Florida Senate - 2019                       CS for CS for SB 524
       By the Committees on Appropriations; and Banking and Insurance;
       and Senators Diaz, Farmer, and Bean
       576-04617A-19                                          2019524c2
    1                        A bill to be entitled                      
    2         An act relating to health insurance; amending s.
    3         110.12303, F.S.; removing an obsolete date;
    4         authorizing the inclusion in the state group insurance
    5         program of products and services offered by entities
    6         providing optional participation in the Medicare
    7         Advantage Prescription Drug Plan; amending s.
    8         110.12315, F.S.; requiring the Department of
    9         Management Services to implement formulary management
   10         cost-saving measures beginning with the 2020 plan
   11         year; specifying requirements for such measures;
   12         requiring the department to report to the Governor and
   13         the Legislature regarding formulary exclusions;
   14         repealing s. 8 of ch. 99-255, Laws of Florida;
   15         repealing a restriction prohibiting the department
   16         from implementing prior authorization or restricted
   17         formulary programs within the state employees’
   18         prescription drug program; creating s. 627.6387, F.S.;
   19         providing a short title; defining terms; authorizing
   20         health insurers, which include health maintenance
   21         organizations, to offer shared savings incentive
   22         programs to insureds; providing that insureds are not
   23         required to participate in such programs; specifying
   24         requirements for health insurers offering such
   25         programs; requiring the Office of Insurance Regulation
   26         to review filed descriptions of programs and make a
   27         certain determination; providing notification and
   28         account credit or deposit requirements for insurers;
   29         specifying the minimum shared savings incentive and
   30         the basis for calculating savings; specifying
   31         requirements for annual reports submitted by insurers
   32         to the office; providing construction; providing that
   33         certain shared saving incentive amounts reduce an
   34         insurer’s direct written premium for purposes of the
   35         insurance premium tax and the retaliatory tax;
   36         authorizing the Financial Services Commission to adopt
   37         rules; providing effective dates.
   39  Be It Enacted by the Legislature of the State of Florida:
   41         Section 1. Section 110.12303, Florida Statutes, is amended
   42  to read:
   43         110.12303 State group insurance program; additional
   44  benefits; price transparency program; reporting.—Beginning with
   45  the 2018 plan year:
   46         (1) In addition to the comprehensive package of health
   47  insurance and other benefits required or authorized to be
   48  included in the state group insurance program, the package of
   49  benefits may also include products and services offered by:
   50         (a) Prepaid limited health service organizations authorized
   51  pursuant to part I of chapter 636.
   52         (b) Discount medical plan organizations authorized pursuant
   53  to part II of chapter 636.
   54         (c) Prepaid health clinics licensed under part II of
   55  chapter 641.
   56         (d) Licensed health care providers, including hospitals and
   57  other health care facilities, health care clinics, and health
   58  professionals, who sell service contracts and arrangements for a
   59  specified amount and type of health services.
   60         (e) Provider organizations, including service networks,
   61  group practices, professional associations, and other
   62  incorporated organizations of providers, who sell service
   63  contracts and arrangements for a specified amount and type of
   64  health services.
   65         (f) Entities that provide specific health services in
   66  accordance with applicable state law and sell service contracts
   67  and arrangements for a specified amount and type of health
   68  services.
   69         (g) Entities that provide health services or treatments
   70  through a bidding process.
   71         (h) Entities that provide health services or treatments
   72  through the bundling or aggregating of health services or
   73  treatments.
   74         (i) Entities that provide optional participation in a
   75  Medicare Advantage Prescription Drug Plan.
   76         (j) Entities that provide other innovative and cost
   77  effective health service delivery methods.
   78         (2)(a) The department shall contract with at least one
   79  entity that provides comprehensive pricing and inclusive
   80  services for surgery and other medical procedures which may be
   81  accessed at the option of the enrollee. The contract shall
   82  require the entity to:
   83         1. Have procedures and evidence-based standards to ensure
   84  the inclusion of only high-quality health care providers.
   85         2. Provide assistance to the enrollee in accessing and
   86  coordinating care.
   87         3. Provide cost savings to the state group insurance
   88  program to be shared with both the state and the enrollee. Cost
   89  savings payable to an enrollee may be:
   90         a. Credited to the enrollee’s flexible spending account;
   91         b. Credited to the enrollee’s health savings account;
   92         c. Credited to the enrollee’s health reimbursement account;
   93  or
   94         d. Paid as additional health plan reimbursements not
   95  exceeding the amount of the enrollee’s out-of-pocket medical
   96  expenses.
   97         4. Provide an educational campaign for enrollees to learn
   98  about the services offered by the entity.
