall be a 30-day supply limit for retail
  168  pharmacy fills, a 90-day supply limit for mail order fills, and
  169  a 90-day supply limit for maintenance drug fills by retail
  170  pharmacies prescription card purchases and 90-day supply limit
  171  for mail order or mail order prescription drug purchases. This
  172  paragraph may not be construed to prohibit fills at any amount
  173  less than the applicable supply limit.
  174         (c) The current pharmacy dispensing fee shall be negotiated
  175  by the department remains in effect.
  176         (d)(3) The department of Management Services shall
  177  establish the reimbursement schedule for prescription drugs and
  178  supplies pharmaceuticals dispensed under the program.
  179  Reimbursement rates for a prescription drug or supply
  180  pharmaceutical must be based on the cost of the generic
  181  equivalent drug or supply if a generic equivalent exists, unless
  182  the physician, advanced registered nurse practitioner, or
  183  physician assistant prescribing the drug or supply
  184  pharmaceutical clearly states on the prescription that the brand
  185  name drug or supply is medically necessary or that the drug or
  186  supply product is included on the formulary of drugs and
  187  supplies drug products that may not be interchanged as provided
  188  in chapter 465, in which case reimbursement must be based on the
  189  cost of the brand name drug or supply as specified in the
  190  reimbursement schedule adopted by the department of Management
  191  Services.
  192         (3) The department shall maintain the generic, preferred
  193  brand name, and the nonpreferred brand name lists of drugs and
  194  supplies to be used in the administration of the state
  195  employees’ prescription drug program.
  196         (4) The department shall maintain a list of maintenance
  197  drugs and supplies.
  198         (a) Preferred provider organization health plan members may
  199  have prescriptions for maintenance drugs and supplies filled up
  200  to three times as a supply for up to 30 days through a retail
  201  pharmacy; thereafter, prescriptions for the same maintenance
  202  drug or supply must be filled for up to 90 days either through
  203  the department’s contracted mail order pharmacy or through a
  204  retail pharmacy.
  205         (b) Health maintenance organization health plan members may
  206  have prescriptions for maintenance drugs and supplies filled for
  207  up to 90 days either through a mail order pharmacy or through a
  208  retail pharmacy.
  209         (5) Copayments made by health plan members for a supply for
  210  up to 90 days through a retail pharmacy shall be the same as
  211  copayments made for a similar supply through the department’s
  212  contracted mail order pharmacy.
  213         (6)(4) The department of Management Services shall conduct
  214  a prescription utilization review program. In order to
  215  participate in the state employees’ prescription drug program,
  216  retail pharmacies dispensing prescription drugs and supplies
  217  medicines to members of the state group health insurance plan or
  218  their covered dependents, or to subscribers or covered
  219  dependents of a health maintenance organization plan under the
  220  state group insurance program, shall make their records
  221  available for this review.
  222         (5) The Department of Management Services shall implement
  223  such additional cost-saving measures and adjustments as may be
  224  required to balance program funding within appropriations
  225  provided, including a trial or starter dose program and
  226  dispensing of long-term-maintenance medication in lieu of acute
  227  therapy medication.
  228         (7)(6) Participating pharmacies must use a point-of-sale
  229  device or an online computer system to verify a participant’s
  230  eligibility for coverage. The state is not liable for
  231  reimbursement of a participating pharmacy for dispensing
  232  prescription drugs and supplies to any person whose current
  233  eligibility for coverage has not been verified by the state’s
  234  contracted administrator or by the department of Management
  235  Services.
  236         (7) Under the state employees’ prescription drug program
  237  copayments must be made as follows:
  238         (8)(a) Effective July 1, 2017 January 1, 2006, for the
  239  State Group Health Insurance Standard Plan, copayments must be
  240  made as follows:
  241         1. For a supply for up to 30 days from a retail pharmacy:
  242         a. For generic drug with card.....................$7 $10.
  243         b.2. For preferred brand name drug with card.....$30 $25.
  244         c.3. For nonpreferred brand name drug with card..$50 $40.
  245         2. For a supply for up to 90 days from a mail order
  246  pharmacy or a retail pharmacy:
  247         a.4. For generic mail order drug.................$14 $20.
  248         b.5. For preferred brand name mail order drug....$60 $50.
  249         c.6. For nonpreferred brand name mail order drug$100 $80.
  250         (b) Effective July 1, 2017 January 1, 2006, for the State
  251  Group Health Insurance High Deductible Plan, coinsurance must be
  252  paid as follows:
  253         1. For a supply for up to 30 days from a retail pharmacy:
  254         a.Retail coinsurance For generic drug with card.....30%.
  255         b.2.Retail coinsurance For preferred brand name drug with
  256  card........................................................30%.
  257         c.3.Retail coinsurance For nonpreferred brand name drug
  258  with card...................................................50%.
  259         2. For a supply for up to 90 days from a mail order
  260  pharmacy or a retail pharmacy:
  261         a.4. Mail order coinsurance For generic drug.........30%.
  262         b.5. Mail order coinsurance For preferred brand name
  263  drug........................................................30%.
  264         c.6. Mail order coinsurance For nonpreferred brand name
  265  drug........................................................50%.
  266         (c) The Department of Management Services shall create a
  267  preferred brand name drug list to be used in the administration
  268  of the state employees’ prescription drug program.
  269         Section 3. This act shall take effect July 1, 2017.