Senate Bill 228 (2024) — Health insurance cost sharing
SB 228
Florida Bills
Florida Senate - 2024 SB 228 By Senator Wright 8-00104-24 2024228__ Page 1 of 12 CODING: Words stricken are deletions; words underlined are additions. A bill to be entitled 1
An act relating to health insurance cost sharing; 2 creating s. 627.6383, F.S.; defining the term “cost-3 sharing requirement”; requiring specified individual 4 health insurers and their pharmacy benefit managers to 5 apply payments by or on behalf of insureds toward the 6 total contributions of the insureds’ cost-sharing 7 requirements; providing construction; providing 8 applicability; amending s. 627.6385, F.S.; providing 9 disclosure requirements for specified health insurers 10 and their pharmacy benefit managers; providing 11 applicability; amending s. 627.64741, F.S.; requiring 12 that specified contracts require pharmacy benefit 13 managers to apply payments by or on behalf of insureds 14 toward the insureds’ total contributions to cost-15 sharing requirements; providing applicability; 16 providing disclosure requirements for such pharmacy 17 benefit managers; creating s. 627.65715, F.S.; 18 defining the term “cost-sharing requirement”; 19 requiring specified group health insurers and their 20 pharmacy benefit managers to apply payments by or on 21 behalf of insureds toward the total contributions of 22 the insureds’ cost-sharing requirements; providing 23 construction; providing disclosure requirements for 24 specified group health insurers and their pharmacy 25 benefit managers; providing applicability; amending s. 26 627.6572, F.S.; requiring that specified contracts 27 require pharmacy benefit managers to apply payments by 28 or on behalf of insureds toward the insureds’ total 29
Florida Senate - 2024 SB 228 8-00104-24 2024228__ Page 2 of 12 CODING: Words stricken are deletions; words underlined are additions. contributions to cost-sharing requirements; providing 30 applicability; providing disclosure requirements for 31 such pharmacy benefit managers; amending s. 627.6699, 32 F.S.; requiring small employer carriers to comply with 33 certain cost-sharing requirements; making technical 34 changes; amending s. 641.31, F.S.; defining the term 35 “cost-sharing requirement”; requiring specified health 36 maintenance organizations and their pharmacy benefit 37 managers to apply payments by or on behalf of 38 subscribers toward the total contributions of the 39 subscribers’ cost-sharing requirements; providing 40 construction; providing disclosure requirements for 41 such health maintenance organizations and pharmacy 42 benefit managers; providing applicability; amending s. 43 641.314, F.S.; requiring specified contracts to 44 require pharmacy benefit managers to apply payments by 45 or on behalf of subscribers toward the subscribers’ 46 total contributions to cost-sharing requirements; 47 providing applicability; providing disclosure 48 requirements for such pharmacy benefit managers; 49 amending s. 409.967, F.S.; conforming a cross-50 reference; amending s. 641.185, F.S.; conforming a 51 provision to changes made by the act; providing a 52 declaration of important state interest; providing an 53 effective date. 54 55 Be It Enacted by the Legislature of the State of Florida: 56 57
Section
Section 627.6383, Florida Statutes, is created 58
Florida Senate - 2024 SB 228 8-00104-24 2024228__ Page 3 of 12 CODING: Words stricken are deletions; words underlined are additions. to read: 59 627.6383 Cost-sharing requirements.— 60
(1) As used in this section, the term “cost-sharing 61 requirement” means a dollar limit, a deductible, a copayment, 62 coinsurance, or any other out-of-pocket expense imposed on an 63 insured, including, but not limited to, the annual limitation on 64 cost sharing subject to 42 U.S.C. s. 18022. 65 (2)(
a) Each health insurer issuing, delivering, or renewing 66 a policy that provides prescription drug coverage in this state, 67 or each pharmacy benefit manager on behalf of such health 68 insurer, shall apply any amount paid by an insured or by another 69 person on behalf of the insured toward the insured’s total 70 contribution to any cost-sharing requirement. 71 (
b) The amount paid by or on behalf of the insured which is 72 applied toward the insured’s total contribution to any cost-73 sharing requirement under paragraph (
a) includes, but is not 74 limited to, any payment with or any discount through financial 75 assistance, a manufacturer copay card, a product voucher, or any 76 other reduction in out-of-pocket expenses made by or on behalf 77 of the insured for a prescription drug. 78
(3) This
section applies to any health insurance policy 79 issued, delivered, or renewed in this state on or after January 80 1, 2025. 81
Section 2. Present subsections (2) and (3) of
section 82 627.6385, Florida Statutes, are redesignated as subsections (3) 83 and (4), respectively, a new subsection (2) is added to that 84 section, and present subsection (2) of that
section is amended, 85 to read: 86 627.6385 Disclosures to policyholders; calculations of cost 87
Florida Senate - 2024 SB 228 8-00104-24 2024228__ Page 4 of 12 CODING: Words stricken are deletions; words underlined are additions. sharing.— 88
(2) Each health insurer issuing, delivering, or renewing a 89 policy that provides prescription drug coverage in this state, 90 regardless of whether the prescription drug benefits are 91 administered or managed by the health insurer or by a pharmacy 92 benefit manager on behalf of the health insurer, shall disclose 93 on its website that any amount paid by a policyholder or by 94 another person on behalf of the policyholder must be applied 95 toward the policyholder’s total contribution to any cost-sharing 96 requirement pursuant to s. 627.6383. This subsection applies to 97 any policy issued, delivered, or renewed in this state on or 98 after January 1, 2025. 99 (3)
(2) Each health insurer shall include in every policy 100 delivered or issued for delivery to any person in this the state 101 or in materials provided as required by s. 627.64725 a notice 102 that the information required by this
section is available 103 electronically and the website address of the website where the 104 information can be accessed.
