Bill Text: FL S0650 | 2019 | Regular Session | Introduced


Bill Title: Health Insurer Authorization

Spectrum: Partisan Bill (Republican 1-0)

Status: (Failed) 2019-05-03 - Died in Banking and Insurance [S0650 Detail]

Download: Florida-2019-S0650-Introduced.html
       Florida Senate - 2019                                     SB 650
       
       
        
       By Senator Mayfield
       
       
       
       
       
       17-00769-19                                            2019650__
    1                        A bill to be entitled                      
    2         An act relating to health insurer authorization;
    3         amending s. 627.42392, F.S.; redefining the term
    4         “health insurer” and defining the term “urgent care
    5         situation”; providing that prior authorization forms
    6         may not require certain information; authorizing the
    7         Financial Services Commission to adopt certain rules;
    8         requiring health insurers and pharmacy benefits
    9         managers on behalf of health insurers to provide, by
   10         specified means, certain information relating to prior
   11         authorization; prohibiting such insurers and pharmacy
   12         benefits managers from implementing or making changes
   13         to requirements or restrictions to obtain prior
   14         authorization, except under certain circumstances;
   15         providing applicability; requiring such insurers and
   16         pharmacy benefits managers to authorize or deny prior
   17         authorization requests and provide certain notices
   18         within specified timeframes; creating s. 627.42393,
   19         F.S.; defining terms; requiring health insurers to
   20         publish on their websites and provide to insureds in
   21         writing a procedure for insureds and health care
   22         providers to request protocol exceptions; specifying
   23         requirements for such a procedure; requiring health
   24         insurers, within specified timeframes, to authorize or
   25         deny a protocol exception request or respond to
   26         appeals of such authorizations or denials; requiring
   27         that authorizations or denials specify certain
   28         information; requiring health insurers to grant
   29         protocol exception requests under certain
   30         circumstances; authorizing health insurers to request
   31         documentation in support of a protocol exception
   32         request; providing an effective date.
   33          
   34  Be It Enacted by the Legislature of the State of Florida:
   35  
   36         Section 1. Section 627.42392, Florida Statutes, is amended
   37  to read:
   38         627.42392 Prior authorization.—
   39         (1) As used in this section, the term:
   40         (a) “Health insurer” means an authorized insurer offering
   41  an individual or a group health insurance policy that provides
   42  major medical or similar comprehensive coverage health insurance
   43  as defined in s. 624.603, a managed care plan as defined in s.
   44  409.962(10), or a health maintenance organization as defined in
   45  s. 641.19(12).
   46         (b)“Urgent care situation” has the same meaning as in s.
   47  627.42393.
   48         (2) Notwithstanding any other provision of law, effective
   49  January 1, 2017, or six (6) months after the effective date of
   50  the rule adopting the prior authorization form, whichever is
   51  later, a health insurer, or a pharmacy benefits manager on
   52  behalf of the health insurer, which does not provide an
   53  electronic prior authorization process for use by its contracted
   54  providers, shall only use the prior authorization form that has
   55  been approved by the Financial Services Commission for granting
   56  a prior authorization for a medical procedure, course of
   57  treatment, or prescription drug benefit. Such form may not
   58  exceed two pages in length, excluding any instructions or
   59  guiding documentation, and must include all clinical
   60  documentation necessary for the health insurer to make a
   61  decision. At a minimum, the form must include: (1) sufficient
   62  patient information to identify the member, date of birth, full
   63  name, and Health Plan ID number; (2) provider name, address and
   64  phone number; (3) the medical procedure, course of treatment, or
   65  prescription drug benefit being requested, including the medical
   66  reason therefor, and all services tried and failed; (4) any
   67  laboratory documentation required; and (5) an attestation that
   68  all information provided is true and accurate. The form, whether
   69  in electronic or paper format, may not require information that
   70  is not necessary for the determination of medical necessity of,
   71  or coverage for, the requested medical procedure, course of
   72  treatment, or prescription drug. The commission may adopt rules
   73  prescribing such necessary information.
   74         (3) The Financial Services Commission in consultation with
   75  the Agency for Health Care Administration shall adopt by rule
   76  guidelines for all prior authorization forms which ensure the
   77  general uniformity of such forms.
   78         (4) Electronic prior authorization approvals do not
   79  preclude benefit verification or medical review by the insurer
   80  under either the medical or pharmacy benefits.
   81         (5)A health insurer, or a pharmacy benefits manager on
   82  behalf of the health insurer, shall provide the following
   83  information in writing or in an electronic format, upon request,
   84  and on a publicly accessible Internet website:
   85         (a)Detailed descriptions, in clear, easily understandable
   86  language, of the requirements for and restrictions on obtaining
   87  prior authorization for coverage of a medical procedure, course
   88  of treatment, or prescription drug. Clinical criteria must be
   89  described in language easily understandable by a health care
   90  provider.
   91         (b)Prior authorization forms.
   92         (6)A health insurer, or a pharmacy benefits manager on
   93  behalf of the health insurer, may not implement any new
   94  requirements or restrictions or make changes to existing
   95  requirements or restrictions to obtain prior authorization
   96  unless:
   97         (a)The changes have been available on a publicly
