Florida Senate - 2017 COMMITTEE AMENDMENT Bill No. CS for CS for SB 182 Ì220914ÇÎ220914 LEGISLATIVE ACTION Senate . House Comm: WD . 04/19/2017 . . . . ————————————————————————————————————————————————————————————————— ————————————————————————————————————————————————————————————————— The Committee on Rules (Lee) recommended the following: 1 Senate Amendment (with title amendment) 2 3 Delete lines 20 - 165 4 and insert: 5 Section 1. Effective January 1, 2018, section 627.42393, 6 Florida Statutes, is created to read: 7 627.42393 Insurance policies; limiting changes to 8 prescription drug formularies.— 9 (1) Other than at the time of coverage renewal, an 10 individual or group insurance policy that is delivered, issued 11 for delivery, renewed, amended, or continued in this state and 12 that provides medical, major medical, or similar comprehensive 13 coverage may not: 14 (a) Remove a covered prescription drug from its list of 15 covered drugs during the policy year unless the United States 16 Food and Drug Administration has issued a statement about the 17 drug which calls into question the clinical safety of the drug, 18 or the manufacturer of the drug has notified the United States 19 Food and Drug Administration of a manufacturing discontinuance 20 or potential discontinuance of the drug as required by s. 506C 21 of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. s. 356c. 22 (b) Reclassify a drug to a more restrictive drug tier or 23 increase the amount that an insured must pay for a copayment, 24 coinsurance, or deductible for prescription drug benefits, or 25 reclassify a drug to a higher cost-sharing tier during the 26 policy year. 27 (2) This section does not prohibit the addition of 28 prescription drugs to the list of drugs covered under the policy 29 during the policy year. 30 (3) This section does not apply to a grandfathered health 31 plan as defined in s. 627.402 or to benefits set forth in s. 32 627.6513(1)-(14). 33 (4) This section does not alter or amend s. 465.025, which 34 provides conditions under which a pharmacist may substitute a 35 generically equivalent drug product for a brand name drug 36 product. 37 (5) This section does not alter or amend s. 465.0252, which 38 provides conditions under which a pharmacist may dispense a 39 substitute biological product for the prescribed biological 40 product. 41 Section 2. Effective January 1, 2018, paragraph (e) of 42 subsection (5) of section 627.6699, Florida Statutes, is amended 43 to read: 44 627.6699 Employee Health Care Access Act.— 45 (5) AVAILABILITY OF COVERAGE.— 46 (e) All health benefit plans issued under this section must 47 comply with the following conditions: 48 1. For employers who have fewer than two employees, a late 49 enrollee may be excluded from coverage for no longer than 24 50 months if he or she was not covered by creditable coverage 51 continually to a date not more than 63 days before the effective 52 date of his or her new coverage. 53 2. Any requirement used by a small employer carrier in 54 determining whether to provide coverage to a small employer 55 group, including requirements for minimum participation of 56 eligible employees and minimum employer contributions, must be 57 applied uniformly among all small employer groups having the 58 same number of eligible employees applying for coverage or 59 receiving coverage from the small employer carrier, except that 60 a small employer carrier that participates in, administers, or 61 issues health benefits pursuant to s. 381.0406 which do not 62 include a preexisting condition exclusion may require as a 63 condition of offering such benefits that the employer has had no 64 health insurance coverage for its employees for a period of at 65 least 6 months. A small employer carrier may vary application of 66 minimum participation requirements and minimum employer 67 contribution requirements only by the size of the small employer 68 group. 69 3. In applying minimum participation requirements with 70 respect to a small employer, a small employer carrier shall not 71 consider as an eligible employee employees or dependents who 72 have qualifying existing coverage in an employer-based group 73 insurance plan or an ERISA qualified self-insurance plan in 74 determining whether the applicable percentage of participation 75 is met. However, a small employer carrier may count eligible 76 employees and dependents who have coverage under another health 77 plan that is sponsored by that employer. 78 4. A small employer carrier shall not increase any 79 requirement for minimum employee participation or any 80 requirement for minimum employer contribution applicable to a 81 small employer at any time after the small employer has been 82 accepted for coverage, unless the employer size has changed, in 83 which case the small employer carrier may apply the requirements 84 that are applicable to the new group size. 85 5. If a small employer carrier offers coverage to a small 86 employer, it must offer coverage to all the small employer’s 87 eligible employees and their dependents. A small employer 88 carrier may not offer coverage limited to certain persons in a 89 group or to part of a group, except with respect to late 90 enrollees. 