Updated: Jan 3, 2023
The Florida Health Insurance Advisory Board (FHIAB), which shares policy recommendations to the Office of Insurance Regulation, the Agency for Health Care Administration, the legislature, and other entities, heard 8 legislative recommendations centered around increasing policyholder protections at their meeting in September.
Florida Voices for Health's Program Director, Louisa McQueeney, who also serves as the Consumer Representative on the board, presented 8 consumer protection policy recommendations. After members of the board take some time to consider the recommendations, a follow up meeting will be scheduled in the next couple of months. At this meeting they will vote on whether to approve each recommendation. Each recommendation with unanimous approval will be sent to the Florida legislature ahead of the 2023 session (March 5 - May 7).
Florida Voices for Health's 8 recommendations include:
1. Deductible Health Credit Transfer.
With the continual rise in annual health insurance deductibles to consumers, having to start a new deductible in the middle of the year creates financial hardship. The deductibles for 2023 could end up being as high as $9,100 for an individual and $18,200 for a family. Some policies require the insured to pay the entire deductible before the insurance company pays anything at all.
When consumers change health insurance plans outside of the Open Enrollment period, because of an employer changing plans outside of annual renewal, or a change of employer, or a change in geographic area,or loss of employer coverage and purchase individual coverage, annual deductibles start all over again even if a consumer has met part or all the accumulators out of their own pocket. This is even more egregious when consumers stay with the same carrier with the expectation already incurred accumulators will be recognized, only to find out that they will not.
*Recommendation: Expand statute 627.666 to include individual on- and off-exchange policy holders a Deductible Health Credit Transfer to a new policy equal to the deductible paid by the policy holder to the prior insurer. The Credit Transfer should be for the entire amountpaid by the consumer without limitations such as a period of 90 days preceding the effective date of the succeeding insurer’s plan or recognition of the expenses actually incurred under the terms of the succeeding insurer’s plan and subject to a similar deductible provision.
2. Provide health care consumers with one free copy of their own medical records.
Patients have a right to their medical records under the Health Insurance Portability and Accountability Act (HIPAA). However, the same law allows providers to charge fees for providing the requested copies. Many requests for records are not honored in a timely fashion if honored at all and some at great expense to the consumer. Obtaining one’s own medical records is especially important when disputes arise with insurance companies, resulting in denial of claims, leaving patients in precarious financial positions. Having a patient see and review their medical records and related provider charges billed to the insurer would also bring down improper billing and potential fraud. This in turn should lead to lower health insurance costs to both plan sponsors and individuals.
* Recommendation: Provide consumer with one free copy of their medical record provided to consumer by mail or electronic mail, at the time of payment request for services provided.
3. Protect Consumers from prescription drug formulary changes during a policy year.
Drug pricing remains at the forefront of consumer complaints when accessing health coverage. Consumers often pick a health insurance plan based on the prescription drugs covered and the cost tiers they are classified in.
Consumers enter a contract with the health insurance plan for a twelve-month period and pay an agreed upon amount per month for this period based on the contract they were presented.Health insurance plans negotiate drug prices with the pharmaceutical companies on behalf of consumers, without any involvement or say of consumers. Insurance carriers then present health plans including drug formularies and premium rates to the Office of Insurance Regulation for approval. The consumer’s input is not part of the process, but the consumer is expected to pick up the extra cost in the end or go without the prescription(s) they contracted for.
In recent years insurance carriers have been making changes to their drug formularies during the policy period. Insurersroutinely reclassify drugs to more access restrictive drug tiers, increase the consumer’s co-payment, co-insurance, or deductible, and reclassify drugs to higher cost sharing tiers. There are also instances of certain drugs being dropped from coverage altogether. Consumers are then informed by mail that they will be financially responsible for the entire cost drug in the middle of the policy year.
