Bill Text: FL S1142 | 2016 | Regular Session | Comm Sub
Bill Title: Treatments for Stable Patients
Spectrum: Bipartisan Bill
Status: (Failed) 2016-03-11 - Died in Appropriations [S1142 Detail]
Download: Florida-2016-S1142-Comm_Sub.html
Florida Senate - 2016 CS for SB 1142
By the Committee on Banking and Insurance; and Senator Hays
597-02875-16 20161142c1
1 A bill to be entitled
2 An act relating to treatments for stable patients;
3 creating s. 627.42392, F.S.; defining terms; requiring
4 a pharmacy benefits manager or a specified individual
5 or group insurance policy to continue to cover a drug
6 for specified insureds under certain circumstances;
7 prohibiting certain actions by a pharmacy benefits
8 manager or an individual or group policy with respect
9 to a drug for a certain insured except under certain
10 circumstances; providing applicability; amending s.
11 627.6699, F.S.; expanding a list of conditions that
12 certain health benefit plans must comply with;
13 amending s. 641.31, F.S.; defining terms; requiring a
14 pharmacy benefits manager or a specified health
15 maintenance contract to continue to cover a drug for
16 specified subscribers under certain circumstances;
17 prohibiting certain actions by a pharmacy benefits
18 manager or a health maintenance contract with respect
19 to a drug for a certain subscriber except under
20 certain circumstances; providing applicability;
21 providing an effective date.
22
23 Be It Enacted by the Legislature of the State of Florida:
24
25 Section 1. Section 627.42392, Florida Statutes, is created
26 to read:
27 627.42392 Continuity of care for medically stable
28 patients.—
29 (1) As used in this section, the term:
30 (a) “Complex or chronic medical condition” means a
31 physical, behavioral, or developmental condition that does not
32 have a known cure or that can be severely debilitating or fatal
33 if left untreated or undertreated.
34 (b) “Rare disease” has the same meaning as in the Public
35 Health Service Act, 42 U.S.C. s. 287a-1.
36 (2) A pharmacy benefits manager or an individual or group
37 insurance policy that is delivered, issued for delivery,
38 renewed, amended, or continued in this state and that provides
39 medical, major medical, or similar comprehensive coverage must
40 continue to cover a drug for an insured with a complex or
41 chronic medical condition or a rare disease if:
42 (a) The drug was previously covered by the insurer for a
43 medical condition or disease of the insured; and
44 (b) The prescribing provider continues to prescribe the
45 drug for the medical condition or disease, provided that the
46 drug is appropriately prescribed and neither of the following
47 has occurred:
48 1. The United States Food and Drug Administration has
49 issued a notice, guidance, warning, announcement, or any other
50 statement about the drug which calls into question the clinical
51 safety of the drug; or
52 2. The manufacturer of the drug has notified the United
53 States Food and Drug Administration of any manufacturing
54 discontinuance or potential discontinuance as required by s.
55 506C of the Federal Food Drug and Cosmetic Act, 21 U.S.C. s.
56 356c.
57 (3) With respect to a drug for an insured with a complex or
58 chronic medical condition or a rare disease which meets the
59 conditions of paragraphs (2)(a) and (2)(b), except during open
60 enrollment periods, a pharmacy benefits manager or an individual
61 or group insurance policy may not:
62 (a) Set forth, by contract, limitations on maximum coverage
63 of prescription drug benefits;
64 (b) Subject the insured to increased out-of-pocket costs;
65 or
66 (c) Move a drug for an insured to a more restrictive tier,
67 if an individual or group insurance policy or a pharmacy
68 benefits manager uses a formulary with tiers.
69 (4) This section does not apply to a grandfathered health
70 plan as defined in s. 627.402, or to benefits set forth in s.
71 627.6561(5)(b), (c), (d), and (e).
72 Section 2. Paragraph (e) of subsection (5) of section
73 627.6699, Florida Statutes, is amended to read:
74 627.6699 Employee Health Care Access Act.—
75 (5) AVAILABILITY OF COVERAGE.—
76 (e) All health benefit plans issued under this section must
77 comply with the following conditions:
78 1. For employers who have fewer than two employees, a late
79 enrollee may be excluded from coverage for no longer than 24
80 months if he or she was not covered by creditable coverage
81 continually to a date not more than 63 days before the effective
82 date of his or her new coverage.
