Florida Senate - 2020 SB 1836 By Senator Bean 4-01734-20 20201836__ Page 1 of 21 CODING: Words stricken are deletions; words underlined are additions. A bill to be entitled 1

An act relating to health insurance and prescription 2 drug coverage; amending s. 110.123, F.S.; requiring 3 the state group insurance program to allow enrollees 4 to obtain health care services and prescription drugs 5 from out-of-network providers and pharmacies if 6 certain conditions are met; providing for the payment 7 to be applied towards the enrollee’s deductible and 8 out-of-pocket maximum; providing notice requirements; 9 amending s. 110.12303, F.S.; revising provider 10 organizations included in benefit packages for the 11 state group insurance program; revising requirements 12 for the contracts between the Department of Management 13 Services and health insurers; requiring the department 14 to offer specified reimbursement as a voluntary 15 supplemental benefit option in the state group 16 insurance program; amending s. 110.12315, F.S.; 17 requiring the state employees’ prescription drug 18 program to allow members and members’ dependents to 19 obtain prescription drugs from out-of-network 20 pharmacies if certain conditions are met; providing 21 for the payment to be applied towards the deductible 22 and out-of-pocket maximum; providing notice 23 requirements; amending s. 110.1238, F.S.; requiring 24 state group health insurance plans to allow 25 participants to obtain health care services and 26 prescription drugs from out-of-network providers and 27 pharmacies if certain conditions are met; providing 28 for the payment to be applied towards the deductible 29

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 2 of 21 CODING: Words stricken are deletions; words underlined are additions. and out-of-pocket maximum; providing notice 30 requirements; creating s. 465.203, F.S.; defining the 31 term “covered individual”; prohibiting pharmacy 32 benefit managers from engaging in specified acts under 33 certain circumstances; creating s. 627.4435, F.S.; 34 defining the term “health insurer”; requiring health 35 insurers to apply certain payments toward deductibles 36 and out-of-pocket maximums within a specified 37 timeframe under certain circumstances; prohibiting 38 health insurers from engaging in specified acts under 39 certain circumstances; providing construction; 40 providing publication and notification requirements; 41 amending ss. 627.6387, 627.6648, and 641.31076, F.S.; 42 revising

definitions; requiring, rather than 43 authorizing, health insurers and health maintenance 44 organizations to offer shared savings incentive 45 programs; revising duties of health insurers and 46 health maintenance organizations with respect to 47 shared savings incentive programs; providing an 48 effective date. 49 50 Be It Enacted by the Legislature of the State of Florida: 51 52

Section 1. Subsection (14) is added to

section 110.123, 53 Florida Statutes, to read: 54 110.123 State group insurance program.— 55

(14) OUT-OF-NETWORK PROVIDERS.— 56 (

a) The state group insurance program shall allow its 57 enrollees to obtain a covered health care service from an out-58

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 3 of 21 CODING: Words stricken are deletions; words underlined are additions. of-network provider at a cost that is the same or less than the 59 in-network average that an enrollee’s insurance plan pays for 60 that health care service. The state group insurance program 61 shall apply, within a reasonable timeframe not to exceed 1 year, 62 the payment made by, or required of, an enrollee for that health 63 care service toward the enrollee’s deductible and out-of-pocket 64 maximum as specified in the enrollee’s insurance plan as if the 65 health care service had been provided by an in-network provider. 66 (

b) If an enrollee uses a pharmacy discount program, drug 67 manufacturer rebate, or other discount or rebate program, 68 including purchasing a prescription drug from a licensed 69 prescribing provider such as a direct primary care provider, and 70 such use results in a lower cost than would have been paid for a 71 covered prescription drug had the enrollee used the enrollee’s 72 insurance plan to purchase the prescription drug, the state 73 group insurance program shall apply, within a reasonable 74 timeframe not to exceed 1 year, the payment made by the enrollee 75 for that covered prescription drug toward the enrollee’s 76 deductible and out-of-pocket maximum as specified in the 77 enrollee’s insurance plan as if the prescription drug had been 78 purchased from an in-network pharmacy. 79 (

c) At a minimum, the state group insurance program shall 80 inform enrollees on its website and in its benefit plan 81 materials of the options of obtaining covered health care 82 services from out-of-network providers and prescription drugs 83 from out-of-network pharmacies under paragraphs (

a) and (b), 84 respectively, with the enrollees’ payments applied to 85 deductibles and out-of-pocket maximums. On its website and in 86 its benefit plan materials, the state group insurance program 87

