Florida Senate - 2014                          SENATOR AMENDMENT
       Bill No. CS/CS/HB 565, 1st Eng.
       
       
       
       
       
       
                                Ì4021964Î402196                         
       
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
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                Floor: 1/AD/2R         .        Floor: SENA1/RC         
             05/01/2014 10:37 AM       .      05/02/2014 09:59 PM       
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       Senator Grimsley moved the following:
       
    1         Senate Amendment (with title amendment)
    2  
    3         Between lines 2811 and 2812
    4  insert:
    5         Section 56. Paragraph (c) of subsection (2) of section
    6  409.967, Florida Statutes, is amended to read:
    7         409.967 Managed care plan accountability.—
    8         (2) The agency shall establish such contract requirements
    9  as are necessary for the operation of the statewide managed care
   10  program. In addition to any other provisions the agency may deem
   11  necessary, the contract must require:
   12         (c) Access.—
   13         1. The agency shall establish specific standards for the
   14  number, type, and regional distribution of providers in managed
   15  care plan networks to ensure access to care for both adults and
   16  children. Each plan must maintain a regionwide network of
   17  providers in sufficient numbers to meet the access standards for
   18  specific medical services for all recipients enrolled in the
   19  plan. The exclusive use of mail-order pharmacies may not be
   20  sufficient to meet network access standards. Consistent with the
   21  standards established by the agency, provider networks may
   22  include providers located outside the region. A plan may
   23  contract with a new hospital facility before the date the
   24  hospital becomes operational if the hospital has commenced
   25  construction, will be licensed and operational by January 1,
   26  2013, and a final order has issued in any civil or
   27  administrative challenge. Each plan shall establish and maintain
   28  an accurate and complete electronic database of contracted
   29  providers, including information about licensure or
   30  registration, locations and hours of operation, specialty
   31  credentials and other certifications, specific performance
   32  indicators, and such other information as the agency deems
   33  necessary. The database must be available online to both the
   34  agency and the public and have the capability of comparing to
   35  compare the availability of providers to network adequacy
   36  standards and to accept and display feedback from each
   37  provider’s patients. Each plan shall submit quarterly reports to
   38  the agency identifying the number of enrollees assigned to each
   39  primary care provider.
   40         2. If establishing a prescribed drug formulary or preferred
   41  drug list, a managed care plan shall:
   42         a. Provide a broad range of therapeutic options for the
   43  treatment of disease states which are consistent with the
   44  general needs of an outpatient population. If feasible, the
   45  formulary or preferred drug list must include at least two
   46  products in a therapeutic class.
   47         b.Each managed care plan must Publish the any prescribed
   48  drug formulary or preferred drug list on the plan’s website in a
   49  manner that is accessible to and searchable by enrollees and
   50  providers. The plan shall must update the list within 24 hours
   51  after making a change. Each plan must ensure that the prior
   52  authorization process for prescribed drugs is readily accessible
   53  to health care providers, including posting appropriate contact
   54  information on its website and providing timely responses to
   55  providers.
   56         3. For enrollees Medicaid recipients diagnosed with
   57  hemophilia who have been prescribed anti-hemophilic-factor
   58  replacement products, the agency shall provide for those
   59  products and hemophilia overlay services through the agency’s
   60  hemophilia disease management program.
   61         3. Managed care plans, and their fiscal agents or
   62  intermediaries, must accept prior authorization requests for any
   63  service electronically.
   64         4. Notwithstanding any other law, in order to establish
   65  uniformity in the submission of prior authorization forms,
   66  effective January 1, 2015, a managed care plan shall use a
   67  single standardized form for obtaining prior authorization for a
   68  medical procedure, course of treatment, or prescription drug
   69  benefit. The form may not exceed two pages in length, excluding
   70  any instructions or guiding documentation.
   71         a. The managed care plan shall make the form available
   72  electronically and online to practitioners. The prescribing
   73  provider may electronically submit the completed prior
   74  authorization form to the managed care plan.
   75         b. If the managed care plan contracts with a pharmacy
   76  benefits manager to perform prior authorization services for a
   77  medical procedure, course of treatment, or prescription drug
   78  benefit, the pharmacy benefits manager must use and accept the
   79  standardized prior authorization form.
   80         c. A completed prior authorization request submitted by a
   81  health care provider using the standardized prior authorization
   82  form is deemed approved upon receipt by the managed care plan
   83  unless the managed care plan responds otherwise within 3
   84  business days.
   85         5. If medications for the treatment of a medical condition
   86  are restricted for use by a managed care plan by a step-therapy
   87  or fail-first protocol, the prescribing provider must have
   88  access to a clear and convenient process to request an override
   89  of the protocol from the managed care plan.