   98  accessible Internet website for at least 60 days before the
   99  implementation of the changes.
  100         (b)Policyholders and health care providers who are
  101  affected by the new requirements and restrictions or changes to
  102  the requirements and restrictions are provided with a written
  103  notice of the changes at least 60 days before the changes are
  104  implemented. Such notice may be delivered electronically or by
  105  other means as agreed to by the insured or the health care
  106  provider.
  107  
  108  This subsection does not apply to the expansion of health care
  109  services coverage.
  110         (7)A health insurer, or a pharmacy benefits manager on
  111  behalf of the health insurer, shall authorize or deny a prior
  112  authorization request and notify the patient and the patient’s
  113  treating health care provider of the decision within:
  114         (a)Seventy-two hours after obtaining a completed prior
  115  authorization form for nonurgent care situations.
  116         (b)Twenty-four hours after obtaining a completed prior
  117  authorization form for urgent care situations.
  118         Section 2. Section 627.42393, Florida Statutes, is created
  119  to read:
  120         627.42393Fail-first protocols.—
  121         (1)As used in this section, the term:
  122         (a)“Fail-first protocol” means a written protocol that
  123  specifies the order in which a certain medical procedure, course
  124  of treatment, or prescription drug must be used to treat an
  125  insured’s condition.
  126         (b)“Health insurer” has the same meaning as provided in s.
  127  627.42392.
  128         (c)“Preceding prescription drug or medical treatment”
  129  means a medical procedure, course of treatment, or prescription
  130  drug that must be used pursuant to a health insurer’s fail-first
  131  protocol as a condition of coverage under a health insurance
  132  policy or a health maintenance contract to treat an insured’s
  133  condition.
  134         (d)“Protocol exception” means a determination by a health
  135  insurer that a fail-first protocol is not medically appropriate
  136  or indicated for treatment of an insured’s condition and the
  137  health insurer authorizes the use of another medical procedure,
  138  course of treatment, or prescription drug prescribed or
  139  recommended by the treating health care provider for the
  140  insured’s condition.
  141         (e)“Urgent care situation” means an injury or condition of
  142  an insured which, if medical care and treatment were not
  143  provided earlier than the time generally considered by the
  144  medical profession to be reasonable for a nonurgent situation,
  145  in the opinion of the insured’s treating physician, physician
  146  assistant, or advanced practice registered nurse, would:
  147         1.Seriously jeopardize the insured’s life, health, or
  148  ability to regain maximum function; or
  149         2.Subject the insured to severe pain that cannot be
  150  adequately managed.
  151         (2)A health insurer shall publish on its website and
  152  provide to an insured in writing a procedure for an insured and
  153  a health care provider to request a protocol exception. The
  154  procedure must include:
  155         (a)A description of the manner in which an insured or
  156  health care provider may request a protocol exception.
  157         (b)The manner and timeframe in which the health insurer is
  158  required to authorize or deny a protocol exception request or to
  159  respond to an appeal of a health insurer’s authorization or
  160  denial of a request.
  161         (c)The conditions under which the protocol exception
  162  request must be granted.
  163         (3)(a)The health insurer shall authorize or deny a
  164  protocol exception request or respond to an appeal of a health
  165  insurer’s authorization or denial of a request within:
  166         1.Seventy-two hours after obtaining a completed prior
  167  authorization form for nonurgent care situations.
  168         2.Twenty-four hours after obtaining a completed prior
  169  authorization form for urgent care situations.
  170         (b)An authorization of the request must specify the
  171  approved medical procedure, course of treatment, or prescription
  172  drug benefits.
  173         (c)A denial of the request must include a detailed,
  174  written explanation of the reason for the denial, the clinical
  175  rationale that supports the denial, and the procedure for
  176  appealing the health insurer’s determination.
  177         (4)A health insurer shall grant a protocol exception
  178  request if any of the following applies:
  179         (a)A preceding prescription drug or medical treatment is
  180  contraindicated or will likely cause an adverse reaction or
  181  physical or mental harm to the insured.
  182         (b)A preceding prescription drug is expected to be
  183  ineffective, based on the medical history of the insured and the
  184  clinical evidence of the characteristics of the preceding
  185  prescription drug or medical treatment.
  186         (c)The insured has previously received a preceding
  187  prescription drug or medical treatment that is in the same
  188  pharmacologic class or has the same mechanism of action, and
  189  such drug or treatment lacked efficacy or effectiveness or
  190  adversely affected the insured.
  191         (d) A preceding prescription drug or medical treatment is
  192  not in the best interest of the insured because the insured’s
  193  use of such drug or treatment is expected to:
  194         1. Cause a significant barrier to the insured’s adherence
  195  to or compliance with the insured’s plan of care;
  196         2. Worsen an insured’s medical condition that exists
  197  simultaneously but independently with the condition under
  198  treatment; or
  199         3. Decrease the insured’s ability to achieve or maintain
  200  his or her ability to perform daily activities.
  201         (e) A preceding prescription drug is an opioid, and the
  202  protocol exception request is for a nonopioid prescription drug
  203  or treatment with a likelihood of similar or better results.
  204         (5)The health insurer may request a copy of relevant
  205  documentation from the insured’s medical record in support of a
  206  protocol exception request.
  207         Section 3. This act shall take effect January 1, 2020.

feedback