83 2. Any requirement used by a small employer carrier in
84 determining whether to provide coverage to a small employer
85 group, including requirements for minimum participation of
86 eligible employees and minimum employer contributions, must be
87 applied uniformly among all small employer groups having the
88 same number of eligible employees applying for coverage or
89 receiving coverage from the small employer carrier, except that
90 a small employer carrier that participates in, administers, or
91 issues health benefits pursuant to s. 381.0406 which do not
92 include a preexisting condition exclusion may require as a
93 condition of offering such benefits that the employer has had no
94 health insurance coverage for its employees for a period of at
95 least 6 months. A small employer carrier may vary application of
96 minimum participation requirements and minimum employer
97 contribution requirements only by the size of the small employer
98 group.
99 3. In applying minimum participation requirements with
100 respect to a small employer, a small employer carrier shall not
101 consider as an eligible employee employees or dependents who
102 have qualifying existing coverage in an employer-based group
103 insurance plan or an ERISA qualified self-insurance plan in
104 determining whether the applicable percentage of participation
105 is met. However, a small employer carrier may count eligible
106 employees and dependents who have coverage under another health
107 plan that is sponsored by that employer.
108 4. A small employer carrier shall not increase any
109 requirement for minimum employee participation or any
110 requirement for minimum employer contribution applicable to a
111 small employer at any time after the small employer has been
112 accepted for coverage, unless the employer size has changed, in
113 which case the small employer carrier may apply the requirements
114 that are applicable to the new group size.
115 5. If a small employer carrier offers coverage to a small
116 employer, it must offer coverage to all the small employer’s
117 eligible employees and their dependents. A small employer
118 carrier may not offer coverage limited to certain persons in a
119 group or to part of a group, except with respect to late
120 enrollees.
121 6. A small employer carrier may not modify any health
122 benefit plan issued to a small employer with respect to a small
123 employer or any eligible employee or dependent through riders,
124 endorsements, or otherwise to restrict or exclude coverage for
125 certain diseases or medical conditions otherwise covered by the
126 health benefit plan.
127 7. An initial enrollment period of at least 30 days must be
128 provided. An annual 30-day open enrollment period must be
129 offered to each small employer’s eligible employees and their
130 dependents. A small employer carrier must provide special
131 enrollment periods as required by s. 627.65615.
132 8. A small employer carrier must provide continuity of care
133 for medically stable patients as required by s. 627.42392.
134 Section 3. Subsection (44) is added to section 641.31,
135 Florida Statutes, to read:
136 641.31 Health maintenance contracts.—
137 (44)(a) As used in this subsection, the term:
138 1. “Complex or chronic medical condition” means a physical,
139 behavioral, or developmental condition that does not have a
140 known cure or that can be severely debilitating or fatal if left
141 untreated or undertreated.
142 2. “Rare disease” has the same meaning as in the Public
143 Health Service Act, 42 U.S.C. s. 287a-1.
144 (b) A pharmacy benefits manager or a health maintenance
145 contract that is delivered, issued for delivery, renewed,
146 amended, or continued in this state and that provides medical,
147 major medical, or similar comprehensive coverage must continue
148 to cover a drug for a subscriber with a complex or chronic
149 medical condition or a rare disease if:
150 1. The drug was previously covered by the health
151 maintenance organization for a medical condition or disease of
152 the subscriber; and
153 2. The prescribing provider continues to prescribe the drug
154 for the medical condition or disease, provided that the drug is
155 appropriately prescribed and neither of the following has
156 occurred:
157 a. The United States Food and Drug Administration has
158 issued a notice, guidance, warning, announcement, or any other
159 statement about the drug which calls into question the clinical
160 safety of the drug; or
161 b. The manufacturer of the drug has notified the United
162 States Food and Drug Administration of any manufacturing
163 discontinuance or potential discontinuance as required by s.
164 506C of the Federal Food Drug and Cosmetic Act, 21 U.S.C. s.
165 356c.
166 (c) With respect to a drug for a subscriber with a complex
167 or chronic medical condition or a rare disease which meets the
168 conditions of subparagraphs (b)1. and (b)2., except during open
169 enrollment periods, a pharmacy benefits manager or a health
170 maintenance contract may not:
171 1. Set forth, by contract, limitations on maximum coverage
172 of prescription drug benefits;
173 2. Subject the subscriber to increased out-of-pocket costs;
174 or
175 3. Move a drug for a subscriber to a more restrictive tier,
176 if a health maintenance contract or a pharmacy benefits manager
177 uses a formulary with tiers.
178 (d) This section does not apply to a grandfathered health
179 plan as defined in s. 627.402.
180 Section 4. This act shall take effect January 1, 2018.
