Bill Amendment: FL H0573 | 2014 | Regular Session
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: Health of Residents
Status: 2014-05-02 - Died on Calendar [H0573 Detail]
Download: Florida-2014-H0573-Senate_Floor_Amendment_305092.html
Bill Title: Health of Residents
Status: 2014-05-02 - Died on Calendar [H0573 Detail]
Download: Florida-2014-H0573-Senate_Floor_Amendment_305092.html
Florida Senate - 2014 SENATOR AMENDMENT Bill No. CS/CS/CS/HB 573, 2nd Eng. Ì305092ÂÎ305092 LEGISLATIVE ACTION Senate . House . . . Floor: 3/WD/2R . 05/01/2014 02:25 PM . ————————————————————————————————————————————————————————————————— ————————————————————————————————————————————————————————————————— Senator Grimsley moved the following: 1 Senate Amendment (with title amendment) 2 3 Between lines 2694 and 2695 4 insert: 5 Section 48. Paragraph (c) of subsection (2) of section 6 409.967, Florida Statutes, is amended to read: 7 409.967 Managed care plan accountability.— 8 (2) The agency shall establish such contract requirements 9 as are necessary for the operation of the statewide managed care 10 program. In addition to any other provisions the agency may deem 11 necessary, the contract must require: 12 (c) Access.— 13 1. The agency shall establish specific standards for the 14 number, type, and regional distribution of providers in managed 15 care plan networks to ensure access to care for both adults and 16 children. Each plan must maintain a regionwide network of 17 providers in sufficient numbers to meet the access standards for 18 specific medical services for all recipients enrolled in the 19 plan. The exclusive use of mail-order pharmacies may not be 20 sufficient to meet network access standards. Consistent with the 21 standards established by the agency, provider networks may 22 include providers located outside the region. A plan may 23 contract with a new hospital facility before the date the 24 hospital becomes operational if the hospital has commenced 25 construction, will be licensed and operational by January 1, 26 2013, and a final order has issued in any civil or 27 administrative challenge. Each plan shall establish and maintain 28 an accurate and complete electronic database of contracted 29 providers, including information about licensure or 30 registration, locations and hours of operation, specialty 31 credentials and other certifications, specific performance 32 indicators, and such other information as the agency deems 33 necessary. The database must be available online toboththe 34 agency and the public and have the capability of comparingto35comparethe availability of providers to network adequacy 36 standards and to accept and display feedback from each 37 provider’s patients. Each plan shall submit quarterly reports to 38 the agency identifying the number of enrollees assigned to each 39 primary care provider. 40 2. If establishing a prescribed drug formulary or preferred 41 drug list, a managed care plan shall: 42 a. Provide a broad range of therapeutic options for the 43 treatment of disease states which are consistent with the 44 general needs of an outpatient population. If feasible, the 45 formulary or preferred drug list must include at least two 46 products in a therapeutic class. 47 b.Each managed care plan mustPublish theanyprescribed 48 drug formulary or preferred drug list on the plan’s website in a 49 manner that is accessible to and searchable by enrollees and 50 providers. The plan shallmustupdate the list within 24 hours 51 after making a change.Each plan must ensure that the prior52authorization process for prescribed drugs is readily accessible53to health care providers, including posting appropriate contact54information on its website and providing timely responses to55providers.56 3. For enrolleesMedicaid recipientsdiagnosed with 57 hemophilia who have been prescribed anti-hemophilic-factor 58 replacement products, the agency shall provide for those 59 products and hemophilia overlay services through the agency’s 60 hemophilia disease management program. 613. Managed care plans, and their fiscal agents or62intermediaries, must accept prior authorization requests for any63service electronically.64 4. Notwithstanding any other law, in order to establish 65 uniformity in the submission of prior authorization forms, 66 effective January 1, 2015, a managed care plan shall use a 67 single standardized form for obtaining prior authorization for a 68 medical procedure, course of treatment, or prescription drug 69 benefit. The form may not exceed two pages in length, excluding 70 any instructions or guiding documentation. 