Title: Health Insurance Cost Sharing

Summary: Requiring specified individual health insurers and their pharmacy benefits managers to apply payments by or on behalf of insureds toward the total contributions of the insureds' cost-sharing requirements; requiring specified individual health insurers to disclose on their websites and in their policies their applications of payments by or on behalf of policyholders toward the policyholders' total contributions to cost-sharing requirements; requiring pharmacy benefits managers to apply payments by or on behalf of insureds and subscribers toward the insureds' and subscribers' total contributions to cost-sharing requirements, etc.

Full Text:
An act relating to health insurance cost sharing; creating s. 627.6383, F.S.; defining the term  cost sharing requirement ; requiring specified individual health insurers and their pharmacy benefits managers to apply payments by or on behalf of insureds toward the total contributions of the insureds  cost-sharing requirements; providing applicability; amending s. 627.6385, F.S.; requiring specified individual health insurers to disclose on their websites and in their policies their applications of payments by or on behalf of policyholders toward the policyholders  total contributions to cost-sharing requirements; providing applicability; amending ss. 627.64741, 627.6572, and 641.314, F.S.; requiring pharmacy benefits managers to apply payments by or on behalf of insureds and subscribers toward the insureds  and subscribers  total contributions to cost-sharing requirements; providing applicability; providing disclosure requirements; creating s. 627.65715, F.S., and amending s. 641.31, F.S.; defining the term  cost sharing requirement ; requiring specified group health insurers and health maintenance organizations and their pharmacy benefits managers to apply payments by or on behalf of insureds and subscribers toward the total contributions of the insureds  and subscribers  cost-sharing requirements, respectively; providing disclosure requirements; providing applicability; amending s. 627.6699, F.S.; providing requirements for small employer carriers; amending s. 409.967, F.S.; conforming a cross-reference; amending s. 641.185, F.S.; conforming a provision to changes made by the act; providing a declaration of important state interest; providing an effective date. Be It Enacted by the Legislature of the State of Florida: Section 1. Section 627.6383, Florida Statutes, is created to read: 627.6383   Cost-sharing requirements.  (1)   As used in this section, the term  cost-sharing requirement  means a dollar limit, deductible, copayment, coinsurance, or any other out-of-pocket expense imposed on an insured, including, but not limited to, the annual limitation on cost sharing subject to U.S.C. s. 18022. (2)(a)   Each health insurer issuing, delivering, or renewing a policy in this state which provides prescription drug coverage or each pharmacy benefits manager on behalf of such health insurer must apply any amount paid by an insured or by another person on behalf of the insured toward the insured s total contribution to any cost-sharing requirement. (b)   The amount paid by or on behalf of the insured which is applied toward the insured s total contribution to any cost sharing requirement under paragraph (a) includes, but is not limited to, any payment with, or any discount through, financial assistance, a manufacturer copay card, a product voucher, or any other reduction in out-of-pocket expenses made by or on behalf of the insured for a prescription drug. (3)   This section applies to any health insurance policy issued, delivered, or renewed in this state on or after January 1, 2022. Section 2. Present subsections (2) and (3) of section 627.6385, Florida Statutes, are redesignated as subsections (3) and (4), respectively, a new subsection (2) is added to that section, and present subsection (2) of that section is amended, to read: 627.6385 Disclosures to policyholders; calculations of cost sharing.  (2)   Each health insurer issuing, delivering, or renewing a policy in this state which provides prescription drug coverage, regardless of whether the prescription drug benefits are administered or managed by the health insurer or by a pharmacy benefits manager on behalf of the health insurer, shall disclose on its website that any amount paid by a policyholder or by another person on behalf of the policyholder shall be applied toward the policyholder s total contribution to any cost-sharing requirement pursuant to s. 627.6383. This subsection applies to any policy issued, delivered, or renewed in this state on or after January 1, 2022. (3) (2)  Each health insurer shall include in every policy delivered or issued for delivery to any person in the state or in materials provided as required by s. 627.64725 notice that the information required by this section is available electronically and the address of the website where the information can be accessed. In addition, each health insurer issuing, delivering, or renewing a policy in this state which provides prescription drug coverage, regardless of whether the prescription drug benefits are administered or managed by the health insurer or by a pharmacy benefits manager on behalf of the health insurer, shall include in every policy that is issued, delivered, or renewed to any person in this state on or after January 1, 2022, the disclosure that any amount paid by a policyholder or by another person on behalf of the policyholder shall be applied toward the policyholder s total contribution to any cost-sharing requirement pursuant to s. 627.6383. Section 3. Paragraph (c) is added to subsection (2) of section 627.64741, Florida Statutes, to read: 627.64741 Pharmacy benefit manager contracts.  (2) A contract between a health insurer and a pharmacy benefit manager must require that the pharmacy benefit manager: (c)1.   