In addition, each health insurer 105 issuing, delivering, or renewing a policy that provides 106 prescription drug coverage in this state, regardless of whether 107 the prescription drug benefits are administered or managed by 108 the health insurer or by a pharmacy benefit manager on behalf of 109 the health insurer, shall include in every policy issued, 110 delivered, or renewed to any person in this state on or after 111 January 1, 2025, the disclosure that any amount paid by a 112 policyholder or by another person on behalf of the policyholder 113 must be applied toward the policyholder’s total contribution to 114 any cost-sharing requirement pursuant to s. 627.6383. 115
Section 3. Paragraph (
c) is added to subsection (2) of 116
Florida Senate - 2024 SB 228 8-00104-24 2024228__ Page 5 of 12 CODING: Words stricken are deletions; words underlined are additions.
section 627.64741, Florida Statutes, to read: 117 627.64741 Pharmacy benefit manager contracts.— 118
(2) In addition to the requirements of
part VII of
chapter 119 626, a contract between a health insurer and a pharmacy benefit 120 manager must require that the pharmacy benefit manager: 121 (c)1. Apply any amount paid by an insured or by another 122 person on behalf of the insured toward the insured’s total 123 contribution to any cost-sharing requirement pursuant to s. 124 627.6383. This subparagraph applies to any insured whose 125 insurance policy is issued, delivered, or renewed in this state 126 on or after January 1, 2025. 127 2.
Disclose to every insured whose insurance policy is 128 issued, delivered, or renewed in this state on or after January 129 1, 2025, that the pharmacy benefit manager shall apply any 130 amount paid by the insured or by another person on behalf of the 131 insured toward the insured’s total contribution to any cost-132 sharing requirement pursuant to s. 627.6383. 133
Section
Section 627.65715, Florida Statutes, is created 134 to read: 135 627.65715 Cost-sharing requirements.— 136
(1) As used in this section, the term “cost-sharing 137 requirement” means a dollar limit, a deductible, a copayment, 138 coinsurance, or any other out-of-pocket expense imposed on an 139 insured, including, but not limited to, the annual limitation on 140 cost sharing subject to 42 U.S.C. s. 18022. 141 (2)(
a) Each insurer issuing, delivering, or renewing a 142 policy that provides prescription drug coverage in this state, 143 or each pharmacy benefit manager on behalf of such insurer, 144 shall apply any amount paid by an insured or by another person 145
Florida Senate - 2024 SB 228 8-00104-24 2024228__ Page 6 of 12 CODING: Words stricken are deletions; words underlined are additions. on behalf of the insured toward the insured’s total contribution 146 to any cost-sharing requirement. 147 (
b) The amount paid by or on behalf of the insured which is 148 applied toward the insured’s total contribution to any cost-149 sharing requirement under paragraph (
a) includes, but is not 150 limited to, any payment with or any discount through financial 151 assistance, a manufacturer copay card, a product voucher, or any 152 other reduction in out-of-pocket expenses made by or on behalf 153 of the insured for a prescription drug. 154
(3) Each insurer issuing, delivering, or renewing a policy 155 that provides prescription drug coverage in this state, 156 regardless of whether the prescription drug benefits are 157 administered or managed by the insurer or by a pharmacy benefit 158 manager on behalf of the insurer, shall disclose on its website 159 and in every policy issued, delivered, or renewed in this state 160 on or after January 1, 2025, that any amount paid by an insured 161 or by another person on behalf of the insured must be applied 162 toward the insured’s total contribution to any cost-sharing 163 requirement. 164
(4) This
section applies to any group health insurance 165 policy issued, delivered, or renewed in this state on or after 166 January 1, 2025. 167
Section 5. Paragraph (
c) is added to subsection (2) of 168
section 627.6572, Florida Statutes, to read: 169 627.6572 Pharmacy benefit manager contracts.— 170
(2) In addition to the requirements of
part VII of
chapter 171 626, a contract between a health insurer and a pharmacy benefit 172 manager must require that the pharmacy benefit manager: 173 (c)1. Apply any amount paid by an insured or by another 174
Florida Senate - 2024 SB 228 8-00104-24 2024228__ Page 7 of 12 CODING: Words stricken are deletions; words underlined are additions. person on behalf of the insured toward the insured’s total 175 contribution to any cost-sharing requirement pursuant to s. 176 627.65715. This subparagraph applies to any insured whose 177 insurance policy is issued, delivered, or renewed in this state 178 on or after January 1, 2025. 179 2.
