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:
8 627.42393 Continuity 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 disease” has 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