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 4 of 21 CODING: Words stricken are deletions; words underlined are additions. shall also provide information on how to use the options under 88 paragraphs (

a) and (

b) if an enrollee is interested in doing so. 89

Section 2. Present paragraph (

e) of subsection (3) and 90 present subsection (4) of

section 110.12303, Florida Statutes, 91 are redesignated as subsections (4) and (5), respectively, a new 92 paragraph (

e) is added to subsection (3) of that section, and 93 paragraph (

e) of subsection (1), paragraph (

a) of subsection 94 (2), paragraph (

d) of subsection (3), and present subsection (4) 95 of that

section are amended, to read: 96 110.12303 State group insurance program; additional 97 benefits; price transparency program; reporting.— 98

(1) In addition to the comprehensive package of health 99 insurance and other benefits required or authorized to be 100 included in the state group insurance program, the package of 101 benefits may also include products and services offered by: 102 (

e) Provider organizations, including service networks, 103 group practices, professional associations, and other 104 incorporated organizations of providers, who sell service 105 contracts and arrangements for a specified amount and type of 106 health services, including direct primary or other medical care 107 provided on a subscription basis. 108 (2)(

a) The department shall contract with at least one 109 entity that provides comprehensive pricing and inclusive 110 services for surgery and other medical procedures which may be 111 accessed at the option of the enrollee. The contract shall 112 require the entity to: 113 1. Have procedures and evidence-based standards to ensure 114 the inclusion of only high-quality health care providers. 115 2. Provide assistance to the enrollee in accessing and 116

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 5 of 21 CODING: Words stricken are deletions; words underlined are additions. coordinating care. 117 3. Provide cost savings to the state group insurance 118 program to be shared with both the state and the enrollee. Cost 119 savings payable to an enrollee may be: 120 a. Credited to the enrollee’s flexible spending account; 121 b. Credited to the enrollee’s health savings account; 122 c. Credited to the enrollee’s health reimbursement account; 123 or 124 d. Credited to the enrollee as a premium or out-of-pocket 125 cost reduction; or 126 e.

Paid directly to the enrollee as cash or a cash 127 equivalent additional health plan reimbursements not exceeding 128 the amount of the enrollee’s out-of-pocket medical expenses. 129 4. Provide an educational campaign for enrollees to learn 130 about the services offered by the entity. 131

(3) The department shall contract with an entity that 132 provides enrollees with online information on the cost and 133 quality of health care services and providers, allows an 134 enrollee to shop for health care services and providers, and 135 rewards the enrollee by sharing savings generated by the 136 enrollee’s choice of services or providers. The contract shall 137 require the entity to: 138 (

d) Identify the savings realized to the enrollee and state 139 if the enrollee chooses high-quality, lower-cost health care 140 services or providers, and facilitate a shared savings payment 141 to the enrollee. The amount of shared savings shall be 142 determined by a methodology approved by the department and shall 143 maximize value-based purchasing by enrollees. The amount payable 144 to the enrollee may be: 145

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 6 of 21 CODING: Words stricken are deletions; words underlined are additions. 1. Credited to the enrollee’s flexible spending account; 146 2. Credited to the enrollee’s health savings account; 147 3. Credited to the enrollee’s health reimbursement account; 148 or 149 4. Credited to the enrollee as a premium or out-of-pocket 150 cost reduction; or 151 5. Paid directly to the enrollee as cash or a cash 152 equivalent additional health plan reimbursements not exceeding 153 the amount of the enrollee’s out-of-pocket medical expenses. 154 (

e) Include infusion therapy in the shared savings 155 incentive program. 156 (5)

(4) The department shall offer, as a voluntary 157 supplemental benefit option:, 158 (

a) International prescription services that offer safe 159 maintenance medications at a reduced cost to enrollees and that 160 meet the standards of the United States Food and Drug 161 Administration personal importation policy. 162 (

b) At a minimum, reimbursement of direct primary care 163 subscription fees. 164

Section 3. Subsection (11) is added to

section 110.12315, 165 Florida Statutes, to read: 166 110.12315 Prescription drug program.—The state employees’ 167 prescription drug program is established. This program shall be 168 administered by the Department of Management Services, according 169 to the terms and conditions of the plan as established by the 170 relevant provisions of the annual General Appropriations Act and 171 implementing legislation, subject to the following conditions: 172 (11)(

a) If a member or a member’s dependent uses a pharmacy 173 discount program, drug manufacturer rebate, or other discount or 174