Apply any amount paid by an insured or by another person on behalf of the insured toward the insured s total contribution to any cost-sharing requirement pursuant to s. 627.6383. This subparagraph applies to any insured whose insurance policy is issued, delivered, or renewed in this state on or after January 1, 2022. 2.   Disclose to every insured whose insurance policy is issued, delivered, or renewed in this state on or after January 1, 2022, that the pharmacy benefits manager shall apply any amount paid by the insured or by another person on behalf of the insured toward the insured s total contribution to any cost sharing requirement pursuant to s. 627.6383. Section 4. Section 627.65715, Florida Statutes, is created to read: 627.65715   Cost-sharing requirements.  (1)   As used in this section, the term  cost-sharing requirement  means a dollar limit, deductible, copayment, coinsurance, or any other out-of-pocket expense imposed on an insured, including, but not limited to, the annual limitation on cost sharing subject to U.S.C. s. 18022. (2)(a)   Each insurer issuing, delivering, or renewing a policy in this state which provides prescription drug coverage or each pharmacy benefits manager on behalf of such insurer must apply any amount paid by an insured or by another person on behalf of the insured toward the insured s total contribution to any cost-sharing requirement. (b)   The amount paid by or on behalf of the insured which is applied toward the insured s total contribution to any cost sharing requirement under paragraph (a) includes, but is not limited to, any payment with, or any discount through, financial assistance, a manufacturer copay card, a product voucher, or any other reduction in out-of-pocket expenses made by or on behalf of the insured for a prescription drug. (3)   Each insurer issuing, delivering, or renewing a policy in this state which provides prescription drug coverage, regardless of whether the prescription drug benefits are administered or managed by the insurer or by a pharmacy benefits manager on behalf of the insurer, shall disclose, on its website and in every policy issued, delivered, or renewed in this state on or after January 1, 2022, that any amount paid by an insured or by another person on behalf of the insured shall be applied toward the insured s total contribution to any cost-sharing requirement. (4)   This section applies to any group health insurance policy issued, delivered, or renewed in this state on or after January 1, 2022. Section 5. Paragraph (c) is added to subsection (2) of section 627.6572, Florida Statutes, to read: 627.6572 Pharmacy benefit manager contracts.  (2) A contract between a health insurer and a pharmacy benefit manager must require that the pharmacy benefit manager: (c)1.   Apply any amount paid by an insured or by another person on behalf of the insured toward the insured s total contribution to any cost-sharing requirement pursuant to s. 627.65715. This subparagraph applies to any insured whose insurance policy is issued, delivered, or renewed in this state on or after January 1, 2022. 2.   Disclose to every insured whose insurance policy is issued, delivered, or renewed in this state on or after January 1, 2022, that the pharmacy benefits manager shall apply any amount paid by the insured or by another person on behalf of the insured toward the insured s total contribution to any cost sharing requirement pursuant to s. 627.65715. Section 6. Paragraph (e) of subsection (5) of section 627.6699, Florida Statutes, is amended to read: 627.6699 Employee Health Care Access Act.  (5) AVAILABILITY OF COVERAGE.  (e) All health benefit plans issued under this section must comply with the following conditions: 1. For employers who have fewer than two employees, a late enrollee may be excluded from coverage for no longer than months if he or she was not covered by creditable coverage continually to a date not more than days before the effective date of his or her new coverage. 2. Any requirement used by a small employer carrier in determining whether to provide coverage to a small employer group, including requirements for minimum participation of eligible employees and minimum employer contributions, must be applied uniformly among all small employer groups having the same number of eligible employees applying for coverage or receiving coverage from the small employer carrier, except that a small employer carrier that participates in, administers, or issues health benefits pursuant to s. 381.0406 which do not include a preexisting condition exclusion may require as a condition of offering such benefits that the employer has had no health insurance coverage for its employees for a period of at least months. A small employer carrier may vary application of minimum participation requirements and minimum employer contribution requirements only by the size of the small employer group. 3. In applying minimum participation requirements with respect to a small employer, a small employer carrier shall not consider as an eligible employee employees or dependents who have qualifying existing coverage in an employer-based group insurance plan or an ERISA qualified self-insurance plan in determining whether the applicable percentage of participation is met. However, a small employer carrier may count eligible employees and dependents who have coverage under another health plan that is sponsored by that employer. 4. A small employer carrier shall not increase any requirement for minimum employee participation or any requirement for minimum employer contribution applicable to a small employer at any time after the small employer has been accepted for coverage, unless the employer size has changed, in which case the small employer carrier may apply the requirements that are applicable to the new group size. 5. If a small employer carrier offers coverage to a small employer, it must offer coverage to all the small employer s eligible employees and their dependents. A small employer carrier may not offer coverage limited to certain persons in a group or to part of a group, except with respect to late enrollees. 