91 6. A small employer carrier may not modify any health 92 benefit plan issued to a small employer with respect to a small 93 employer or any eligible employee or dependent through riders, 94 endorsements, or otherwise to restrict or exclude coverage for 95 certain diseases or medical conditions otherwise covered by the 96 health benefit plan. 97 7. An initial enrollment period of at least 30 days must be 98 provided. An annual 30-day open enrollment period must be 99 offered to each small employer’s eligible employees and their 100 dependents. A small employer carrier must provide special 101 enrollment periods as required by s. 627.65615. 102 8. A small employer carrier must limit changes to 103 prescription drug formularies as required by s. 627.42393. 104 Section 3. Effective January 1, 2018, subsection (36) of 105 section 641.31, Florida Statutes, is amended to read: 106 641.31 Health maintenance contracts.— 107 (36) A health maintenance organization may increase the 108 copayment for any benefit, or delete, amend, or limit any of the 109 benefits to which a subscriber is entitled under the group 110 contract only, upon written notice to the contract holder at 111 least 45 days in advance of the time of coverage renewal. The 112 health maintenance organization may amend the contract with the 113 contract holder, with such amendment to be effective immediately 114 at the time of coverage renewal. The written notice to the 115 contract holder must
shallspecifically identify any deletions, 116 amendments, or limitations to any of the benefits provided in 117 the group contract during the current contract period which will 118 be included in the group contract upon renewal. This subsection 119 does not apply to any increases in benefits. The 45-day notice 120 requirement does shallnot apply if benefits are amended, 121 deleted, or limited at the request of the contract holder. 122 (a) Other than at the time of coverage renewal, a health 123 maintenance organization that provides medical, major medical, 124 or similar comprehensive coverage may not: 125 1. Remove a covered prescription drug from its list of 126 covered drugs during the contract year unless the United States 127 Food and Drug Administration has issued a statement about the 128 drug which calls into question the clinical safety of the drug, 129 or the manufacturer of the drug has notified the United States 130 Food and Drug Administration of a manufacturing discontinuance 131 or potential discontinuance of the drug as required by s. 506C 132 of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. s. 356c. 133 2. Reclassify a drug to a more restrictive drug tier or 134 increase the amount that an insured must pay for a copayment, 135 coinsurance, or deductible for prescription drug benefits, or 136 reclassify a drug to a higher cost-sharing tier during the 137 contract year. 138 (b) This subsection does not: 139 1. Prohibit the addition of prescription drugs to the list 140 of drugs covered during the contract year. 141 2. Apply to a grandfathered health plan as defined in s. 142 627.402 or to benefits set forth in s. 627.6513(1)-(14). 143 3. Alter or amend s. 465.025, which provides conditions 144 under which a pharmacist may substitute a generically equivalent 145 drug product for a brand name drug product. 146 4. Alter or amend s. 465.0252, which provides conditions 147 under which a pharmacist may dispense a substitute biological 148 product for the prescribed biological product. 149 Section 4. The Legislature finds that the creation of 150 section 627.42393, Florida Statutes, and the amendments made by 151 this act to sections 627.6699 and 641.31, Florida Statutes, 152 fulfill an important state interest. 153 Section 5. Subsection (4) of section 409.977, Florida 154 Statutes, is amended to read: 155 409.977 Enrollment.— 156 (4) The agency shall: 157 (a) Develop a process to enable a recipient with access to 158 employer-sponsored health care coverage to opt out of all 159 managed care plans and to use Medicaid financial assistance to 160 pay for the recipient’s share of the cost in such employer 161 sponsored coverage. 162 (b) Contingent upon federal approval, the agency shall also163 enable recipients with access to other insurance or related 164 products providing access to health care services created 165 pursuant to state law, including any product available under the 166 Florida Health Choices Program, or any health exchange, to opt 167 out. 168 (c) Provide The amount offinancial assistance providedfor 169 each recipient in an amount maynot to exceed the amount of the 170 Medicaid premium which thatwould have been paid to a managed 171 care plan for that recipient opting to receive services under 172 this subsection. 173 (d) The agency shallSeek federal approval to require 174 Medicaid recipients with access to employer-sponsored health 175 care coverage to enroll in that coverage and use Medicaid 176 financial assistance to pay for the recipient’s share of the 177 cost for such coverage. The amount of financial assistance 178 provided for each recipient may not exceed the amount of the 179 Medicaid premium that would have been paid to a managed care 180 plan for that recipient. 181 (e) By January 1, 2018, resubmit an appropriate federal 182 waiver or waiver amendment to the Centers for Medicare and 183 Medicaid Services, the United States Department of Health and 184 Human Services, or any other designated federal entity to 185 incorporate the election by a recipient for a direct primary 186 care agreement, as defined in s. 456.0625, within the Statewide 187 Medicaid Managed Care program. 188 Section 6. Section 456.0625, Florida Statutes, is created 189 to read: 190 456.0625 Direct primary care agreements.