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 7 of 21 CODING: Words stricken are deletions; words underlined are additions. rebate program, including purchasing a prescription drug from a 175 licensed prescribing provider such as a direct primary care 176 provider, and such use results in a lower cost than would have 177 been paid for a covered prescription drug had the member or 178 member’s dependent used the state group health insurance plan or 179 a pharmacy participating in the state employees’ prescription 180 drug program to purchase the prescription drug, the department 181 must apply the payments made by the member or member’s dependent 182 for that covered prescription drug toward the member’s 183 deductible and out-of-pocket maximum as specified in the state 184 group health insurance plan or state employees’ prescription 185 drug program as if the prescription drug had been purchased from 186 a pharmacy participating in the state employees’ prescription 187 drug program. 188 (

b) At a minimum, the department, on its website and in its 189 materials, shall inform the program’s members on the program 190 benefits of the option of obtaining prescription drugs from 191 nonparticipating pharmacies under paragraph (

a) and shall 192 provide information on how to use such option to a member or a 193 member’s dependent. 194

Section

Section 110.1238, Florida Statutes, is amended 195 to read: 196 110.1238 State group health insurance plans; refunds with 197 respect to overcharges by providers; out-of-network providers.— 198

(1) A participant in a state group health insurance plan 199 who discovers that he or she was overcharged by a health care 200 provider shall receive a refund of 50 percent of any amount 201 recovered as a result of such overcharge, up to a maximum of 202 $1,000. 203

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 8 of 21 CODING: Words stricken are deletions; words underlined are additions.

(2) A state group health insurance plan shall allow its 204 participants to obtain a covered health care service from an 205 out-of-network provider at a cost that is the same or less than 206 the in-network average that the state group health insurance 207 plan pays for that health care service. The state group health 208 insurance plan shall apply, within a reasonable timeframe not to 209 exceed 1 year, the payment made by, or required of, a 210 participant for that health care service toward the 211 participant’s deductible and out-of-pocket maximum as specified 212 in the state group health insurance plan as if the health care 213 service had been provided by an in-network provider. 214

(3) If a participant uses a pharmacy discount program, drug 215 manufacturer rebate, or other discount or rebate program, 216 including purchasing a prescription drug from a licensed 217 prescribing provider such as a direct primary care provider, and 218 such use results in a lower cost than would have been paid for a 219 covered prescription drug had the participant used the state 220 group health insurance plan to purchase the prescription drug, 221 the state group health insurance plan must apply the payment 222 made by the participant for that covered prescription drug 223 toward the participant’s deductible and out-of-pocket maximum as 224 specified in the state group health insurance plan as if the 225 prescription drug had been purchased from an in-network 226 pharmacy. 227

(4) At a minimum, a state group health insurance plan shall 228 inform participants on its website and in its benefit plan 229 materials of the options of obtaining covered health care 230 services from out-of-network providers and prescription drugs 231 from out-of-network pharmacies under subsections (2) and (3), 232

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 9 of 21 CODING: Words stricken are deletions; words underlined are additions. respectively, with the participants’ payments applied to 233 deductibles and out-of-pocket maximums. On its website and in 234 its benefit plan materials, a state group health insurance plan 235 shall also provide information on how to use the options under 236 subsections (2) and (3) if a participant is interested in doing 237 so. 238

Section

Section 465.203, Florida Statutes, is created to 239 read: 240 465.203 Pharmacy benefit managers; prohibited acts.— 241

(1) As used in this section, the term “covered individual” 242 means a member, a participant, an enrollee, a contract holder, a 243 policyholder, or a beneficiary of a health plan, health plan 244 sponsor, health plan provider, health insurer, health 245 maintenance organization, or any other payor that uses pharmacy 246 benefit management services in this state. 247

(2) A pharmacy benefit manager may not impose on a covered 248 individual a copayment or any other charge that exceeds the 249 claim cost of a prescription drug. If information related to a 250 covered individual’s out-of-pocket cost, the clinical efficacy 251 of a prescription drug, or alternative medication is available 252 to a pharmacy provider, a pharmacy benefit manager may not 253 penalize the pharmacy provider for providing that information to 254 the covered individual. 255

Section

Section 627.4435, Florida Statutes, is created 256 to read: 257 627.4435 Coverage for out-of-network providers and 258 prescription drugs.— 259

(1) DEFINITION.—As used in this section, the term “health 260 insurer” has the same meaning as provided in s. 408.07. 261

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 10 of 21 CODING: Words stricken are deletions; words underlined are additions.