71 a. The managed care plan shall make the form available 72 electronically and online to practitioners. The prescribing 73 provider may electronically submit the completed prior 74 authorization form to the managed care plan. 75 b. If the managed care plan contracts with a pharmacy 76 benefits manager to perform prior authorization services for a 77 medical procedure, course of treatment, or prescription drug 78 benefit, the pharmacy benefits manager must use and accept the 79 standardized prior authorization form. 80 c. A completed prior authorization request submitted by a 81 health care provider using the standardized prior authorization 82 form is deemed approved upon receipt by the managed care plan 83 unless the managed care plan responds otherwise within 3 84 business days. 85 5. If medications for the treatment of a medical condition 86 are restricted for use by a managed care plan by a step-therapy 87 or fail-first protocol, the prescribing provider must have 88 access to a clear and convenient process to request an override 89 of the protocol from the managed care plan. 90 a. The managed care plan shall grant an override within 72 91 hours if the prescribing provider documents that: 92 (I) Based on sound clinical evidence, the preferred 93 treatment required under the step-therapy or fail-first protocol 94 has been ineffective in the treatment of the enrollee’s disease 95 or medical condition; or 96 (II) Based on sound clinical evidence or medical and 97 scientific evidence, the preferred treatment required under the 98 step-therapy or fail-first protocol: 99 (A) Is expected or is likely to be ineffective based on 100 known relevant physical or mental characteristics of the 101 enrollee and known characteristics of the drug regimen; or 102 (B) Will cause or will likely cause an adverse reaction or 103 other physical harm to the enrollee. 104 b. If the prescribing provider allows the enrollee to enter 105 the step-therapy or fail-first protocol recommended by the 106 managed care plan, the duration of the step-therapy or fail 107 first protocol may not exceed the customary period for use of 108 the medication if the prescribing provider demonstrates such 109 treatment to be clinically ineffective. If the managed care plan 110 can, through sound clinical evidence, demonstrate that the 111 originally prescribed medication is likely to require more than 112 the customary period to provide any relief or amelioration to 113 the enrollee, the step-therapy or fail-first protocol may be 114 extended for an additional period, but no longer than the 115 original customary period for use of the medication. 116 Notwithstanding this provision, a step-therapy or fail-first 117 protocol shall be terminated if the prescribing provider 118 determines that the enrollee is having an adverse reaction or is 119 suffering from other physical harm resulting from the use of the 120 medication. 121 Section 49. Section 627.42392, Florida Statutes, is created 122 to read: 123 627.42392 Prior authorization.— 124 (1) Notwithstanding any other law, in order to establish 125 uniformity in the submission of prior authorization forms, 126 effective January 1, 2015, a health insurer that delivers, 127 issues for delivery, renews, amends, or continues an individual 128 or group health insurance policy in this state, including a 129 policy issued to a small employer as defined in s. 627.6699, 130 shall use a single standardized form for obtaining prior 131 authorization for a medical procedure, course of treatment, or 132 prescription drug benefit. The form may not exceed two pages in 133 length, excluding any instructions or guiding documentation. 134 (a) The health insurer shall make the form available 135 electronically and online to practitioners. The prescribing 136 provider may submit the completed prior authorization form 137 electronically to the health insurer. 138 (b) If the health insurer contracts with a pharmacy 139 benefits manager to perform prior authorization services for a 140 medical procedure, course of treatment, or prescription drug 141 benefit, the pharmacy benefits manager must use and accept the 142 standardized prior authorization form. 143 (c) A completed prior authorization request submitted by a 144 health care provider using the standardized prior authorization 145 form is deemed approved upon receipt by the health insurer 146 unless the health insurer responds otherwise within 3 business 147 days. 148 (2) This section does not apply to a grandfathered health 149 plan as defined in s. 627.402. 