Disclose to every insured whose insurance policy is 180 issued, delivered, or renewed in this state on or after January 181 1, 2025, that the pharmacy benefit manager shall apply any 182 amount paid by the insured or by another person on behalf of the 183 insured toward the insured’s total contribution to any cost-184 sharing requirement pursuant to s. 627.65715. 185
Section 6. Paragraph (
e) of subsection (5) of
section 186 627.6699, Florida Statutes, is amended to read: 187 627.6699 Employee Health Care Access Act.— 188
(5) AVAILABILITY OF COVERAGE.— 189 (
e) All health benefit plans issued under this
section must 190 comply with the following conditions: 191 1. For employers who have fewer than two employees, a late 192 enrollee may be excluded from coverage for no longer than 24 193 months if he or she was not covered by creditable coverage 194 continually to a date not more than 63 days before the effective 195 date of his or her new coverage. 196 2.
Any requirement used by a small employer carrier in 197 determining whether to provide coverage to a small employer 198 group, including requirements for minimum participation of 199 eligible employees and minimum employer contributions, must be 200 applied uniformly among all small employer groups having the 201 same number of eligible employees applying for coverage or 202 receiving coverage from the small employer carrier, except that 203
Florida Senate - 2024 SB 228 8-00104-24 2024228__ Page 8 of 12 CODING: Words stricken are deletions; words underlined are additions. a small employer carrier that participates in, administers, or 204 issues health benefits pursuant to s. 381.0406 which do not 205 include a preexisting condition exclusion may require as a 206 condition of offering such benefits that the employer has had no 207 health insurance coverage for its employees for a period of at 208 least 6 months.
A small employer carrier may vary application of 209 minimum participation requirements and minimum employer 210 contribution requirements only by the size of the small employer 211 group. 212 3. In applying minimum participation requirements with 213 respect to a small employer, a small employer carrier may shall 214 not consider as an eligible employee employees or dependents who 215 have qualifying existing coverage in an employer-based group 216 insurance plan or an ERISA qualified self-insurance plan in 217 determining whether the applicable percentage of participation 218 is met.
However, a small employer carrier may count eligible 219 employees and dependents who have coverage under another health 220 plan that is sponsored by that employer. 221 4. A small employer carrier may shall not increase any 222 requirement for minimum employee participation or any 223 requirement for minimum employer contribution applicable to a 224 small employer at any time after the small employer has been 225 accepted for coverage, unless the employer size has changed, in 226 which case the small employer carrier may apply the requirements 227 that are applicable to the new group size. 228 5.
If a small employer carrier offers coverage to a small 229 employer, it must offer coverage to all the small employer’s 230 eligible employees and their dependents. A small employer 231 carrier may not offer coverage limited to certain persons in a 232
Florida Senate - 2024 SB 228 8-00104-24 2024228__ Page 9 of 12 CODING: Words stricken are deletions; words underlined are additions. group or to part of a group, except with respect to late 233 enrollees. 234 6. A small employer carrier may not modify any health 235 benefit plan issued to a small employer with respect to a small 236 employer or any eligible employee or dependent through riders, 237 endorsements, or otherwise to restrict or exclude coverage for 238 certain diseases or medical conditions otherwise covered by the 239 health benefit plan. 240 7.
An initial enrollment period of at least 30 days must be 241 provided. An annual 30-day open enrollment period must be 242 offered to each small employer’s eligible employees and their 243 dependents. A small employer carrier must provide special 244 enrollment periods as required by s. 627.65615. 245 8. A small employer carrier shall comply with s. 627.65715 246 with respect to contribution to cost-sharing requirements, as 247 defined in that section. 248
Section 7. Subsection (48) is added to
section 641.31, 249 Florida Statutes, to read: 250 641.31 Health maintenance contracts.— 251 (48)(
a) As used in this subsection, the term “cost-sharing 252 requirement” means a dollar limit, a deductible, a copayment, 253 coinsurance, or any other out-of-pocket expense imposed on a 254 subscriber, including, but not limited to, the annual limitation 255 on cost sharing subject to 42 U.S.C. s. 18022. 256 (b)1. Each health maintenance organization issuing, 257 delivering, or renewing a health maintenance contract or 258 certificate that provides prescription drug coverage in this 259 state, or each pharmacy benefit manager on behalf of such health 260 maintenance organization, shall apply any amount paid by a 261
Florida Senate - 2024 SB 228 8-00104-24 2024228__ Page 10 of 12 CODING: Words stricken are deletions; words underlined are additions. subscriber or by another person on behalf of the subscriber 262 toward the subscriber’s total contribution to any cost-sharing 263 requirement. 264 2.