*Recommendation: Prohibit insurance carriers from amending or removing a covered prescription drug during the policy year. This will not preclude the insurance carrier from expanding the formulary and lowering prices throughout the policy year. This would exclude the formulary for Florida Medicaid which is covered under section 409.91195, Florida Statutes
4. Cap the cost of insulin at $35 a month.
The Inflation Reduction Act, recently signed into law, will reduce the cost of insulin to no more than $35 per month for people on Medicare starting 2023. This includes insulin pumps. However, the new law doesn’t extend to individual and group health plans. The cost of insulin, which has been around for 100 years, is 10 times higher in the US than any other developed country and creates an enormous financial burden on Floridians who cannot survive without. We have all heard the heartbreaking stories. While there is no high cost of development to insulin and innovation is limited, there is also no “free” market where market forces would drive down the cost to consumers. This lack of “free” market allows for price increases at will for this lifesaving medicine. Putting a cap on the price of insulin will save money through less hospital admissions for high blood sugar emergencies and less health complications resulting in disability. Putting a cap on the cost of insulin would drive down the cost of healthcare for all Floridians
*Recommendation: Require individual & group health insurance policies to cap insured's monthly cost-sharing obligation for covered prescription insulin drugs at $35 starting with 2023 plans; require health maintenance contracts to cap subscriber's monthly cost-sharing obligation for covered prescription insulin drugs at $35 starting with 2023 plans.
5. Prohibit balance billing for ground emergency medical transportation.
The No Surprises Act of 2019 addressed many balance billing or “surprise” billing issues for consumers. However, it didn’t address the cost of ground emergency medical transportation. Consumers in a life-threatening accident or major medical emergency in need of ground emergency transportation to receive immediate health care attention at a nearby facility, are not able to make an informed decision or negotiate at arms-length about the cost of the transport. Health insurance companies provide coverage for this event, but this coverage gap can leave consumers with surprise high medical bills for the service.
* Recommendation: Apply the balance bill rules under HB221, signed into law by Governor Scott, to include ground emergency transportation.
6. Include Applied Behavioral Analysis as a covered benefit in all insurance plans.
As required by federal law Florida’s Medicaid program covers medically necessary Applied Behavioral Analysis (ABA) services to correct, or ameliorate a defect, a condition, or a physical or mental illness for eligible recipients under the age of twenty-one.
These services are extremely important for recipients with developmental disabilities. In the health insurance market these services are required under statute section 627.6686, and applicable to a group health insurance policy or group health benefit plan offered by an insurer which includes the state group insurance program provided under s. 110.123. However, these services are not required to be included in any health insurance plan offered in the individual market, any health insurance plan that is individually underwritten, or any health insurance plan provided to a small employer.
Once a recipient loses Medicaid eligibility, they lose coverage for these important services. Neither KidCare program policies or exchange and off exchange policies cover ABA services, placing an undue financial burden on families already dealing with very difficult circumstances. Expanding some plans off and on exchange to include coverage for ABA services could provide relief for this population.
*Recommendation: Require each carrier authorized to sell health insurance in Florida to include at minimum one plan in each service area to cover Applied Analysis Services as covered by Medicaid.
7. Add Fetal Alcohol Spectrum Disorder (FASD) to include to the definition of the term developmental disabilities.
Harm to Florida’s children from prenatal alcohol exposure (PAE) is a significant public health problem and the leading known cause of preventable developmental disabilities in the United States. Given that nearly half of pregnancies are unintended and women often don’t realize they are pregnant until they are 6 weeks along or more, makes it easy to understand that women could drink alcohol while not knowing they are expecting. Many myths and misconceptions about the risk of alcohol use during pregnancy remain despite nearly 50 years of research.
Recent studies show an alarming prevalence of up to 1 in 20 first graders in the United States meeting criteria for Fetal Alcohol Spectrum Disorders (FASD) classification. PAE is especially harmful to the developing brain and could impact all facets of a child’s life. Research also shows alcohol causes far greater harm to the brain than other drugs, yet recognition of the disability -- with appropriate FASD-informed supports and services -- can prevent secondary disabilities. Without these supports and services, many young adults with FASD may end up incarcerated, homeless, vulnerable to substance abuse, unemployed, and reduced access to health care.