— 191 (1) As used in this section, the term: 192 (a) “Direct primary care agreement” means a contract 193 between a primary care provider and a patient, the patient’s 194 legal representative, or an employer which meets the 195 requirements specified under subsection (3) and which does not 196 indemnify for services provided by a third party. 197 (b) “Primary care provider” means a health care 198 practitioner licensed under chapter 458, chapter 459, chapter 199 460, or chapter 464 or a primary care group practice that 200 provides medical services to patients which are commonly 201 provided without referral from another health care provider. 202 (c) “Primary care service” means the screening, assessment, 203 diagnosis, and treatment of a patient for the purpose of 204 promoting health or detecting and managing disease or injury 205 within the competency and training of the primary care provider. 206 (2) A primary care provider or an agent of the primary care 207 provider may enter into a direct primary care agreement for 208 providing primary care services. Section 624.27 applies to a 209 direct primary care agreement. 210 (3) A direct primary care agreement must: 211 (a) Be in writing. 212 (b) Be signed by the primary care provider or an agent of 213 the primary care provider and the patient, the patient’s legal 214 representative, or an employer. 215 (c) Allow a party to terminate the agreement by giving the 216 other party at least 30 days’ advance written notice. The 217 agreement may provide for immediate termination due to a 218 violation of the physician-patient relationship or a breach of 219 the terms of the agreement. 220 (d) Describe the scope of primary care services that are 221 covered by the monthly fee. 222 (e) Specify the monthly fee and any fees for primary care 223 services not covered by the monthly fee. 224 (f) Specify the duration of the agreement and any automatic 225 renewal provisions. 226 (g) Offer a refund to the patient of monthly fees paid in 227 advance if the primary care provider ceases to offer primary 228 care services for any reason. 229 (h) Contain, in contrasting color and in not less than 12 230 point type, the following statements on the same page as the 231 applicant’s signature: 232 1. This agreement is not health insurance, and the primary 233 care provider will not file any claims against the patient’s 234 health insurance policy or plan for reimbursement of any primary 235 care services covered by this agreement. 236 2. This agreement does not qualify as minimum essential 237 coverage to satisfy the individual shared responsibility 238 provision of the federal Patient Protection and Affordable Care 239 Act, Pub. L. No. 111-148. 240 3. This agreement is not workers’ compensation insurance 241 and may not replace the employer’s obligations under chapter 242 440, Florida Statutes. 243 Section 7. Section 624.27, Florida Statutes, is created to 244 read: 245 624.27 Application of code as to direct primary care 246 agreements.— 247 (1) A direct primary care agreement, as defined in s. 248 456.0625, does not constitute insurance and is not subject to 249 any chapter of the Florida Insurance Code. The act of entering 250 into a direct primary care agreement does not constitute the 251 business of insurance and is not subject to any chapter of the 252 Florida Insurance Code. 253 (2) A primary care provider or an agent of a primary care 254 provider is not required to obtain a certificate of authority or 255 license under any chapter of the Florida Insurance Code to 256 market, sell, or offer to sell a direct primary care agreement 257 pursuant to s. 456.0625. 258 Section 8. Except as otherwise expressly provided in this 259 act, this act shall take effect July 1, 2017. 260 261 ================= T I T L E A M E N D M E N T ================ 262 And the title is amended as follows: 263 Delete lines 2 - 16 264 and insert: 265 An act relating to health care; creating s. 627.42393, 266 F.S.; limiting, under specified circumstances, changes 267 to a health insurance policy prescription drug 268 formulary during a policy year; providing construction 269 and applicability; amending s. 627.6699, F.S.; 270 requiring small employer carriers to limit changes to 271 prescription drug formularies under certain 272 circumstances; amending s. 641.31, F.S.; limiting, 273 under specified circumstances, changes to a health 274 maintenance contract prescription drug formulary 275 during a contract year; providing construction and 276 applicability; providing a declaration of important 277 state interest; amending s. 409.977, F.S.; requiring 278 the Agency for Health Care Administration to provide 279 specified financial assistance to certain Medicaid 280 recipients; requiring the agency to resubmit, by a 281 specified date, certain federal waivers or waiver 282 amendments to specified federal entities to 283 incorporate recipient elections of certain direct 284 primary care agreements; creating s. 456.0625, F.S.; 285 defining terms; authorizing primary care providers or 286 their agents to enter into direct primary care 287 agreements for providing primary care services; 288 providing applicability; specifying requirements for 289 direct primary care agreements; creating s. 624.27, 290 F.S.; providing construction and applicability of the 291 Florida Insurance Code as to direct primary care 292 agreements; providing an exception for primary care 293 providers or their agents from certain requirements 294 under the code under certain circumstances; providing 295 effective dates.