(2) HEALTH CARE SERVICES FROM OUT-OF-NETWORK PROVIDERS.—262 Beginning on January 1, 2021, upon approval of a health 263 insurer’s rate filings: 264 (

a) If an insured obtains a covered health care service 265 from an out-of-network provider at a cost that is the same or 266 less than the in-network average that the health insurer pays 267 for that health care service, the health insurer must apply, 268 within a reasonable timeframe not to exceed 1 year, the payment 269 made by, or required of, an insured for that health care service 270 toward the insured’s deductible and out-of-pocket maximum as 271 specified in the insured’s health insurance policy, plan, or 272 contract as if the health care service had been provided by an 273 in-network provider. 274 (

b) A health insurer may not deny payment for any in-275 network health care service covered under an insured’s health 276 insurance policy, plan, or contract based solely on the basis 277 that the insured’s referral was made by an out-of-network 278 provider. The health insurer may not apply a deductible, 279 coinsurance, or copayment greater than the applicable 280 deductible, coinsurance, or copayment that would apply to the 281 same health care service if the health care service was referred 282 by an in-network provider. 283

(3) PRESCRIPTION DRUGS.— 284 (

a) A health insurer or a pharmacy benefit manager on 285 behalf of a health insurer may not impose on an insured a 286 copayment or other charge that exceeds the claim cost of a 287 prescription drug. If information related to an insured’s out-288 of-pocket cost, the clinical efficacy of a prescription drug, or 289 alternative medication is available to a pharmacy provider, a 290

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 11 of 21 CODING: Words stricken are deletions; words underlined are additions. health insurer or a pharmacy benefit manager on behalf of a 291 health insurer may not penalize the pharmacy provider for 292 providing that information to the insured. 293 (

b) If an insured uses a pharmacy discount program, drug 294 manufacturer rebate, or other discount or rebate program, 295 including purchasing a prescription drug from a licensed 296 prescribing provider such as a direct primary care provider, and 297 such use results in a lower cost than would have been paid for a 298 covered prescription drug had the insured used the health 299 insurance policy, plan, or contract to purchase the prescription 300 drug, the health insurer or the pharmacy benefit manager on 301 behalf of a health insurer shall apply the payment made by the 302 insured for that covered prescription drug toward the insured’s 303 deductible and out-of-pocket maximum as specified in the 304 insured’s health insurance policy, plan, or contract as if the 305 prescription drug had been purchased from an in-network 306 pharmacy. 307 (

c) This

section does not restrict a health insurer from 308 requiring standard preauthorization or other precertification 309 requirements, such as the use of a formulary, that would 310 otherwise be required under the insured’s health insurance 311 policy, plan, or contract. 312

(4) NOTIFICATION TO INSUREDS.— 313 (

a) At a minimum, a health insurer shall inform insureds on 314 its website and in its benefit policy, plan, or contract 315 materials of the options of obtaining health care services from 316 out-of-network providers and prescription drugs from out-of-317 network pharmacies under subsections (2) and (3), respectively, 318 with the insureds’ payments applied to deductibles and out-of-319

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 12 of 21 CODING: Words stricken are deletions; words underlined are additions. pocket maximums. On its website and in its benefit policy, plan, 320 or contract materials, the health insurer shall also inform 321 insureds on the process to obtain information on the average 322 amount paid to an in-network provider or in-network pharmacy for 323 a procedure, service, or prescription drug. The health insurer 324 shall provide on its website a downloadable or interactive form 325 for insureds to submit proof of payment to an out-of-network 326 provider or out-of-network pharmacy. 327 (

b) If an insured who is in a group health insurance 328 policy, plan, or contract has paid for a health care service and 329 the paid contracted rate for the provider was in the highest 330 third for in-network providers for that insured’s group health 331 insurance policy, plan, or contract, the health insurer must 332 inform the insured, by mail, electronic transmission, or 333 telephone, that the insured has overpaid for the health care 334 service, and the health insurer must also inform the insured of 335 tools or methods the insured could use next time to elect a 336 lower-cost option if the insured is interested in doing so. 337

