Florida Senate - 2017 SENATOR AMENDMENT
Bill No. HB 7117, 1st Eng.
Ì1909909Î190990
LEGISLATIVE ACTION
Senate . House
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Floor: 1c/RE/2R .
05/03/2017 07:06 PM .
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Senator Steube moved the following:
1 Senate Amendment to Amendment (449058) (with title
2 amendment)
3
4 Between lines 755 and 756
5 insert:
6 Section 17. Subsection (11) of section 627.6131, Florida
7 Statutes, is amended to read:
8 627.6131 Payment of claims.—
9 (11) A health insurer may not retroactively deny a claim
10 because of insured ineligibility:
11 (a) At any time, if the health insurer verified the
12 eligibility of an insured at the time of treatment and provided
13 an authorization number. This paragraph applies to policies
14 entered into or renewed on or after January 1, 2018.
15 (b) More than 1 year after the date of payment of the
16 claim.
17 Section 18. Subsection (10) of section 641.3155, Florida
18 Statutes, is amended to read:
19 641.3155 Prompt payment of claims.—
20 (10) A health maintenance organization may not
21 retroactively deny a claim because of subscriber ineligibility:
22 (a) At any time, if the health maintenance organization
23 verified the eligibility of a subscriber at the time of
24 treatment and provided an authorization number. This paragraph
25 applies to contracts entered into or renewed on or after January
26 1, 2018. This paragraph does not apply to Medicaid managed care
27 plans pursuant to part IV of chapter 409.
28 (b) More than 1 year after the date of payment of the
29 claim.
30 Section 19. Section 627.42392, Florida Statutes, is amended
31 to read:
32 627.42392 Prior authorization.—
33 (1) As used in this section, the term:
34 (a) “Health insurer” means an authorized insurer offering
35 an individual or group insurance policy that provides major
36 medical or similar comprehensive coverage health insurance as
37 defined in s. 624.603, a managed care plan as defined in s.
38 409.962(10) s. 409.962(9), or a health maintenance organization
39 as defined in s. 641.19(12).
40 (b) “Urgent care situation” has the same meaning as in s.
41 627.42393.
42 (2) Notwithstanding any other provision of law, effective
43 January 1, 2017, or six (6) months after the effective date of
44 the rule adopting the prior authorization form, whichever is
45 later, a health insurer, or a pharmacy benefits manager on
46 behalf of the health insurer, which does not provide an
47 electronic prior authorization process for use by its contracted
48 providers, shall only use the prior authorization form that has
49 been approved by the Financial Services Commission for granting
50 a prior authorization for a medical procedure, course of
51 treatment, or prescription drug benefit. Such form may not
52 exceed two pages in length, excluding any instructions or
53 guiding documentation, and must include all clinical
54 documentation necessary for the health insurer to make a
55 decision. At a minimum, the form must include: (1) sufficient
56 patient information to identify the member, date of birth, full
57 name, and Health Plan ID number; (2) provider name, address and
58 phone number; (3) the medical procedure, course of treatment, or
59 prescription drug benefit being requested, including the medical
60 reason therefor, and all services tried and failed; (4) any
61 laboratory documentation required; and (5) an attestation that
62 all information provided is true and accurate. The form, whether
63 in electronic or paper format, may not require information that
64 is not necessary for the determination of medical necessity of,
65 or coverage for, the requested medical procedure, course of
66 treatment, or prescription drug.
67 (3) The Financial Services Commission in consultation with
68 the Agency for Health Care Administration shall adopt by rule
69 guidelines for all prior authorization forms which ensure the
70 general uniformity of such forms.
71 (4) Electronic prior authorization approvals do not
72 preclude benefit verification or medical review by the insurer
73 under either the medical or pharmacy benefits.
74 (5) A health insurer or a pharmacy benefits manager on
75 behalf of the health insurer must provide the following
76 information in writing or in an electronic format upon request,
77 and on a publicly accessible Internet website:
78 (a) Detailed descriptions of requirements and restrictions
79 to obtain prior authorization for coverage of a medical
80 procedure, course of treatment, or prescription drug in clear,
81 easily understandable language. Clinical criteria must be
82 described in language easily understandable by a health care
83 provider.
84 (b) Prior authorization forms.
85 (6) A health insurer or a pharmacy benefits manager on
86 behalf of the health insurer may not implement any new
87 requirements or restrictions or make changes to existing
88 requirements or restrictions to obtain prior authorization
89 unless:
90 (a) The changes have been available on a publicly
91 accessible Internet website at least 60 days before the
92 implementation of the changes.
93 (b) Policyholders and health care providers who are
94 affected by the new requirements and restrictions or changes to
95 the requirements and restrictions are provided with a written
96 notice of the changes at least 60 days before the changes are
97 implemented. Such notice may be delivered electronically or by
98 other means as agreed to by the insured or health care provider.
99
100 This subsection does not apply to expansion of health care
101 services coverage.
102 (7) A health insurer or a pharmacy benefits manager on
103 behalf of the health insurer must authorize or deny a prior
104 authorization request and notify the patient and the patient’s
105 treating health care provider of the decision within:
106 (a) Seventy-two hours of obtaining a completed prior
107 authorization form for nonurgent care situations.
108 (b) Twenty-four hours of obtaining a completed prior
109 authorization form for urgent care situations.