   99         (b) On or before January 15 of each year, the department
  100  shall report to the Governor, the President of the Senate, and
  101  the Speaker of the House of Representatives on the participation
  102  level and cost-savings to both the enrollee and the state
  103  resulting from the contract or contracts described in this
  104  subsection.
  105         (3) The department shall contract with an entity that
  106  provides enrollees with online information on the cost and
  107  quality of health care services and providers, allows an
  108  enrollee to shop for health care services and providers, and
  109  rewards the enrollee by sharing savings generated by the
  110  enrollee’s choice of services or providers. The contract shall
  111  require the entity to:
  112         (a) Establish an Internet-based, consumer-friendly platform
  113  that educates and informs enrollees about the price and quality
  114  of health care services and providers, including the average
  115  amount paid in each county for health care services and
  116  providers. The average amounts paid for such services and
  117  providers may be expressed for service bundles, which include
  118  all products and services associated with a particular treatment
  119  or episode of care, or for separate and distinct products and
  120  services.
  121         (b) Allow enrollees to shop for health care services and
  122  providers using the price and quality information provided on
  123  the Internet-based platform.
  124         (c) Permit a certified bargaining agent of state employees
  125  to provide educational materials and counseling to enrollees
  126  regarding the Internet-based platform.
  127         (d) Identify the savings realized to the enrollee and state
  128  if the enrollee chooses high-quality, lower-cost health care
  129  services or providers, and facilitate a shared savings payment
  130  to the enrollee. The amount of shared savings shall be
  131  determined by a methodology approved by the department and shall
  132  maximize value-based purchasing by enrollees. The amount payable
  133  to the enrollee may be:
  134         1. Credited to the enrollee’s flexible spending account;
  135         2. Credited to the enrollee’s health savings account;
  136         3. Credited to the enrollee’s health reimbursement account;
  137  or
  138         4. Paid as additional health plan reimbursements not
  139  exceeding the amount of the enrollee’s out-of-pocket medical
  140  expenses.
  141         (e) On or before January 1 of 2019, 2020, and 2021, the
  142  department shall report to the Governor, the President of the
  143  Senate, and the Speaker of the House of Representatives on the
  144  participation level, amount paid to enrollees, and cost-savings
  145  to both the enrollees and the state resulting from the
  146  implementation of this subsection.
  147         Section 2. Subsection (9) is added to section 110.12315,
  148  Florida Statutes, to read:
  149         110.12315 Prescription drug program.—The state employees’
  150  prescription drug program is established. This program shall be
  151  administered by the Department of Management Services, according
  152  to the terms and conditions of the plan as established by the
  153  relevant provisions of the annual General Appropriations Act and
  154  implementing legislation, subject to the following conditions:
  155         (9)(a) Beginning with the 2020 plan year, the department
  156  must implement formulary management for prescription drugs and
  157  supplies. Such management practices must require prescription
  158  drugs to be subject to formulary inclusion or exclusion but may
  159  not restrict access to the most clinically appropriate,
  160  clinically effective, and lowest net-cost prescription drugs and
  161  supplies. Drugs excluded from the formulary must be available
  162  for inclusion if a physician, advanced registered nurse
  163  practitioner, or physician assistant prescribing a
  164  pharmaceutical clearly states on the prescription that the
  165  excluded drug is medically necessary. Prescription drugs and
  166  supplies first made available in the marketplace after January
  167  1, 2020, may not be covered by the prescription drug program
  168  until specifically included in the list of covered prescription
  169  drugs and supplies.
  170         (b) No later than October 1, 2019, and by each October 1
  171  thereafter, the department must submit to the Governor, the
  172  President of the Senate, and the Speaker of the House of
  173  Representatives the list of prescription drugs and supplies that
  174  will be excluded from program coverage for the next plan year.
  175  If the department proposes to exclude prescription drugs and
  176  supplies after the plan year has commenced, the department must
  177  provide notice to the Governor, the President of the Senate, and
  178  the Speaker of the House of Representatives of such exclusions
  179  at least 60 days before implementation of such exclusions.
  180         Section 3. Effective December 31, 2019, section 8 of
  181  chapter 99-255, Laws of Florida, is repealed.
  182         Section 4. Effective January 1, 2020, section 627.6387,
  183  Florida Statutes, is created to read:
  184         627.6387Shared savings incentive program.—
  185         (1)This section may be cited as the “Patient Savings Act.”