Among medical and behavioral health professionals, inconsistent use or limited knowledge of diagnostic criteria and clinical guidelines result in many (if not most) children and adults living with FASD going undiagnosed or misdiagnosed. Families struggling with children with FASD, many of them adopted or fostered, cannot find systems of care that are familiar with or equipped to diagnose and address FASD-related disabilities. Although there is no cure for individuals impacted by FASD, research shows intervention services and supports, including social, environmental, and educational strategies can prevent subsequent trauma to the individual, their caregivers, and society.
* Recommendation: Include Fetal Alcohol Spectrum Disorder to the list of definitions of the term developmental disabilities in statute 627.6686.
8. Apply payments by, or on behalf of, a beneficiary to count toward the out-of-pocket cost sharing calculations.
Patients, even those with health insurance, are having difficulty affording their medications as a result of steadily rising out-of-pocket costs. To help cover the patients’ copays, some drug manufacturers, charitable assistance foundations, and other third parties offer copay assistance programs to help patients afford their specialty drugs. These programs are intended to provide relief to policyholders who have trouble paying for their prescription drug copays. Most patients, who use copay assistance require highly specialized, life-saving medications to treat hemophilia, MS, HIV, cancer, and other rare and chronic diseases for which, in many cases, no generics or lower-cost drugs are available.
In recent years, insurance companies and pharmacy benefit manager (PBMs) have implemented so-called "copay accumulator adjustment programs” where none of these payments made on behalf of the patient would count towards their deductible and annual maximum out of pocket costs. In addition, most insurance plans make it very difficult for a patient to find out if they have an accumulator program, using very vague language, if any at all in plan policy documents.
The financial assistance that patients receive is a specified amount per year based on the cost of the prescription. Patients often discover mid plan year that the copay assistance limit has been reached and they have to pay the entire cost of the prescription drug because none of the third-party payments were counted towards their out-of-pocket costs – defeating the purpose of the copay assistance. Research has shown that many patients will abandon their medication at the pharmacy or ration doses when they have to pay more than $75 to $225 out of pocket, foregoing life-saving medication. With copay accumulator programs, insurers and PBMs are collecting the financial assistance intended for the patient, and then requiring the patient to pay the deductible again, making it harder for consumers get their medications and other health care.
14 states have passed legislation prohibiting copay accumulator policies: Arkansas, Arizona, Connecticut, Georgia, Illinois, Kentucky, Louisiana, Maine, North Carolina, Oklahoma, Tennessee, Virginia, Washington, West Virginia.
Earlier this summer, Governor DeSantis issued an executive order (number 22-164) directing the state to implement healthcare reforms that reduce costs to consumers, promote transparency, and hold PBMs accountable. Adopting copay accumulator legislation that prohibits the harmful and deceitful practices of insurers and PBMs aligns with the Governor’s commitment to protect advancing Floridians health.
* Recommendation: Require each health insurer, issuing, delivering, or renewing a policy in Florida, which provides prescription drug coverage, administered by the insurer or pharmacy benefit manager, to count any amount paid by the insured or paid on his or her behalf through a third party (including but not limited to manufacturer or provider cost share assistance payments such as manufacturer cost share assistance) toward the policyholder’s total contribution to any deductible or out-of-pocket requirement. Insurers must include in policy documents, such as the summary of benefits, and on websites that these payments will be applied to the policyholder’s out-of-pocket maximum, deductible, or copayment responsibility.
In the absence of legislation prohibiting copay accumulator policies, each health insurer, issuing, delivering, or renewing a policy in Florida, which provides prescription drug coverage, administered by the insurer or PBM must clearly disclose the copay accumulator in the summary of benefits, in policy documents and on websites, made available to consumers prior to enrollment in a policy and that payments paid on his or her behalf will not count towards the policyholder’s out-of-pocket costs maximum, deductible, or copayment responsibility. In addition, payments made on behalf of the policy holder must appear on the explanation of benefits (EOB) as a payment the insurer will not apply towards the policyholder’s out-of-pocket maximum, deductible or copayment responsibility.