Florida Senate - 2021 SB 1846
By Senator Polsky
29-01491-21 20211846__
1 A bill to be entitled
2 An act relating to health insurance prior
3 authorization; amending s. 627.42392, F.S.; defining
4 the terms “pharmacy benefit manager” and “urgent
5 health care service”; requiring health insurers and
6 pharmacy benefit managers to establish an online
7 electronic prior authorization process by a certain
8 date; specifying requirements for, and restrictions
9 on, such online electronic prior authorization
10 process; requiring all prior authorization requests to
11 health insurers and pharmacy benefit managers to be
12 made using such online electronic prior authorization
13 process by a certain date; deleting provisions
14 requiring prior authorization forms to be approved by
15 the Financial Services Commission under certain
16 circumstances; specifying requirements for, and
17 restrictions on, health insurers and pharmacy benefit
18 managers relating to prior authorization information,
19 requirements, restrictions, and changes; providing
20 applicability; specifying timeframes within which
21 prior authorization requests must be authorized or
22 denied and the patient and the patient’s provider must
23 be notified; amending ss. 627.6131 and 641.3156, F.S.;
24 prohibiting health insurers and health maintenance
25 organizations, respectively, from imposing an
26 additional prior authorization requirement with
27 respect to certain surgical or invasive procedures or
28 certain items; providing an effective date.
29
30 Be It Enacted by the Legislature of the State of Florida:
31
32 Section 1. Section 627.42392, Florida Statutes, is amended
33 to read:
34 627.42392 Prior authorization.—
35 (1) As used in this section, the term:
36 (a) “Health insurer” means an authorized insurer offering
37 health insurance as defined in s. 624.603, a managed care plan
38 as defined in s. 409.962(10), or a health maintenance
39 organization as defined in s. 641.19(12).
40 (b) “Pharmacy benefit manager” has the same meaning as
41 provided in s. 624.490.
42 (c) “Urgent health care service” means a health care
43 service that, if not provided earlier than the time the medical
44 profession generally considers reasonable for making a nonurgent
45 prior authorization, in the opinion of a physician with
46 knowledge of the patient’s medical condition, could:
47 1. Seriously jeopardize the life or health of the patient
48 or the ability of the patient to regain maximum function; or
49 2. Subject the patient to severe pain that cannot be
50 adequately managed without the care or treatment that is the
51 subject of the prior authorization request.
52 (2) Beginning January 1, 2022, a health insurer, or a
53 pharmacy benefit manager on behalf of the health insurer, must
54 establish and offer a secure, interactive online electronic
55 prior authorization process for accepting electronic prior
56 authorization requests. The process must allow a person seeking
57 the prior authorization to upload documentation if such
58 documentation is required by the health insurer or pharmacy
59 benefit manager to adjudicate the prior authorization request.
60 The electronic prior authorization process may not include
61 transmissions through a facsimile machine.
62 (3) Beginning January 1, 2022, all prior authorization
63 requests to a health insurer or to a pharmacy benefit manager by
64 a health care provider for medical procedures, surgical
65 procedures, prescription drugs, or any other medical service
66 must be made using the interactive online prior authorization
67 process required in subsection (2).
68 (2) Notwithstanding any other provision of law, effective
69 January 1, 2017, or six (6) months after the effective date of
70 the rule adopting the prior authorization form, whichever is
71 later, a health insurer, or a pharmacy benefits manager on
72 behalf of the health insurer, which does not provide an
73 electronic prior authorization process for use by its contracted
74 providers, shall only use the prior authorization form that has
75 been approved by the Financial Services Commission for granting
76 a prior authorization for a medical procedure, course of
77 treatment, or prescription drug benefit. Such form may not
78 exceed two pages in length, excluding any instructions or
79 guiding documentation, and must include all clinical
80 documentation necessary for the health insurer to make a
81 decision. At a minimum, the form must include: (1) sufficient
82 patient information to identify the member, date of birth, full
83 name, and Health Plan ID number; (2) provider name, address and
84 phone number; (3) the medical procedure, course of treatment, or
85 prescription drug benefit being requested, including the medical
86 reason therefor, and all services tried and failed; (4) any
87 laboratory documentation required; and (5) an attestation that
88 all information provided is true and accurate.
89 (3) The Financial Services Commission in consultation with
90 the Agency for Health Care Administration shall adopt by rule
91 guidelines for all prior authorization forms which ensure the
92 general uniformity of such forms.
93 (4) Electronic prior authorization approvals do not
94 preclude benefit verification or medical review by the insurer
95 under either the medical or pharmacy benefits.
96 (5) The prior authorization process may not require
97 information that is not needed to make a determination or
98 facilitate a determination of medical necessity of the requested
99 medical procedure, course of treatment, or prescription drug
100 benefit.
101 (6) A health insurer, or a pharmacy benefit manager on
102 behalf of the health insurer, shall make any current prior
103 authorization requirements and restrictions readily accessible
104 on its website.
105 (7) A health insurer, or a pharmacy benefit manager on
106 behalf of the health insurer, may not implement any new
107 requirements or restrictions or make changes to existing
108 requirements for or restrictions on obtaining prior
109 authorization unless:
110 (a) The changes have been available on a publicly
111 accessible website for at least 60 days before they are
112 implemented; and
113 (b) Policyholders and health care providers who are
114 affected by the new requirements and restrictions or changes to
115 the requirements and restrictions are provided with a written
116 notice of the changes at least 60 days before they are
117 implemented. Such notice must be delivered electronically or by
118 other means as agreed to by the insured or the health care
119 provider.
120
121 This subsection does not apply to the expansion of health care
122 services coverage.
123 (8) A health insurer, or a pharmacy benefit manager on
124 behalf of the health insurer, must authorize or deny a prior
125 authorization request and notify the patient and the patient’s
126 treating health care provider of the decision within:
127 (a) Three calendar days after receiving all necessary
128 information to make the decision on the prior authorization
129 request for nonurgent care situations.
130 (b) Twenty-four hours after receiving all necessary
131 information to make the decision on the prior authorization
132 request for urgent care situations.
133 Section 2. Subsection (20) is added to section 627.6131,
134 Florida Statutes, to read:
135 627.6131 Payment of claims.—
136 (20) A health insurer may not impose an additional prior
137 authorization requirement with respect to a surgical or
138 otherwise invasive procedure, or any item furnished as part of
139 the surgical or invasive procedure, if the procedure or item is
140 furnished during the perioperative period of another procedure
141 for which prior authorization was granted by the health insurer.
142 Section 3. Subsection (4) is added to section 641.3156,
143 Florida Statutes, to read:
144 641.3156 Treatment authorization; payment of claims.—
145 (4) A health maintenance organization may not impose an
146 additional prior authorization requirement with respect to a
147 surgical or otherwise invasive procedure, or any item furnished
148 as part of the surgical or invasive procedure, if the procedure
149 or item is furnished during the perioperative period of another
150 procedure for which prior authorization was granted by the
151 health maintenance organization.
152 Section 4. This act shall take effect July 1, 2021.