Florida Senate - 2017 SENATOR AMENDMENT
Bill No. CS for CS for CS for SB 240
Ì620636*Î620636
LEGISLATIVE ACTION
Senate . House
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Floor: NC/2R .
05/04/2017 07:51 PM .
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Senator Steube moved the following:
1 Senate Amendment (with title amendment)
2
3 Before line 24
4 insert:
5 Section 1. Section 627.42392, Florida Statutes, is amended
6 to read:
7 627.42392 Prior authorization.—
8 (1) As used in this section, the term:
9 (a) “Health insurer” means an authorized insurer offering
10 an individual or group insurance policy that provides major
11 medical or similar comprehensive coverage health insurance as
12 defined in s. 624.603, a managed care plan as defined in s.
13 409.962(10) s. 409.962(9), or a health maintenance organization
14 as defined in s. 641.19(12).
15 (b) “Urgent care situation” has the same meaning as in s.
16 627.42393.
17 (2) Notwithstanding any other provision of law, effective
18 January 1, 2017, or six (6) months after the effective date of
19 the rule adopting the prior authorization form, whichever is
20 later, a health insurer, or a pharmacy benefits manager on
21 behalf of the health insurer, which does not provide an
22 electronic prior authorization process for use by its contracted
23 providers, shall only use the prior authorization form that has
24 been approved by the Financial Services Commission for granting
25 a prior authorization for a medical procedure, course of
26 treatment, or prescription drug benefit. Such form may not
27 exceed two pages in length, excluding any instructions or
28 guiding documentation, and must include all clinical
29 documentation necessary for the health insurer to make a
30 decision. At a minimum, the form must include: (1) sufficient
31 patient information to identify the member, date of birth, full
32 name, and Health Plan ID number; (2) provider name, address and
33 phone number; (3) the medical procedure, course of treatment, or
34 prescription drug benefit being requested, including the medical
35 reason therefor, and all services tried and failed; (4) any
36 laboratory documentation required; and (5) an attestation that
37 all information provided is true and accurate. The form, whether
38 in electronic or paper format, may not require information that
39 is not necessary for the determination of medical necessity of,
40 or coverage for, the requested medical procedure, course of
41 treatment, or prescription drug.
42 (3) The Financial Services Commission in consultation with
43 the Agency for Health Care Administration shall adopt by rule
44 guidelines for all prior authorization forms which ensure the
45 general uniformity of such forms.
46 (4) Electronic prior authorization approvals do not
47 preclude benefit verification or medical review by the insurer
48 under either the medical or pharmacy benefits.
49 (5) A health insurer or a pharmacy benefits manager on
50 behalf of the health insurer must provide the following
51 information in writing or in an electronic format upon request,
52 and on a publicly accessible Internet website:
53 (a) Detailed descriptions of requirements and restrictions
54 to obtain prior authorization for coverage of a medical
55 procedure, course of treatment, or prescription drug in clear,
56 easily understandable language. Clinical criteria must be
57 described in language easily understandable by a health care
58 provider.
59 (b) Prior authorization forms.
60 (6) A health insurer or a pharmacy benefits manager on
61 behalf of the health insurer may not implement any new
62 requirements or restrictions or make changes to existing
63 requirements or restrictions to obtain prior authorization
64 unless:
65 (a) The changes have been available on a publicly
66 accessible Internet website at least 60 days before the
67 implementation of the changes.
68 (b) Policyholders and health care providers who are
69 affected by the new requirements and restrictions or changes to
70 the requirements and restrictions are provided with a written
71 notice of the changes at least 60 days before the changes are
72 implemented. Such notice may be delivered electronically or by
73 other means as agreed to by the insured or health care provider.
74
75 This subsection does not apply to expansion of health care
76 services coverage.
77 (7) A health insurer or a pharmacy benefits manager on
78 behalf of the health insurer must authorize or deny a prior
79 authorization request and notify the patient and the patient’s
80 treating health care provider of the decision within:
81 (a) Seventy-two hours of obtaining a completed prior
82 authorization form for nonurgent care situations.
83 (b) Twenty-four hours of obtaining a completed prior
84 authorization form for urgent care situations.
85 Section 2. Section 627.42393, Florida Statutes, is created
86 to read:
87 627.42393 Fail-first protocols.—
88 (1) As used in this section, the term:
89 (a) “Fail-first protocol” means a written protocol that
90 specifies the order in which a certain medical procedure, course
91 of treatment, or prescription drug must be used to treat an
92 insured’s condition.
93 (b) “Health insurer” has the same meaning as provided in s.
94 627.42392.
95 (c) “Preceding prescription drug or medical treatment”
96 means a medical procedure, course of treatment, or prescription
97 drug that must be used pursuant to a health insurer’s fail-first
98 protocol as a condition of coverage under a health insurance
99 policy or a health maintenance contract to treat an insured’s
100 condition.
101 (d) “Protocol exception” means a determination by a health
102 insurer that a fail-first protocol is not medically appropriate
103 or indicated for treatment of an insured’s condition and the
104 health insurer authorizes the use of another medical procedure,
105 course of treatment, or prescription drug prescribed or
106 recommended by the treating health care provider for the
107 insured’s condition.
