Bill Text: FL S0530 | 2017 | Regular Session | Comm Sub

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Bill Title: Health Insurer Authorization

Spectrum:

Status: (Failed) 2017-05-05 - Died in Messages [S0530 Detail]

Download: Florida-2017-S0530-Comm_Sub.html

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       Florida Senate - 2017                              CS for SB 530
       
       
        
       By the Committee on Banking and Insurance; and Senator Steube
       
       
       
       
       
       597-02949-17                                           2017530c1
    1                        A bill to be entitled                      
    2         An act relating to health insurer authorization;
    3         amending s. 627.42392, F.S.; revising and providing
    4         definitions; revising criteria for prior authorization
    5         forms; requiring health insurers and pharmacy benefits
    6         managers on behalf of health insurers to provide
    7         certain information relating to prior authorization in
    8         a specified manner; prohibiting such insurers and
    9         pharmacy benefits managers from implementing or making
   10         changes to requirements or restrictions to obtain
   11         prior authorization, except under certain
   12         circumstances; providing applicability; requiring such
   13         insurers or pharmacy benefits managers to authorize or
   14         deny prior authorization requests and provide certain
   15         notices within specified timeframes; creating s.
   16         627.42393, F.S.; providing definitions; requiring
   17         health insurers to publish on their websites and
   18         provide in writing to insureds a specified procedure
   19         to obtain protocol exceptions; specifying timeframes
   20         in which health insurers must authorize or deny
   21         protocol exception requests and respond to an appeal
   22         to a health insurer’s authorization or denial of a
   23         request; requiring authorizations or denials to
   24         specify certain information; providing circumstances
   25         in which health insurers must grant a protocol
   26         exception request; authorizing health insurers to
   27         request documentation in support of a protocol
   28         exception request; 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  an individual or group insurance policy that provides major
   38  medical or similar comprehensive coverage health insurance as
   39  defined in s. 624.603, a managed care plan as defined in s.
   40  409.962(10) s. 409.962(9), or a health maintenance organization
   41  as defined in s. 641.19(12).
   42         (b) “Urgent care situation” has the same meaning as in s.
   43  627.42393.
   44         (2) Notwithstanding any other provision of law, effective
   45  January 1, 2017, or six (6) months after the effective date of
   46  the rule adopting the prior authorization form, whichever is
   47  later, a health insurer, or a pharmacy benefits manager on
   48  behalf of the health insurer, which does not provide an
   49  electronic prior authorization process for use by its contracted
   50  providers, shall only use the prior authorization form that has
   51  been approved by the Financial Services Commission for granting
   52  a prior authorization for a medical procedure, course of
   53  treatment, or prescription drug benefit. Such form may not
   54  exceed two pages in length, excluding any instructions or
   55  guiding documentation, and must include all clinical
   56  documentation necessary for the health insurer to make a
   57  decision. At a minimum, the form must include: (1) sufficient
   58  patient information to identify the member, date of birth, full
   59  name, and Health Plan ID number; (2) provider name, address and
   60  phone number; (3) the medical procedure, course of treatment, or
   61  prescription drug benefit being requested, including the medical
   62  reason therefor, and all services tried and failed; (4) any
   63  laboratory documentation required; and (5) an attestation that
   64  all information provided is true and accurate. The form, whether
   65  in electronic or paper format, may not require information that
   66  is not necessary for the determination of medical necessity of,
   67  or coverage for, the requested medical procedure, course of
   68  treatment, or prescription drug.
   69         (3) The Financial Services Commission in consultation with
   70  the Agency for Health Care Administration shall adopt by rule
   71  guidelines for all prior authorization forms which ensure the
   72  general uniformity of such forms.
   73         (4) Electronic prior authorization approvals do not
   74  preclude benefit verification or medical review by the insurer
   75  under either the medical or pharmacy benefits.
   76         (5) A health insurer or a pharmacy benefits manager on
   77  behalf of the health insurer must provide the following
   78  information in writing or in an electronic format upon request,
   79  and on a publicly accessible Internet website:
   80         (a) Detailed descriptions of requirements and restrictions
   81  to obtain prior authorization for coverage of a medical
   82  procedure, course of treatment, or prescription drug in clear,
   83  easily understandable language. Clinical criteria must be
   84  described in language easily understandable by a health care
   85  provider.
   86         (b) Prior authorization forms.
   87         (6) A health insurer or a pharmacy benefits manager on
   88  behalf of the health insurer may not implement any new
   89  requirements or restrictions or make changes to existing
   90  requirements or restrictions to obtain prior authorization
   91  unless:
   92         (a) The changes have been available on a publicly
   93  accessible Internet website at least 60 days before the
   94  implementation of the changes.