Section 7. Paragraphs (c), (d), and (

e) of subsection (2) 338 and subsection (3) of

section 627.6387, Florida Statutes, are 339 amended to read: 340 627.6387 Shared savings incentive program.— 341

(2) As used in this section, the term: 342 (c) “Shared savings incentive” means a voluntary and 343 optional financial incentive that a health insurer provides may 344 provide to an insured for choosing certain shoppable health care 345 services under a shared savings incentive program and may 346 include, but is not limited to, the incentives described in s. 347 626.9541(4)(a). 348

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 13 of 21 CODING: Words stricken are deletions; words underlined are additions. (d) “Shared savings incentive program” means an a voluntary 349 and optional incentive program established by a health insurer 350 pursuant to this section. 351 (e) “Shoppable health care service” means a lower-cost, 352 high-quality nonemergency health care service for which a shared 353 savings incentive is available for insureds under a health 354 insurer’s shared savings incentive program.

Shoppable health 355 care services may be provided within or outside this state and 356 include, but are not limited to: 357 1. Clinical laboratory services. 358 2. Infusion therapy. 359 3. Inpatient and outpatient surgical procedures. 360 4. Obstetrical and gynecological services. 361 5. Inpatient and outpatient nonsurgical diagnostic tests 362 and procedures. 363 6. Physical and occupational therapy services. 364 7. Radiology and imaging services. 365 8. Prescription drugs. 366 9. Services provided through telehealth. 367 10.

Any additional services identified by the Florida 368 Center for Health Information and Transparency which commonly 369 have a wide price variation. 370

(3) A health insurer shall may offer a shared savings 371 incentive program to provide incentives to an insured when the 372 insured obtains a shoppable health care service from the health 373 insurer’s shared savings list. An insured may not be required to 374 participate in a shared savings incentive program. A health 375 insurer that offers a shared savings incentive program must: 376 (

a) Establish the program as a component part of the policy 377

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 14 of 21 CODING: Words stricken are deletions; words underlined are additions. or certificate of insurance provided by the health insurer and 378 notify the insureds and the office at least 30 days before 379 program termination. 380 (a)(

b) File a description of the program on a form 381 prescribed by commission rule. The office must review the filing 382 and determine whether the shared savings incentive program 383 complies with this section. 384 (b)(

c) Notify an insured annually and at the time of 385 renewal, and an applicant for insurance at the time of 386 enrollment, of the availability of the shared savings incentive 387 program and the procedure to participate in the program. 388 (c)(

d) Publish on a webpage easily accessible to insureds 389 and to applicants for insurance a list of shoppable health care 390 services and health care providers and the shared savings 391 incentive amount applicable for each service. A shared savings 392 incentive may not be less than 25 percent of the savings 393 generated by the insured’s participation in any shared savings 394 incentive offered by the health insurer.

The baseline for the 395 savings calculation is the average in-network amount paid for 396 that service in the most recent 12-month period or some other 397 methodology established by the health insurer and approved by 398 the office. The health insurer must also offer a toll-free 399 telephone number that an insured may call to compare services 400 that qualify for a shared savings incentive. 401 (d)(

e) At least quarterly, credit or deposit the shared 402 savings incentive amount to the insured’s account as a return or 403 reduction in premium, or credit the shared savings incentive 404 amount to the insured’s flexible spending account, health 405 savings account, or health reimbursement account, or reward the 406

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 15 of 21 CODING: Words stricken are deletions; words underlined are additions. insured directly with cash or a cash equivalent such that the 407 amount does not constitute income to the insured. 408 (e)(

f) Submit an annual report to the office within 90 409 business days after the close of each plan year. At a minimum, 410 the report must include the following information: 411 1. The number of insureds who participated in the program 412 during the plan year and the number of instances of 413 participation. 414 2. The total cost of services provided as a part of the 415 program. 416 3.