108 (e) “Urgent care situation” means an injury or condition of
109 an insured which, if medical care and treatment is not provided
110 earlier than the time generally considered by the medical
111 profession to be reasonable for a nonurgent situation, in the
112 opinion of the insured’s treating physician, would:
113 1. Seriously jeopardize the insured’s life, health, or
114 ability to regain maximum function; or
115 2. Subject the insured to severe pain that cannot be
116 adequately managed.
117 (2) A health insurer must publish on its website, and
118 provide to an insured in writing, a procedure for an insured and
119 health care provider to request a protocol exception. The
120 procedure must include:
121 (a) A description of the manner in which an insured or
122 health care provider may request a protocol exception.
123 (b) The manner and timeframe in which the health insurer is
124 required to authorize or deny a protocol exception request or
125 respond to an appeal to a health insurer’s authorization or
126 denial of a request.
127 (c) The conditions in which the protocol exception request
128 must be granted.
129 (3)(a) The health insurer must authorize or deny a protocol
130 exception request or respond to an appeal to a health insurer’s
131 authorization or denial of a request within:
132 1. Seventy-two hours of obtaining a completed prior
133 authorization form for nonurgent care situations.
134 2. Twenty-four hours of obtaining a completed prior
135 authorization form for urgent care situations.
136 (b) An authorization of the request must specify the
137 approved medical procedure, course of treatment, or prescription
138 drug benefits.
139 (c) A denial of the request must include a detailed,
140 written explanation of the reason for the denial, the clinical
141 rationale that supports the denial, and the procedure to appeal
142 the health insurer’s determination.
143 (4) A health insurer must grant a protocol exception
144 request if:
145 (a) A preceding prescription drug or medical treatment is
146 contraindicated or will likely cause an adverse reaction or
147 physical or mental harm to the insured;
148 (b) A preceding prescription drug is expected to be
149 ineffective, based on the medical history of the insured and the
150 clinical evidence of the characteristics of the preceding
151 prescription drug or medical treatment;
152 (c) The insured has previously received a preceding
153 prescription drug or medical treatment that is in the same
154 pharmacologic class or has the same mechanism of action, and
155 such drug or treatment lacked efficacy or effectiveness or
156 adversely affected the insured; or
157 (d) A preceding prescription drug or medical treatment is
158 not in the best interest of the insured because the insured’s
159 use of such drug or treatment is expected to:
160 1. Cause a significant barrier to the insured’s adherence
161 to or compliance with the insured’s plan of care;
162 2. Worsen an insured’s medical condition that exists
163 simultaneously but independently with the condition under
164 treatment; or
165 3. Decrease the insured’s ability to achieve or maintain
166 his or her ability to perform daily activities.
167 (5) The health insurer may request a copy of relevant
168 documentation from the insured’s medical record in support of a
169 protocol exception request.
170 Section 3. Subsection (11) of section 627.6131, Florida
171 Statutes, is amended to read:
172 627.6131 Payment of claims.—
173 (11) A health insurer may not retroactively deny a claim
174 because of insured ineligibility:
175 (a) At any time, if the health insurer verified the
176 eligibility of an insured at the time of treatment and provided
177 an authorization number. This paragraph applies to policies
178 entered into or renewed on or after January 1, 2018.
179 (b) More than 1 year after the date of payment of the
180 claim.
181 Section 4. Subsection (10) of section 641.3155, Florida
182 Statutes, is amended to read:
183 641.3155 Prompt payment of claims.—
184 (10) A health maintenance organization may not
185 retroactively deny a claim because of subscriber ineligibility:
186 (a) At any time, if the health maintenance organization
187 verified the eligibility of a subscriber at the time of
188 treatment and provided an authorization number. This paragraph
189 applies to contracts entered into or renewed on or after January
190 1, 2018. This paragraph does not apply to Medicaid managed care
191 plans pursuant to part IV of chapter 409.
192 (b) More than 1 year after the date of payment of the
193 claim.
194
195 ================= T I T L E A M E N D M E N T ================
196 And the title is amended as follows:
197 Delete line 2
198 and insert:
199 An act relating to health care; amending s. 627.42392,
200 F.S.; revising and providing definitions; revising
201 criteria for prior authorization forms; requiring
202 health insurers and pharmacy benefits managers on
203 behalf of health insurers to provide certain
204 information relating to prior authorization in a
205 specified manner; prohibiting such insurers and
206 pharmacy benefits managers from implementing or making
207 changes to requirements or restrictions to obtain
208 prior authorization, except under certain
209 circumstances; providing applicability; requiring such
210 insurers and pharmacy benefits managers to authorize
211 or deny prior authorization requests and provide
212 certain notices within specified timeframes; creating
213 s. 627.42393, F.S.; providing definitions; requiring
214 health insurers to publish on their websites and
215 provide in writing to insureds a specified procedure
216 to obtain protocol exceptions; specifying timeframes
217 in which health insurers must authorize or deny
218 protocol exception requests and respond to an appeal
219 to a health insurer’s authorization or denial of a
220 request; requiring authorizations or denials to
221 specify certain information; providing circumstances
222 in which health insurers must grant a protocol
223 exception request; authorizing health insurers to
224 request documentation in support of a protocol
225 exception request; amending s. 627.6131, F.S.;
226 prohibiting a health insurer from retroactively
227 denying a claim under specified circumstances;
228 providing applicability; amending s. 641.3155, F.S.;
229 prohibiting a health maintenance organization from
230 retroactively denying a claim under specified
231 circumstances; providing applicability; exempting
232 certain Medicaid managed care plans; amending s.