6. A small employer carrier may not modify any health benefit plan issued to a small employer with respect to a small employer or any eligible employee or dependent through riders, endorsements, or otherwise to restrict or exclude coverage for certain diseases or medical conditions otherwise covered by the health benefit plan. 7. An initial enrollment period of at least days must be provided. An annual 30-day open enrollment period must be offered to each small employer s eligible employees and their dependents. A small employer carrier must provide special enrollment periods as required by s. 627.65615. 8.   A small employer carrier shall comply with s. 627.65715 with respect to contribution to cost-sharing requirements, as defined in that section. Section 7. Subsection (48) is added to section 641.31, Florida Statutes, to read: 641.31 Health maintenance contracts.  (48)(a)   As used in this subsection, the term  cost-sharing requirement  means a dollar limit, deductible, copayment, coinsurance, or any other out-of-pocket expense imposed on a subscriber, including, but not limited to, the annual limitation on cost sharing subject to U.S.C. s. 18022. (b)1. Each health maintenance organization issuing, delivering, or renewing a health maintenance contract or certificate in this state which provides prescription drug coverage or each pharmacy benefits manager on behalf of such health maintenance organization must apply any amount paid by a subscriber or by another person on behalf of the subscriber toward the subscriber s total contribution to any cost-sharing requirement. 2. The amount paid by or on behalf of the subscriber which is applied toward the subscriber s total contribution to any cost-sharing requirement under subparagraph 1. includes, but is not limited to, any payment with, or any discount through, financial assistance, a manufacturer copay card, a product voucher, or any other reduction in out-of-pocket expenses made by or on behalf of the subscriber for a prescription drug. (c) Each health maintenance organization issuing, delivering, or renewing a health maintenance contract or certificate in this state which provides prescription drug coverage, regardless of whether the prescription drug benefits are administered or managed by the health maintenance organization or by a pharmacy benefits manager on behalf of the health maintenance organization, shall disclose, on its website and in every subscriber s health maintenance contract, certificate, or member handbook issued, delivered, or renewed in this state on or after January 1, 2022, that any amount paid by a subscriber or by another person on behalf of the subscriber shall be applied toward the subscriber s total contribution to any cost-sharing requirement. (d) This subsection applies to any health maintenance contract or certificate issued, delivered, or renewed in this state on or after January 1, 2022. Section 8. Paragraph (c) is added to subsection (2) of section 641.314, Florida Statutes, to read: 641.314 Pharmacy benefit manager contracts.  (2) A contract between a health maintenance organization and a pharmacy benefit manager must require that the pharmacy benefit manager: (c)1. Apply any amount paid by a subscriber or by another person on behalf of the subscriber toward the subscriber s total contribution to any cost-sharing requirement pursuant to s. 641.31(48). This subparagraph applies to any subscriber whose health maintenance contract or certificate is issued, delivered, or renewed in this state on or after January 1, 2022. 2. Disclose to every subscriber whose health maintenance contract or certificate is issued, delivered, or renewed in this state on or after January 1, 2022, that the pharmacy benefits manager shall apply any amount paid by the subscriber or by another person on behalf of the subscriber toward the subscriber s total contribution to any cost-sharing requirement pursuant to s. 641.31(48). Section 9. Paragraph (o) of subsection (2) of section 409.967, Florida Statutes, is amended to read: 409.967 Managed care plan accountability.  (2) The agency shall establish such contract requirements as are necessary for the operation of the statewide managed care program. In addition to any other provisions the agency may deem necessary, the contract must require: (o)  Transparency. Managed care plans shall comply with ss. 627.6385(4) ss. 627.6385(3) and 641.54(7). Section 10. Paragraph (k) of subsection (1) of section 641.185, Florida Statutes, is amended to read: 641.185 Health maintenance organization subscriber protections.  (1) With respect to the provisions of this part and part III, the principles expressed in the following statements serve as standards to be followed by the commission, the office, the department, and the Agency for Health Care Administration in exercising their powers and duties, in exercising administrative discretion, in administrative interpretations of the law, in enforcing its provisions, and in adopting rules: (k) A health maintenance organization subscriber shall be given a copy of the applicable health maintenance contract, certificate, or member handbook specifying: all the provisions, disclosure, and limitations required pursuant to s. 641.31(1),and (4),and (48);the covered services, including those services, medical conditions, and provider types specified in ss. 641.31, 641.31094, 641.31095, 641.31096, 641.51(11), and 641.513; and where and in what manner services may be obtained pursuant to s. 641.31(4). Section 11.  The Legislature finds that this act fulfills an important state interest. Section 12. This act shall take effect July 1, 2021.