   95         (b) Policyholders and health care providers who are
   96  affected by the new requirements and restrictions or changes to
   97  the requirements and restrictions are provided with a written
   98  notice of the changes at least 60 days before the changes are
   99  implemented. Such notice may be delivered electronically or by
  100  other means as agreed to by the insured or health care provider.
  101  
  102  This subsection does not apply to expansion of health care
  103  services coverage.
  104         (7) A health insurer or a pharmacy benefits manager on
  105  behalf of the health insurer must authorize or deny a prior
  106  authorization request and notify the patient and the patient’s
  107  treating health care provider of the decision within:
  108         (a) Seventy-two hours of obtaining a completed prior
  109  authorization form for nonurgent care situations.
  110         (b) Twenty-four hours of obtaining a completed prior
  111  authorization form for urgent care situations.
  112         Section 2. Section 627.42393, Florida Statutes, is created
  113  to read:
  114         627.42393 Fail-first protocols.—
  115         (1) As used in this section, the term:
  116         (a) “Fail-first protocol” means a written protocol that
  117  specifies the order in which a certain medical procedure, course
  118  of treatment, or prescription drug must be used to treat an
  119  insured’s condition.
  120         (b) “Health insurer” has the same meaning as provided in s.
  121  627.42392.
  122         (c) “Preceding prescription drug or medical treatment”
  123  means a medical procedure, course of treatment, or prescription
  124  drug that must be used pursuant to a health insurer’s fail-first
  125  protocol as a condition of coverage under a health insurance
  126  policy or a health maintenance contract to treat an insured’s
  127  condition.
  128         (d) “Protocol exception” means a determination by a health
  129  insurer that a fail-first protocol is not medically appropriate
  130  or indicated for treatment of an insured’s condition and the
  131  health insurer authorizes the use of another medical procedure,
  132  course of treatment, or prescription drug prescribed or
  133  recommended by the treating health care provider for the
  134  insured’s condition.
  135         (e) “Urgent care situation” means an injury or condition of
  136  an insured which, if medical care and treatment is not provided
  137  earlier than the time generally considered by the medical
  138  profession to be reasonable for a nonurgent situation, in the
  139  opinion of the insured’s treating physician, would:
  140         1. Seriously jeopardize the insured’s life, health, or
  141  ability to regain maximum function; or
  142         2. Subject the insured to severe pain that cannot be
  143  adequately managed.
  144         (2) A health insurer must publish on its website, and
  145  provide to an insured in writing, a procedure for an insured and
  146  health care provider to request a protocol exception. The
  147  procedure must include:
  148         (a) A description of the manner in which an insured or
  149  health care provider may request a protocol exception.
  150         (b) The manner and timeframe in which the health insurer is
  151  required to authorize or deny a protocol exception request or
  152  respond to an appeal to a health insurer’s authorization or
  153  denial of a request.
  154         (c) The conditions in which the protocol exception request
  155  must be granted.
  156         (3)(a) The health insurer must authorize or deny a protocol
  157  exception request or respond to an appeal to a health insurer’s
  158  authorization or denial of a request within:
  159         1. Seventy-two hours of obtaining a completed prior
  160  authorization form for nonurgent care situations.
  161         2. Twenty-four hours of obtaining a completed prior
  162  authorization form for urgent care situations.
  163         (b) An authorization of the request must specify the
  164  approved medical procedure, course of treatment, or prescription
  165  drug benefits.
  166         (c) A denial of the request must include a detailed,
  167  written explanation of the reason for the denial, the clinical
  168  rationale that supports the denial, and the procedure to appeal
  169  the health insurer’s determination.
  170         (4) A health insurer must grant a protocol exception
  171  request if:
  172         (a) A preceding prescription drug or medical treatment is
  173  contraindicated or will likely cause an adverse reaction or
  174  physical or mental harm to the insured;
  175         (b) A preceding prescription drug is expected to be
  176  ineffective, based on the medical history of the insured and the
  177  clinical evidence of the characteristics of the preceding
  178  prescription drug or medical treatment;
  179         (c) The insured has previously received a preceding
  180  prescription drug or medical treatment that is in the same
  181  pharmacologic class or has the same mechanism of action, and
  182  such drug or treatment lacked efficacy or effectiveness or
  183  adversely affected the insured; or
  184         (d) A preceding prescription drug or medical treatment is
  185  not in the best interest of the insured because the insured’s
  186  use of such drug or treatment is expected to:
  187         1. Cause a significant barrier to the insured’s adherence
  188  to or compliance with the insured’s plan of care;
  189         2. Worsen an insured’s medical condition that exists
  190  simultaneously but independently with the condition under
  191  treatment; or
  192         3. Decrease the insured’s ability to achieve or maintain
  193  his or her ability to perform daily activities.
  194         (5) The health insurer may request a copy of relevant
  195  documentation from the insured’s medical record in support of a
  196  protocol exception request.
  197         Section 3. This act shall take effect July 1, 2017.