Florida Senate - 2016                          SENATOR AMENDMENT
       Bill No. HB 85
       
       
       
       
       
       
                                Ì861542ÂÎ861542                         
       
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
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               Floor: 1c/OO/2R         .                                
             03/08/2016 05:32 PM       .                                
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       Senator Hays moved the following:
       
    1         Senate Amendment to Amendment (725590) (with title
    2  amendment)
    3  
    4         Delete lines 442 - 469
    5  and insert:
    6         Section 8. Effective January 1, 2018, section 627.42393,
    7  Florida Statutes, is created to read:
    8         627.42393Continuity of care for medically stable
    9  patients.—
   10         (1) As used in this section, the term:
   11         (a) “Complex or chronic medical condition” means a
   12  physical, behavioral, or developmental condition that does not
   13  have a known cure or that can be severely debilitating or fatal
   14  if left untreated or undertreated.
   15         (b) “Rare diseasehas the same meaning as in 42 U.S.C. s.
   16  287a-1(c).
   17         (2) A pharmacy benefits manager or an individual or a group
   18  insurance policy that is delivered, issued for delivery,
   19  renewed, amended, or continued in this state and that provides
   20  medical, major medical, or similar comprehensive coverage must
   21  continue to cover a drug for an insured with a complex or
   22  chronic medical condition or a rare disease if:
   23         (a) The drug was previously covered by the insurer for a
   24  medical condition or disease of the insured; and
   25         (b) The prescribing provider continues to prescribe the
   26  drug for the medical condition or disease, the drug is
   27  appropriately prescribed, and neither of the following has
   28  occurred:
   29         1. The United States Food and Drug Administration has
   30  issued a notice, a guidance, a warning, an announcement, or any
   31  other statement about the drug which calls into question the
   32  clinical safety of the drug; or
   33         2. The manufacturer of the drug has notified the United
   34  States Food and Drug Administration of any manufacturing
   35  discontinuance or potential discontinuance as required by s.
   36  506C of the Federal Food Drug and Cosmetic Act, 21 U.S.C. s.
   37  356c.
   38         (3) With respect to a drug for an insured with a complex or
   39  chronic medical condition or a rare disease which meets the
   40  conditions of paragraphs (2)(a) and (b), except during open
   41  enrollment periods, a pharmacy benefits manager or an individual
   42  or a group insurance policy may not:
   43         (a) Set forth, by contract, limitations on maximum coverage
   44  of prescription drug benefits;
   45         (b) Subject the insured to increased out-of-pocket costs;
   46  or
   47         (c) Move a drug for an insured to a more restrictive tier,
   48  if an individual or a group insurance policy or a pharmacy
   49  benefits manager uses a formulary with tiers.
   50         (4) This section does not apply to a grandfathered health
   51  plan as defined in s. 627.402, or to benefits set forth in s.
   52  627.6561(5)(b)-(e).
   53         Section 9. Effective January 1, 2018, paragraph (e) of
   54  subsection (5) of section 627.6699, Florida Statutes, is amended
   55  to read:
   56         627.6699 Employee Health Care Access Act.—
   57         (5) AVAILABILITY OF COVERAGE.—
   58         (e) All health benefit plans issued under this section must
   59  comply with the following conditions:
   60         1. For employers who have fewer than two employees, a late
   61  enrollee may be excluded from coverage for no longer than 24
   62  months if he or she was not covered by creditable coverage
   63  continually to a date not more than 63 days before the effective
   64  date of his or her new coverage.
   65         2. Any requirement used by a small employer carrier in
   66  determining whether to provide coverage to a small employer
   67  group, including requirements for minimum participation of
   68  eligible employees and minimum employer contributions, must be
   69  applied uniformly among all small employer groups having the
   70  same number of eligible employees applying for coverage or
   71  receiving coverage from the small employer carrier, except that
   72  a small employer carrier that participates in, administers, or
   73  issues health benefits pursuant to s. 381.0406 which do not
   74  include a preexisting condition exclusion may require as a
   75  condition of offering such benefits that the employer has had no
   76  health insurance coverage for its employees for a period of at
   77  least 6 months. A small employer carrier may vary application of
   78  minimum participation requirements and minimum employer
   79  contribution requirements only by the size of the small employer
   80  group.
   81         3. In applying minimum participation requirements with
   82  respect to a small employer, a small employer carrier shall not
   83  consider as an eligible employee employees or dependents who
   84  have qualifying existing coverage in an employer-based group
   85  insurance plan or an ERISA qualified self-insurance plan in
   86  determining whether the applicable percentage of participation
   87  is met. However, a small employer carrier may count eligible
   88  employees and dependents who have coverage under another health
   89  plan that is sponsored by that employer.
   90         4. A small employer carrier shall not increase any
   91  requirement for minimum employee participation or any
   92  requirement for minimum employer contribution applicable to a
   93  small employer at any time after the small employer has been
   94  accepted for coverage, unless the employer size has changed, in
   95  which case the small employer carrier may apply the requirements
   96  that are applicable to the new group size.
   97         5. If a small employer carrier offers coverage to a small
   98  employer, it must offer coverage to all the small employer’s
   99  eligible employees and their dependents. A small employer
  100  carrier may not offer coverage limited to certain persons in a
  101  group or to part of a group, except with respect to late
  102  enrollees.
  103         6. A small employer carrier may not modify any health
  104  benefit plan issued to a small employer with respect to a small
  105  employer or any eligible employee or dependent through riders,