110 Section 20. Section 627.42393, Florida Statutes, is created
111 to read:
112 627.42393 Fail-first protocols.—
113 (1) As used in this section, the term:
114 (a) “Fail-first protocol” means a written protocol that
115 specifies the order in which a certain medical procedure, course
116 of treatment, or prescription drug must be used to treat an
117 insured’s condition.
118 (b) “Health insurer” has the same meaning as provided in s.
119 627.42392.
120 (c) “Preceding prescription drug or medical treatment”
121 means a medical procedure, course of treatment, or prescription
122 drug that must be used pursuant to a health insurer’s fail-first
123 protocol as a condition of coverage under a health insurance
124 policy or a health maintenance contract to treat an insured’s
125 condition.
126 (d) “Protocol exception” means a determination by a health
127 insurer that a fail-first protocol is not medically appropriate
128 or indicated for treatment of an insured’s condition and the
129 health insurer authorizes the use of another medical procedure,
130 course of treatment, or prescription drug prescribed or
131 recommended by the treating health care provider for the
132 insured’s condition.
133 (e) “Urgent care situation” means an injury or condition of
134 an insured which, if medical care and treatment is not provided
135 earlier than the time generally considered by the medical
136 profession to be reasonable for a nonurgent situation, in the
137 opinion of the insured’s treating physician, would:
138 1. Seriously jeopardize the insured’s life, health, or
139 ability to regain maximum function; or
140 2. Subject the insured to severe pain that cannot be
141 adequately managed.
142 (2) A health insurer must publish on its website, and
143 provide to an insured in writing, a procedure for an insured and
144 health care provider to request a protocol exception. The
145 procedure must include:
146 (a) A description of the manner in which an insured or
147 health care provider may request a protocol exception.
148 (b) The manner and timeframe in which the health insurer is
149 required to authorize or deny a protocol exception request or
150 respond to an appeal to a health insurer’s authorization or
151 denial of a request.
152 (c) The conditions in which the protocol exception request
153 must be granted.
154 (3)(a) The health insurer must authorize or deny a protocol
155 exception request or respond to an appeal to a health insurer’s
156 authorization or denial of a request within:
157 1. Seventy-two hours of obtaining a completed prior
158 authorization form for nonurgent care situations.
159 2. Twenty-four hours of obtaining a completed prior
160 authorization form for urgent care situations.
161 (b) An authorization of the request must specify the
162 approved medical procedure, course of treatment, or prescription
163 drug benefits.
164 (c) A denial of the request must include a detailed,
165 written explanation of the reason for the denial, the clinical
166 rationale that supports the denial, and the procedure to appeal
167 the health insurer’s determination.
168 (4) A health insurer must grant a protocol exception
169 request if:
170 (a) A preceding prescription drug or medical treatment is
171 contraindicated or will likely cause an adverse reaction or
172 physical or mental harm to the insured;
173 (b) A preceding prescription drug is expected to be
174 ineffective, based on the medical history of the insured and the
175 clinical evidence of the characteristics of the preceding
176 prescription drug or medical treatment;
177 (c) The insured has previously received a preceding
178 prescription drug or medical treatment that is in the same
179 pharmacologic class or has the same mechanism of action, and
180 such drug or treatment lacked efficacy or effectiveness or
181 adversely affected the insured; or
182 (d) A preceding prescription drug or medical treatment is
183 not in the best interest of the insured because the insured’s
184 use of such drug or treatment is expected to:
185 1. Cause a significant barrier to the insured’s adherence
186 to or compliance with the insured’s plan of care;
187 2. Worsen an insured’s medical condition that exists
188 simultaneously but independently with the condition under
189 treatment; or
190 3. Decrease the insured’s ability to achieve or maintain
191 his or her ability to perform daily activities.
192 (5) The health insurer may request a copy of relevant
193 documentation from the insured’s medical record in support of a
194 protocol exception request.
195
196 ================= T I T L E A M E N D M E N T ================
197 And the title is amended as follows:
198 Delete line 851
199 and insert:
200 under the code under certain circumstances; amending
201 s. 627.6131, F.S.; prohibiting a health insurer from
202 retroactively denying a claim under specified
203 circumstances; providing applicability; amending s.
204 641.3155, F.S.; prohibiting a health maintenance
205 organization from retroactively denying a claim under
206 specified circumstances; providing applicability;
207 exempting certain Medicaid managed care plans;
208 amending s. 627.42392, F.S.; revising and providing
209 definitions; revising criteria for prior authorization
210 forms; requiring health insurers and pharmacy benefits
211 managers on behalf of health insurers to provide
212 certain information relating to prior authorization in
213 a specified manner; prohibiting such insurers and
214 pharmacy benefits managers from implementing or making
215 changes to requirements or restrictions to obtain
216 prior authorization, except under certain
217 circumstances; providing applicability; requiring such
218 insurers and pharmacy benefits managers to authorize
219 or deny prior authorization requests and provide
220 certain notices within specified timeframes; creating
221 s. 627.42393, F.S.; providing definitions; requiring
222 health insurers to publish on their websites and
223 provide in writing to insureds a specified procedure
224 to obtain protocol exceptions; specifying timeframes
225 in which health insurers must authorize or deny
226 protocol exception requests and respond to an appeal
227 to a health insurer’s authorization or denial of a
228 request; requiring authorizations or denials to
229 specify certain information; providing circumstances
230 in which health insurers must grant a protocol
231 exception request; authorizing health insurers to
232 request documentation in support of a protocol
233 exception request; providing