  186         (2)As used in this section, the term:
  187         (a)“Health care provider” means a hospital or facility
  188  licensed under chapter 395; an entity licensed under chapter
  189  400; a health care practitioner as defined in s. 456.001; a
  190  blood bank, plasma center, industrial clinic, or renal dialysis
  191  facility; or a professional association, partnership,
  192  corporation, joint venture, or other association for
  193  professional activity by health care providers. The term
  194  includes entities and professionals outside of this state with
  195  an active, unencumbered license for an equivalent facility or
  196  practitioner type issued by another state, the District of
  197  Columbia, or a possession or territory of the United States.
  198         (b)“Health insurer” means an authorized insurer offering
  199  health insurance as defined in s. 624.603 or a health
  200  maintenance organization as defined in s. 641.19. The term does
  201  not include the state group health insurance program provided
  202  under s. 110.123.
  203         (c)“Shared savings incentive” means a voluntary and
  204  optional financial incentive that a health insurer may provide
  205  to an insured for choosing certain shoppable health care
  206  services under a shared savings incentive program and may
  207  include, but is not limited to, the incentives described in s.
  208  626.9541(4)(a).
  209         (d)“Shared savings incentive program” means a voluntary
  210  and optional incentive program established by a health insurer
  211  pursuant to this section.
  212         (e)“Shoppable health care service” means a lower-cost,
  213  high-quality nonemergency health care service for which a shared
  214  savings incentive is available for insureds under a health
  215  insurer’s shared savings incentive program. Shoppable health
  216  care services may be provided within or outside of this state
  217  and include, but are not limited to:
  218         1.Clinical laboratory services.
  219         2.Infusion therapy.
  220         3.Inpatient and outpatient surgical procedures.
  221         4.Obstetrical and gynecological services.
  222         5.Inpatient and outpatient nonsurgical diagnostic tests
  223  and procedures.
  224         6.Physical and occupational therapy services.
  225         7.Radiology and imaging services.
  226         8.Prescription drugs.
  227         9.Services provided through telehealth.
  228         (3)A health insurer may offer a shared savings incentive
  229  program to provide incentives to an insured when the insured
  230  obtains a shoppable health care service from the health
  231  insurer’s shared savings list. An insured may not be required to
  232  participate in a shared savings incentive program. A health
  233  insurer that offers a shared savings incentive program must:
  234         (a)Establish the program as a component part of the
  235  policy, contract, or certificate of insurance provided by the
  236  health insurer and notify the insureds and the office at least
  237  30 days before program termination.
  238         (b)File a description of the program on a form prescribed
  239  by commission rule. The office must review the filing and
  240  determine whether the shared savings incentive program complies
  241  with this section.
  242         (c)Notify an insured annually and at the time of renewal,
  243  and an applicant for insurance at the time of enrollment, of the
  244  availability of the shared savings incentive program and the
  245  procedure to participate in the program.
  246         (d)Publish on a webpage easily accessible to insureds and
  247  to applicants for insurance a list of shoppable health care
  248  services and health care providers and the shared savings
  249  incentive amount applicable for each service. A shared savings
  250  incentive may not be less than 25 percent of the savings
  251  generated by the insured’s participation in any shared savings
  252  incentive offered by the health insurer. The baseline for the
  253  savings calculation is the average in-network amount paid for
  254  that service in the most recent 12-month period or some other
  255  methodology established by the health insurer and approved by
  256  the office.
  257         (e)At least quarterly, credit or deposit the shared
  258  savings incentive amount to the insured’s account as a return or
  259  reduction in premium, or credit the shared savings incentive
  260  amount to the insured’s flexible spending account, health
  261  savings account, or health reimbursement account, such that the
  262  amount does not constitute income to the insured.
  263         (f)Submit an annual report to the office within 90
  264  business days after the close of each plan year. At a minimum,
  265  the report must include the following information:
  266         1.The number of insureds who participated in the program
  267  during the plan year and the number of instances of
  268  participation.
  269         2.The total cost of services provided as a part of the
  270  program.
  271         3.The total value of the shared savings incentive payments
  272  made to insureds participating in the program and the values
  273  distributed as premium reductions, credits to flexible spending
  274  accounts, credits to health savings accounts, or credits to
  275  health reimbursement accounts.
  276         4.An inventory of the shoppable health care services
  277  offered by the health insurer.
  278         (4)(a)A shared savings incentive offered by a health
  279  insurer in accordance with this section:
  280         1.Is not an administrative expense for rate development or
  281  rate filing purposes.
  282         2.Does not constitute an unfair method of competition or
  283  an unfair or deceptive act or practice under s. 626.9541 and is
  284  presumed to be appropriate unless credible data clearly
  285  demonstrates otherwise.
  286         (b)A shared saving incentive amount provided as a return
  287  or reduction in premium reduces the health insurer’s direct
  288  written premium by the shared saving incentive dollar amount for
  289  the purposes of the taxes in ss. 624.509 and 624.5091.
  290         (5)The commission may adopt rules necessary to implement
  291  and enforce this section.
  292         Section 5. Except as otherwise expressly provided in this
  293  act, this act shall take effect July 1, 2019.