Florida Senate - 2010 SB 1132
By Senator Sobel
31-00797A-10 20101132__
1 A bill to be entitled
2 An act relating to antiretroviral drugs; amending ss.
3 409.912 and 627.6265, F.S.; prohibiting limitations on
4 the prescribing of antiretroviral drugs for treating
5 human immunodeficiency virus infection; amending s.
6 627.6515, F.S.; conforming provisions to changes made
7 by the act; creating ss. 627.65736 and 641.31093,
8 F.S.; prohibiting health insurance policies and health
9 maintenance organizations from limiting the
10 prescribing of antiretroviral drugs for treating human
11 immunodeficiency virus infection; providing an
12 effective date.
13
14 Be It Enacted by the Legislature of the State of Florida:
15
16 Section 1. Subsection (54) is added to section 409.912,
17 Florida Statutes, to read:
18 409.912 Cost-effective purchasing of health care.—The
19 agency shall purchase goods and services for Medicaid recipients
20 in the most cost-effective manner consistent with the delivery
21 of quality medical care. To ensure that medical services are
22 effectively utilized, the agency may, in any case, require a
23 confirmation or second physician’s opinion of the correct
24 diagnosis for purposes of authorizing future services under the
25 Medicaid program. This section does not restrict access to
26 emergency services or poststabilization care services as defined
27 in 42 C.F.R. part 438.114. Such confirmation or second opinion
28 shall be rendered in a manner approved by the agency. The agency
29 shall maximize the use of prepaid per capita and prepaid
30 aggregate fixed-sum basis services when appropriate and other
31 alternative service delivery and reimbursement methodologies,
32 including competitive bidding pursuant to s. 287.057, designed
33 to facilitate the cost-effective purchase of a case-managed
34 continuum of care. The agency shall also require providers to
35 minimize the exposure of recipients to the need for acute
36 inpatient, custodial, and other institutional care and the
37 inappropriate or unnecessary use of high-cost services. The
38 agency shall contract with a vendor to monitor and evaluate the
39 clinical practice patterns of providers in order to identify
40 trends that are outside the normal practice patterns of a
41 provider’s professional peers or the national guidelines of a
42 provider’s professional association. The vendor must be able to
43 provide information and counseling to a provider whose practice
44 patterns are outside the norms, in consultation with the agency,
45 to improve patient care and reduce inappropriate utilization.
46 The agency may mandate prior authorization, drug therapy
47 management, or disease management participation for certain
48 populations of Medicaid beneficiaries, certain drug classes, or
49 particular drugs to prevent fraud, abuse, overuse, and possible
50 dangerous drug interactions. The Pharmaceutical and Therapeutics
51 Committee shall make recommendations to the agency on drugs for
52 which prior authorization is required. The agency shall inform
53 the Pharmaceutical and Therapeutics Committee of its decisions
54 regarding drugs subject to prior authorization. The agency is
55 authorized to limit the entities it contracts with or enrolls as
56 Medicaid providers by developing a provider network through
57 provider credentialing. The agency may competitively bid single
58 source-provider contracts if procurement of goods or services
59 results in demonstrated cost savings to the state without
60 limiting access to care. The agency may limit its network based
61 on the assessment of beneficiary access to care, provider
62 availability, provider quality standards, time and distance
63 standards for access to care, the cultural competence of the
64 provider network, demographic characteristics of Medicaid
65 beneficiaries, practice and provider-to-beneficiary standards,
66 appointment wait times, beneficiary use of services, provider
67 turnover, provider profiling, provider licensure history,
68 previous program integrity investigations and findings, peer
69 review, provider Medicaid policy and billing compliance records,
70 clinical and medical record audits, and other factors. Providers
71 shall not be entitled to enrollment in the Medicaid provider
72 network. The agency shall determine instances in which allowing
73 Medicaid beneficiaries to purchase durable medical equipment and
74 other goods is less expensive to the Medicaid program than long
75 term rental of the equipment or goods. The agency may establish
76 rules to facilitate purchases in lieu of long-term rentals in
77 order to protect against fraud and abuse in the Medicaid program
78 as defined in s. 409.913. The agency may seek federal waivers
79 necessary to administer these policies.
80 (54) Notwithstanding any other provision of this section,
81 antiretroviral drugs prescribed to treat human immunodeficiency
82 virus infection must be included on a provider’s formulary and
83 may not be restricted through a requirement for prior
84 authorization, a step-therapy approval process, or other
85 limitation that restricts access to antiretroviral drugs.
86 Section 2. Section 627.6265, Florida Statutes, is amended
87 to read:
88 627.6265 HIV infection Cancellation or nonrenewal
89 prohibited.—
90 (1) Notwithstanding any other provision of law to the
91 contrary, an no insurer may not shall cancel or nonrenew the
92 health insurance policy of an any insured because of diagnosis
93 or treatment of human immunodeficiency virus infection or
94 acquired immune deficiency syndrome.
95 (2) Antiretroviral drugs prescribed to treat the human
96 immunodeficiency virus infection of an insured must be included
97 on a health plan formulary and may not be restricted through a
98 requirement for prior authorization, a step-therapy approval
99 process, or other limitation that restricts access to
100 antiretroviral drugs.
101 Section 3. Paragraph (c) of subsection (2) of section
102 627.6515, Florida Statutes, is amended to read:
103 627.6515 Out-of-state groups.—
104 (2) Except as otherwise provided in this part, this part
105 does not apply to a group health insurance policy issued or
106 delivered outside this state under which a resident of this
107 state is provided coverage if:
108 (c) The policy provides the benefits specified in ss.
109 627.419, 627.65736, 627.6574, 627.6575, 627.6579, 627.6612,
110 627.66121, 627.66122, 627.6613, 627.667, 627.6675, 627.6691, and
111 627.66911.
112 Section 4. Section 627.65736, Florida Statutes, is created
113 to read:
114 627.65736 HIV infection.—Antiretroviral drugs prescribed to
115 treat the human immunodeficiency virus infection of an insured
116 must be included on a health plan formulary and may not be
117 restricted through a requirement for prior authorization, a
118 step-therapy approval process, or other limitation that
119 restricts access to antiretroviral drugs.
120 Section 5. Section 641.31093, Florida Statutes, is created
121 to read:
122 641.31093 HIV infection.—Antiretroviral drugs prescribed to
123 treat the human immunodeficiency virus infection of a subscriber
124 must be included on a health plan formulary and may not be
125 restricted through a requirement for prior authorization, a
126 step-therapy approval process, or other limitation that
127 restricts access to antiretroviral drugs.
128 Section 6. This act shall take effect July 1, 2010.