The amount paid by or on behalf of the subscriber which 265 is applied toward the subscriber’s total contribution to any 266 cost-sharing requirement under subparagraph 1. includes, but is 267 not limited to, any payment with or any discount through 268 financial assistance, a manufacturer copay card, a product 269 voucher, or any other reduction in out-of-pocket expenses made 270 by or on behalf of the subscriber for a prescription drug. 271 (
c) Each health maintenance organization issuing, 272 delivering, or renewing a health maintenance contract or 273 certificate that provides prescription drug coverage in this 274 state, regardless of whether the prescription drug benefits are 275 administered or managed by the health maintenance organization 276 or by a pharmacy benefit manager on behalf of the health 277 maintenance organization, shall disclose on its website and in 278 every subscriber’s health maintenance contract, certificate, or 279 member handbook issued, delivered, or renewed in this state on 280 or after January 1, 2025, that any amount paid by a subscriber 281 or by another person on behalf of the subscriber must be applied 282 toward the subscriber’s total contribution to any cost-sharing 283 requirement. 284 (
d) This subsection applies to any health maintenance 285 contract or certificate issued, delivered, or renewed in this 286 state on or after January 1, 2025. 287
Section 8. Paragraph (
c) is added to subsection (2) of 288
section 641.314, Florida Statutes, to read: 289 641.314 Pharmacy benefit manager contracts.— 290
Florida Senate - 2024 SB 228 8-00104-24 2024228__ Page 11 of 12 CODING: Words stricken are deletions; words underlined are additions.
(2) In addition to the requirements of
part VII of
chapter 291 626, a contract between a health maintenance organization and a 292 pharmacy benefit manager must require that the pharmacy benefit 293 manager: 294 (c)1. Apply any amount paid by a subscriber or by another 295 person on behalf of the subscriber toward the subscriber’s total 296 contribution to any cost-sharing requirement pursuant to s. 297 641.31(48). This subparagraph applies to any subscriber whose 298 health maintenance contract or certificate is issued, delivered, 299 or renewed in this state on or after January 1, 2025. 300 2.
Disclose to every subscriber whose health maintenance 301 contract or certificate is issued, delivered, or renewed in this 302 state on or after January 1, 2025, that the pharmacy benefit 303 manager shall apply any amount paid by the subscriber or by 304 another person on behalf of the subscriber toward the 305 subscriber’s total contribution to any cost-sharing requirement 306 pursuant to s. 641.31(48). 307
Section 9. Paragraph (
o) of subsection (2) of
section 308 409.967, Florida Statutes, is amended to read: 309 409.967 Managed care plan accountability.— 310
(2) The agency shall establish such contract requirements 311 as are necessary for the operation of the statewide managed care 312 program. In addition to any other provisions the agency may deem 313 necessary, the contract must require: 314 (
o) Transparency.—Managed care plans shall comply with ss. 315 627.6385(4) and 641.54(7) ss. 627.6385(3) and 641.54(7). 316
Section 10. Paragraph (
k) of subsection (1) of
section 317 641.185, Florida Statutes, is amended to read: 318 641.185 Health maintenance organization subscriber 319
Florida Senate - 2024 SB 228 8-00104-24 2024228__ Page 12 of 12 CODING: Words stricken are deletions; words underlined are additions. protections.— 320
(1) With respect to the provisions of this part and
part 321 III, the principles expressed in the following statements serve 322 as standards to be followed by the commission, the office, the 323 department, and the Agency for Health Care Administration in 324 exercising their powers and duties, in exercising administrative 325 discretion, in administrative
interpretations of the law, in 326 enforcing its provisions, and in adopting rules: 327 (
k) A health maintenance organization subscriber shall be 328 given a copy of the applicable health maintenance contract, 329 certificate, or member handbook specifying: all the provisions, 330 disclosure, and limitations required pursuant to s. 641.31(1), 331 and (4), and (48); the covered services, including those 332 services, medical conditions, and provider types specified in 333 ss. 641.31, 641.31094, 641.31095, 641.31096, 641.51(11), and 334 641.513; and where and in what manner services may be obtained 335 pursuant to s. 641.31(4). 336