   90         a. The managed care plan shall grant an override within 72
   91  hours if the prescribing provider documents that:
   92         (I) Based on sound clinical evidence, the preferred
   93  treatment required under the step-therapy or fail-first protocol
   94  has been ineffective in the treatment of the enrollee’s disease
   95  or medical condition; or
   96         (II) Based on sound clinical evidence or medical and
   97  scientific evidence, the preferred treatment required under the
   98  step-therapy or fail-first protocol:
   99         (A) Is expected or is likely to be ineffective based on
  100  known relevant physical or mental characteristics of the
  101  enrollee and known characteristics of the drug regimen; or
  102         (B) Will cause or will likely cause an adverse reaction or
  103  other physical harm to the enrollee.
  104         b. If the prescribing provider allows the enrollee to enter
  105  the step-therapy or fail-first protocol recommended by the
  106  managed care plan, the duration of the step-therapy or fail
  107  first protocol may not exceed the customary period for use of
  108  the medication if the prescribing provider demonstrates such
  109  treatment to be clinically ineffective. If the managed care plan
  110  can, through sound clinical evidence, demonstrate that the
  111  originally prescribed medication is likely to require more than
  112  the customary period to provide any relief or amelioration to
  113  the enrollee, the step-therapy or fail-first protocol may be
  114  extended for an additional period, but no longer than the
  115  original customary period for use of the medication.
  116  Notwithstanding this provision, a step-therapy or fail-first
  117  protocol shall be terminated if the prescribing provider
  118  determines that the enrollee is having an adverse reaction or is
  119  suffering from other physical harm resulting from the use of the
  120  medication.
  121         Section 57. Section 627.42392, Florida Statutes, is created
  122  to read:
  123         627.42392 Prior authorization.—
  124         (1) Notwithstanding any other law, in order to establish
  125  uniformity in the submission of prior authorization forms,
  126  effective January 1, 2015, a health insurer that delivers,
  127  issues for delivery, renews, amends, or continues an individual
  128  or group health insurance policy in this state, including a
  129  policy issued to a small employer as defined in s. 627.6699,
  130  shall use a single standardized form for obtaining prior
  131  authorization for a medical procedure, course of treatment, or
  132  prescription drug benefit. The form may not exceed two pages in
  133  length, excluding any instructions or guiding documentation.
  134         (a)The health insurer shall make the form available
  135  electronically and online to practitioners. The prescribing
  136  provider may submit the completed prior authorization form
  137  electronically to the health insurer.
  138         (b) If the health insurer contracts with a pharmacy
  139  benefits manager to perform prior authorization services for a
  140  medical procedure, course of treatment, or prescription drug
  141  benefit, the pharmacy benefits manager must use and accept the
  142  standardized prior authorization form.
  143         (c)A completed prior authorization request submitted by a
  144  health care provider using the standardized prior authorization
  145  form is deemed approved upon receipt by the health insurer
  146  unless the health insurer responds otherwise within 3 business
  147  days.
  148         (2) This section does not apply to a grandfathered health
  149  plan as defined in s. 627.402.
  150         Section 58. Section 627.42393, Florida Statutes, is created
  151  to read:
  152         627.42393 Medication protocol override.—If an individual or
  153  group health insurance policy, including a policy issued by a
  154  small employer as defined in s. 627.6699, restricts medications
  155  for the treatment of a medical condition by a step-therapy or
  156  fail-first protocol, the prescribing provider must have access
  157  to a clear and convenient process to request an override of the
  158  protocol from the health insurer.
  159         (1) The health insurer shall authorize an override of the
  160  protocol within 72 hours if the prescribing provider documents
  161  that:
  162         (a) Based on sound clinical evidence, the preferred
  163  treatment required under the step-therapy or fail-first protocol
  164  has been ineffective in the treatment of the insured’s disease
  165  or medical condition; or
  166         (b) Based on sound clinical evidence or medical and
  167  scientific evidence, the preferred treatment required under the
  168  step-therapy or fail-first protocol:
  169         1. Is expected or is likely to be ineffective based on
  170  known relevant physical or mental characteristics of the insured
  171  and known characteristics of the drug regimen; or
  172         2.Will cause or is likely to cause an adverse reaction or
  173  other physical harm to the insured.
  174         (2) If the prescribing provider allows the insured to enter
  175  the step-therapy or fail-first protocol recommended by the
  176  health insurer, the duration of the step-therapy or fail-first
  177  protocol may not exceed the customary period for use of the
  178  medication if the prescribing provider demonstrates such
  179  treatment to be clinically ineffective. If the health insurer
  180  can, through sound clinical evidence, demonstrate that the
  181  originally prescribed medication is likely to require more than
  182  the customary period for such medication to provide any relief
  183  or amelioration to the insured, the step-therapy or fail-first
  184  protocol may be extended for an additional period of time, but
  185  no longer than the original customary period for the medication.