  106  endorsements, or otherwise to restrict or exclude coverage for
  107  certain diseases or medical conditions otherwise covered by the
  108  health benefit plan.
  109         7. An initial enrollment period of at least 30 days must be
  110  provided. An annual 30-day open enrollment period must be
  111  offered to each small employer’s eligible employees and their
  112  dependents. A small employer carrier must provide special
  113  enrollment periods as required by s. 627.65615.
  114         8. A small employer carrier must provide continuity of care
  115  for medically stable patients as required by s. 627.42393.
  116         Section 10. Effective January 1, 2018, subsections (44) and
  117  (45) are added to section 641.31, Florida Statutes, to read:
  118         641.31 Health maintenance contracts.—
  119         (44) A health maintenance organization may not require a
  120  health care provider, by contract with another health care
  121  provider, a patient, or another individual or entity, to use a
  122  clinical decision support system or a laboratory benefits
  123  management program before the provider may order clinical
  124  laboratory services or in an attempt to direct or limit the
  125  provider’s medical decisionmaking relating to the use of such
  126  services. This subsection may not be construed to prohibit any
  127  prior authorization requirements that the health maintenance
  128  organization may have regarding the provision of clinical
  129  laboratory services. As used in this subsection, the term:
  130         (a) “Clinical decision support system” means software
  131  designed to direct or assist clinical decisionmaking by matching
  132  the characteristics of an individual patient to a computerized
  133  clinical knowledge base and providing patient-specific
  134  assessments or recommendations based on the match.
  135         (b) “Clinical laboratory services” means the examination of
  136  fluids or other materials taken from the human body, which
  137  examination is ordered by a health care provider for use in the
  138  diagnosis, prevention, or treatment of a disease or in the
  139  identification or assessment of a medical or physical condition.
  140         (c) “Laboratory benefits management program” means a health
  141  maintenance organization protocol that dictates or limits health
  142  care provider decisionmaking relating to the use of clinical
  143  laboratory services.
  144         (45)(a) A pharmacy benefits manager or a health maintenance
  145  contract that is delivered, issued for delivery, renewed,
  146  amended, or continued in this state and that provides medical,
  147  major medical, or similar comprehensive coverage must continue
  148  to cover a drug for a subscriber with a complex or chronic
  149  medical condition or a rare disease if:
  150         1. The drug was previously covered by the health
  151  maintenance organization for a medical condition or disease of
  152  the subscriber; and
  153         2. The prescribing provider continues to prescribe the drug
  154  for the medical condition or disease, the drug is appropriately
  155  prescribed, and neither of the following has occurred:
  156         a. The United States Food and Drug Administration has
  157  issued a notice, a guidance, a warning, an announcement, or any
  158  other statement about the drug which calls into question the
  159  clinical safety of the drug; or
  160         b. The manufacturer of the drug has notified the United
  161  States Food and Drug Administration of any manufacturing
  162  discontinuance or potential discontinuance as required by s.
  163  506C of the Federal Food Drug and Cosmetic Act, 21 U.S.C. s.
  164  356c.
  165         (b) With respect to a drug for a subscriber with a complex
  166  or chronic medical condition or a rare disease that meets the
  167  conditions of subparagraph (c)1. or subparagraph (c)2., except
  168  during open enrollment periods, a pharmacy benefits manager or a
  169  health maintenance contract may not:
  170         1.Set forth, by contract, limitations on maximum coverage
  171  of prescription drug benefits;
  172         2. Subject the subscriber to increased out-of-pocket costs;
  173  or
  174         3. Move a drug for a subscriber to a more restrictive tier,
  175  if a health maintenance contract or a pharmacy benefits manager
  176  uses a formulary with tiers.
  177         (c) As used in this subsection, the term:
  178         1.“Complex or chronic medical condition” means a physical,
  179  behavioral, or developmental condition that does not have a
  180  known cure or that can be severely debilitating or fatal if left
  181  untreated or undertreated.
  182         2.“Rare disease” has the same meaning as in 42 U.S.C. s.
  183  287a-1(c).
  184         (d) This section does not apply to a grandfathered health
  185  plan as defined in s. 627.402.
  186  
  187  ================= T I T L E  A M E N D M E N T ================
  188  And the title is amended as follows:
  189         Delete lines 798 - 804
  190  and insert:
  191         defining the term “fail-first protocol”; creating s.
  192         627.42393, F.S.; defining terms; requiring a pharmacy
  193         benefits manager or a specified individual or group
  194         insurance policy to continue to cover a drug for
  195         specified insureds under certain circumstances;
  196         prohibiting certain actions by a pharmacy benefits
  197         manager or an individual or a group policy with
  198         respect to a drug for a certain insured except under
  199         certain circumstances; providing applicability;
  200         amending s. 627.6699, F.S.; expanding a list of
  201         conditions that certain health benefit plans must
  202         comply with; amending s. 641.31, F.S.; prohibiting a
  203         health maintenance organization from requiring that a
  204         health care provider use a clinical decision support
  205         system or a laboratory benefits management program in
  206         certain circumstances; providing for construction;
  207         defining terms; requiring a pharmacy benefits manager
  208         or a specified health maintenance contract to continue
  209         to cover a drug for specified subscribers under
  210         certain circumstances; prohibiting certain actions by
  211         a pharmacy benefits manager or a health maintenance
  212         contract with respect to a drug for a certain
  213         subscriber except under certain circumstances;
  214         defining terms; providing applicability; creating s.
  215         641.394, F.S.; requiring a