The total value of the shared savings incentive payments 417 made to insureds participating in the program and the values 418 distributed as premium reductions, credits to flexible spending 419 accounts, credits to health savings accounts, or credits to 420 health reimbursement accounts. 421 4. An inventory of the shoppable health care services 422 offered by the health insurer. 423

Section 8. Paragraphs (c), (d), and (

e) of subsection (2) 424 and subsection (3) of

section 627.6648, Florida Statutes, are 425 amended to read: 426 627.6648 Shared savings incentive program.— 427

(2) As used in this section, the term: 428 (c) “Shared savings incentive” means a voluntary and 429 optional financial incentive that a health insurer provides may 430 provide to an insured for choosing certain shoppable health care 431 services under a shared savings incentive program and may 432 include, but is not limited to, the incentives described in s. 433 626.9541(4)(a). 434 (d) “Shared savings incentive program” means an a voluntary 435

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 16 of 21 CODING: Words stricken are deletions; words underlined are additions. and optional incentive program established by a health insurer 436 pursuant to this section. 437 (e) “Shoppable health care service” means a lower-cost, 438 high-quality nonemergency health care service for which a shared 439 savings incentive is available for insureds under a health 440 insurer’s shared savings incentive program. Shoppable health 441 care services may be provided within or outside this state and 442 include, but are not limited to: 443 1.

Clinical laboratory services. 444 2. Infusion therapy. 445 3. Inpatient and outpatient surgical procedures. 446 4. Obstetrical and gynecological services. 447 5. Inpatient and outpatient nonsurgical diagnostic tests 448 and procedures. 449 6. Physical and occupational therapy services. 450 7. Radiology and imaging services. 451 8. Prescription drugs. 452 9. Services provided through telehealth. 453 10. Any additional services identified by the Florida 454 Center for Health Information and Transparency which commonly 455 have a wide price variation. 456

(3) A health insurer shall may offer a shared savings 457 incentive program to provide incentives to an insured when the 458 insured obtains a shoppable health care service from the health 459 insurer’s shared savings list. An insured may not be required to 460 participate in a shared savings incentive program. A health 461 insurer that offers a shared savings incentive program must: 462 (

a) Establish the program as a component part of the policy 463 or certificate of insurance provided by the health insurer and 464

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 17 of 21 CODING: Words stricken are deletions; words underlined are additions. notify the insureds and the office at least 30 days before 465 program termination. 466 (a)(

b) File a description of the program on a form 467 prescribed by commission rule. The office must review the filing 468 and determine whether the shared savings incentive program 469 complies with this section. 470 (b)(

c) Notify an insured annually and at the time of 471 renewal, and an applicant for insurance at the time of 472 enrollment, of the availability of the shared savings incentive 473 program and the procedure to participate in the program. 474 (c)(

d) Publish on a webpage easily accessible to insureds 475 and to applicants for insurance a list of shoppable health care 476 services and health care providers and the shared savings 477 incentive amount applicable for each service. A shared savings 478 incentive may not be less than 25 percent of the savings 479 generated by the insured’s participation in any shared savings 480 incentive offered by the health insurer.

The baseline for the 481 savings calculation is the average in-network amount paid for 482 that service in the most recent 12-month period or some other 483 methodology established by the health insurer and approved by 484 the office. The health insurer must also offer a toll-free 485 telephone number that an insured may call to compare services 486 that qualify for a shared savings incentive. 487 (d)(

e) At least quarterly, credit or deposit the shared 488 savings incentive amount to the insured’s account as a return or 489 reduction in premium, or credit the shared savings incentive 490 amount to the insured’s flexible spending account, health 491 savings account, or health reimbursement account, or reward the 492 insured directly with cash or a cash equivalent such that the 493

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 18 of 21 CODING: Words stricken are deletions; words underlined are additions. amount does not constitute income to the insured. 494 (e)(

f) Submit an annual report to the office within 90 495 business days after the close of each plan year. At a minimum, 496 the report must include the following information: 497 1. The number of insureds who participated in the program 498 during the plan year and the number of instances of 499 participation. 500 2. The total cost of services provided as a part of the 501 program. 502 3.