  186  Notwithstanding this provision, a step-therapy or fail-first
  187  protocol shall be terminated if the prescribing provider
  188  determines that the insured is having an adverse reaction or is
  189  suffering from other physical harm resulting from the use of the
  190  medication.
  191         (3) This section does not apply to grandfathered health
  192  plans, as defined in s. 627.402.
  193         Section 59. Subsection (11) of section 627.6131, Florida
  194  Statutes, is amended to read:
  195         627.6131 Payment of claims.—
  196         (11) A health insurer may not retroactively deny a claim
  197  because of insured ineligibility:
  198         (a) More than 1 year after the date of payment of the
  199  claim; or
  200         (b) If, under a policy compliant with the federal Patient
  201  Protection and Affordable Care Act, as amended by the Health
  202  Care and Education Reconciliation Act of 2010, and the
  203  regulations adopted pursuant to those acts, the health insurer
  204  verified the eligibility of the insured at the time of treatment
  205  and provided an authorization number, unless, at the time
  206  eligibility was verified, the provider was notified that the
  207  insured was delinquent in paying the premium.
  208         Section 60. Subsection (2) of section 627.6471, Florida
  209  Statutes, is amended to read:
  210         627.6471 Contracts for reduced rates of payment;
  211  limitations; coinsurance and deductibles.—
  212         (2) An Any insurer issuing a policy of health insurance in
  213  this state, which insurance includes coverage for the services
  214  of a preferred provider shall, must provide each policyholder
  215  and certificateholder with a current list of preferred
  216  providers, shall and must make the list available for public
  217  inspection during regular business hours at the principal office
  218  of the insurer within the state, and shall post a link to the
  219  list of preferred providers on the home page of the insurer’s
  220  website. Changes to the list of preferred providers must be
  221  reflected on the insurer’s website within 24 hours.
  222         Section 61. Paragraph (c) of subsection (2) of section
  223  627.6515, Florida Statutes, is amended to read:
  224         627.6515 Out-of-state groups.—
  225         (2) Except as otherwise provided in this part, this part
  226  does not apply to a group health insurance policy issued or
  227  delivered outside this state under which a resident of this
  228  state is provided coverage if:
  229         (c) The policy provides the benefits specified in ss.
  230  627.419, 627.42392, 627.42393, 627.6574, 627.6575, 627.6579,
  231  627.6612, 627.66121, 627.66122, 627.6613, 627.667, 627.6675,
  232  627.6691, and 627.66911, and complies with the requirements of
  233  s. 627.66996.
  234         Section 62. Subsection (10) of section 641.3155, Florida
  235  Statutes, is amended to read:
  236         641.3155 Prompt payment of claims.—
  237         (10) A health maintenance organization may not
  238  retroactively deny a claim because of subscriber ineligibility:
  239         (a) More than 1 year after the date of payment of the
  240  claim; or
  241         (b) If, under a policy in compliance with the federal
  242  Patient Protection and Affordable Care Act, as amended by the
  243  Health Care and Education Reconciliation Act of 2010, and the
  244  regulations adopted pursuant to those acts, the health
  245  maintenance organization verified the eligibility of the
  246  subscriber at the time of treatment and provided an
  247  authorization number, unless, at the time eligibility was
  248  verified, the provider was notified that the subscriber was
  249  delinquent in paying the premium.
  250         Section 63. Section 641.393, Florida Statutes, is created
  251  to read:
  252         641.393 Prior authorization.—Notwithstanding any other law,
  253  in order to establish uniformity in the submission of prior
  254  authorization forms, effective January 1, 2015, a health
  255  maintenance organization shall use a single standardized form
  256  for obtaining prior authorization for prescription drug
  257  benefits. The form may not exceed two pages in length, excluding
  258  any instructions or guiding documentation.
  259         (1) A health maintenance organization shall make the form
  260  available electronically and online to practitioners. A health
  261  care provider may electronically submit the completed form to
  262  the health maintenance organization.
  263         (2) If a health maintenance organization contracts with a
  264  pharmacy benefits manager to perform prior authorization
  265  services for prescription drug benefits, the pharmacy benefits
  266  manager must use and accept the standardized prior authorization
  267  form.
  268         (3) A completed prior authorization request submitted by a
  269  health care provider using the standardized prior authorization
  270  form required under this section is deemed approved upon receipt
  271  by the health maintenance organization unless the health
  272  maintenance organization responds otherwise within 3 business
  273  days.