The total value of the shared savings incentive payments 503 made to insureds participating in the program and the values 504 distributed as premium reductions, credits to flexible spending 505 accounts, credits to health savings accounts, or credits to 506 health reimbursement accounts. 507 4. An inventory of the shoppable health care services 508 offered by the health insurer. 509

Section 9. Paragraphs (c), (d), and (

e) of subsection (2) 510 and subsection (3) of

section 641.31076, Florida Statutes, are 511 amended to read: 512 641.31076 Shared savings incentive program.— 513

(2) As used in this section, the term: 514 (c) “Shared savings incentive” means a voluntary and 515 optional financial incentive that a health maintenance 516 organization provides may provide to a subscriber for choosing 517 certain shoppable health care services under a shared savings 518 incentive program and may include, but is not limited to, the 519 incentives described in s. 641.3903(15). 520 (d) “Shared savings incentive program” means an a voluntary 521 and optional incentive program established by a health 522

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 19 of 21 CODING: Words stricken are deletions; words underlined are additions. maintenance organization pursuant to this section. 523 (e) “Shoppable health care service” means a lower-cost, 524 high-quality nonemergency health care service for which a shared 525 savings incentive is available for subscribers under a health 526 maintenance organization’s shared savings incentive program. 527 Shoppable health care services may be provided within or outside 528 this state and include, but are not limited to: 529 1. Clinical laboratory services. 530 2.

Infusion therapy. 531 3. Inpatient and outpatient surgical procedures. 532 4. Obstetrical and gynecological services. 533 5. Inpatient and outpatient nonsurgical diagnostic tests 534 and procedures. 535 6. Physical and occupational therapy services. 536 7. Radiology and imaging services. 537 8. Prescription drugs. 538 9. Services provided through telehealth. 539 10. Any additional services identified by the Florida 540 Center for Health Information and Transparency which commonly 541 have a wide price variation. 542

(3) A health maintenance organization shall may offer a 543 shared savings incentive program to provide incentives to a 544 subscriber when the subscriber obtains a shoppable health care 545 service from the health maintenance organization’s shared 546 savings list. A subscriber may not be required to participate in 547 a shared savings incentive program. A health maintenance 548 organization that offers a shared savings incentive program 549 must: 550 (

a) Establish the program as a component part of the 551

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 20 of 21 CODING: Words stricken are deletions; words underlined are additions. contract of coverage provided by the health maintenance 552 organization and notify the subscribers and the office at least 553 30 days before program termination. 554 (a)(

b) File a description of the program on a form 555 prescribed by commission rule. The office must review the filing 556 and determine whether the shared savings incentive program 557 complies with this section. 558 (b)(

c) Notify a subscriber annually and at the time of 559 renewal, and an applicant for coverage at the time of 560 enrollment, of the availability of the shared savings incentive 561 program and the procedure to participate in the program. 562 (c)(

d) Publish on a webpage easily accessible to 563 subscribers and to applicants for coverage a list of shoppable 564 health care services and health care providers and the shared 565 savings incentive amount applicable for each service. A shared 566 savings incentive may not be less than 25 percent of the savings 567 generated by the subscriber’s participation in any shared 568 savings incentive offered by the health maintenance 569 organization.

The baseline for the savings calculation is the 570 average in-network amount paid for that service in the most 571 recent 12-month period or some other methodology established by 572 the health maintenance organization and approved by the office. 573 The health maintenance organization must also offer a toll-free 574 telephone number that a subscriber may call to compare services 575 that qualify for a shared savings incentive. 576 (d)(

e) At least quarterly, credit or deposit the shared 577 savings incentive amount to the subscriber’s account as a return 578 or reduction in premium, or credit the shared savings incentive 579 amount to the subscriber’s flexible spending account, health 580

Florida Senate - 2020 SB 1836 4-01734-20 20201836__ Page 21 of 21 CODING: Words stricken are deletions; words underlined are additions. savings account, or health reimbursement account, or reward the 581 subscriber directly with cash or a cash equivalent such that the 582 amount does not constitute income to the subscriber. 583 (e)(

f) Submit an annual report to the office within 90 584 business days after the close of each plan year. At a minimum, 585 the report must include the following information: 586 1. The number of subscribers who participated in the 587 program during the plan year and the number of instances of 588 participation. 589 2. The total cost of services provided as a part of the 590 program. 591 3.

The total value of the shared savings incentive payments 592 made to subscribers participating in the program and the values 593 distributed as premium reductions, credits to flexible spending 594 accounts, credits to health savings accounts, or credits to 595 health reimbursement accounts. 596 4. An inventory of the shoppable health care services 597 offered by the health maintenance organization. 598

Section 10. This act shall take effect January 1, 2021. 599