  274         (4) This section does not apply to grandfathered health
  275  plans, as defined in s. 627.402.
  276         Section 64. Section 641.394, Florida Statutes, is created
  277  to read:
  278         641.394 Medication protocol override.—If a health
  279  maintenance organization contract restricts medications for the
  280  treatment of a medical condition by a step-therapy or fail-first
  281  protocol, the prescribing provider shall have access to a clear
  282  and convenient process to request an override of the protocol
  283  from the health maintenance organization.
  284         (1) The health maintenance organization shall grant an
  285  override within 72 hours if the prescribing provider documents
  286  that:
  287         (a) Based on sound clinical evidence, the preferred
  288  treatment required under the step-therapy or fail-first protocol
  289  has been ineffective in the treatment of the subscriber’s
  290  disease or medical condition; or
  291         (b) Based on sound clinical evidence or medical and
  292  scientific evidence, the preferred treatment required under the
  293  step-therapy or fail-first protocol:
  294         1. Is expected or is likely to be ineffective based on
  295  known relevant physical or mental characteristics of the
  296  subscriber and known characteristics of the drug regimen; or
  297         2.Will cause or is likely to cause an adverse reaction or
  298  other physical harm to the subscriber.
  299         (2) If the prescribing provider allows the subscriber to
  300  enter the step-therapy or fail-first protocol recommended by the
  301  health maintenance organization, the duration of the step
  302  therapy or fail-first protocol may not exceed the customary
  303  period for use of the medication if the prescribing provider
  304  demonstrates such treatment to be clinically ineffective. If the
  305  health maintenance organization can, through sound clinical
  306  evidence, demonstrate that the originally prescribed medication
  307  is likely to require more than the customary period to provide
  308  any relief or amelioration to the subscriber, the step-therapy
  309  or fail-first protocol may be extended for an additional period,
  310  but no longer than the original customary period for use of the
  311  medication. Notwithstanding this provision, a step-therapy or
  312  fail-first protocol shall be terminated if the prescribing
  313  provider determines that the subscriber is having an adverse
  314  reaction or is suffering from other physical harm resulting from
  315  the use of the medication.
  316         (3)This section does not apply to grandfathered health
  317  plans, as defined in s. 627.402.
  318  
  319  ================= T I T L E  A M E N D M E N T ================
  320  And the title is amended as follows:
  321         Delete line 206
  322  and insert:
  323         associations; amending s. 409.967, F.S.; revising
  324         contract requirements for Medicaid managed care
  325         programs; providing requirements for plans
  326         establishing a drug formulary or preferred drug list;
  327         requiring the use of a standardized prior
  328         authorization form; providing requirements for the
  329         form and for the availability and submission of the
  330         form; requiring a pharmacy benefits manager to use and
  331         accept the form under certain circumstances;
  332         establishing a process for providers to override
  333         certain treatment restrictions; providing requirements
  334         for approval of such overrides; providing an exception
  335         to the override protocol in certain circumstances;
  336         creating s. 627.42392, F.S.; requiring health insurers
  337         to use a standardized prior authorization form;
  338         providing requirements for the form and for the
  339         availability and submission of the form; requiring a
  340         pharmacy benefits manager to use and accept the form
  341         under certain circumstances; providing an exemption;
  342         creating s. 627.42393, F.S.; establishing a process
  343         for providers to override certain treatment
  344         restrictions; providing requirements for approval of
  345         such overrides; providing an exception to the override
  346         protocol in certain circumstances; providing an
  347         exemption; amending s. 627.6131, F.S.; prohibiting an
  348         insurer from retroactively denying a claim in certain
  349         circumstances; amending s. 627.6471, F.S.; requiring
  350         insurers to post preferred provider information on a
  351         website; specifying that changes to such a website
  352         must be made within a certain time; amending s.
  353         627.6515, F.S.; applying provisions relating to prior
  354         authorization and override protocols to out-of-state
  355         groups; amending s. 641.3155, F.S.; prohibiting a
  356         health maintenance organization from retroactively
  357         denying a claim in certain circumstances; creating s.
  358         641.393, F.S.; requiring the use of a standardized
  359         prior authorization form by a health maintenance
  360         organization; providing requirements for the
  361         availability and submission of the form; requiring a
  362         pharmacy benefits manager to use and accept the form
  363         under certain circumstances; providing an exemption;
  364         creating s. 641.394, F.S.; establishing a process for
  365         providers to override certain treatment restrictions;
  366         providing requirements for approval of such overrides;
  367         providing an exception to the override protocol in
  368         certain circumstances; providing an exemption;
  369         providing effective dates.