150 Section 50. Section 627.42393, Florida Statutes, is created 151 to read: 152 627.42393 Medication protocol override.—If an individual or 153 group health insurance policy, including a policy issued by a 154 small employer as defined in s. 627.6699, restricts medications 155 for the treatment of a medical condition by a step-therapy or 156 fail-first protocol, the prescribing provider must have access 157 to a clear and convenient process to request an override of the 158 protocol from the health insurer. 159 (1) The health insurer shall authorize an override of the 160 protocol within 72 hours if the prescribing provider documents 161 that: 162 (a) Based on sound clinical evidence, the preferred 163 treatment required under the step-therapy or fail-first protocol 164 has been ineffective in the treatment of the insured’s disease 165 or medical condition; or 166 (b) Based on sound clinical evidence or medical and 167 scientific evidence, the preferred treatment required under the 168 step-therapy or fail-first protocol: 169 1. Is expected or is likely to be ineffective based on 170 known relevant physical or mental characteristics of the insured 171 and known characteristics of the drug regimen; or 172 2. Will cause or is likely to cause an adverse reaction or 173 other physical harm to the insured. 174 (2) If the prescribing provider allows the insured to enter 175 the step-therapy or fail-first protocol recommended by the 176 health insurer, the duration of the step-therapy or fail-first 177 protocol may not exceed the customary period for use of the 178 medication if the prescribing provider demonstrates such 179 treatment to be clinically ineffective. If the health insurer 180 can, through sound clinical evidence, demonstrate that the 181 originally prescribed medication is likely to require more than 182 the customary period for such medication to provide any relief 183 or amelioration to the insured, the step-therapy or fail-first 184 protocol may be extended for an additional period of time, but 185 no longer than the original customary period for the medication. 186 Notwithstanding this provision, a step-therapy or fail-first 187 protocol shall be terminated if the prescribing provider 188 determines that the insured is having an adverse reaction or is 189 suffering from other physical harm resulting from the use of the 190 medication. 191 (3) This section does not apply to grandfathered health 192 plans, as defined in s. 627.402. 193 Section 51. Subsection (11) of section 627.6131, Florida 194 Statutes, is amended to read: 195 627.6131 Payment of claims.— 196 (11) A health insurer may not retroactively deny a claim 197 because of insured ineligibility: 198 (a) More than 1 year after the date of payment of the 199 claim; or 200 (b) If, under a policy compliant with the federal Patient 201 Protection and Affordable Care Act, as amended by the Health 202 Care and Education Reconciliation Act of 2010, and the 203 regulations adopted pursuant to those acts, the health insurer 204 verified the eligibility of the insured at the time of treatment 205 and provided an authorization number, unless, at the time 206 eligibility was verified, the provider was notified that the 207 insured was delinquent in paying the premium. 208 Section 52. Subsection (2) of section 627.6471, Florida 209 Statutes, is amended to read: 210 627.6471 Contracts for reduced rates of payment; 211 limitations; coinsurance and deductibles.— 212 (2) AnAnyinsurer issuing a policy of health insurance in 213 this state,whichinsuranceincludes coverage for the services 214 of a preferred provider shall,mustprovide each policyholder 215 and certificateholder with a current list of preferred 216 providers, shalland mustmake the list available for public 217 inspection during regular business hours at the principal office 218 of the insurer within the state, and shall post a link to the 219 list of preferred providers on the home page of the insurer’s 220 website. Changes to the list of preferred providers must be 221 reflected on the insurer’s website within 24 hours. 222 Section 53. Paragraph (c) of subsection (2) of section 223 627.6515, Florida Statutes, is amended to read: 224 627.6515 Out-of-state groups.— 225 (2) Except as otherwise provided in this part, this part 226 does not apply to a group health insurance policy issued or 227 delivered outside this state under which a resident of this 228 state is provided coverage if: 229 (c) The policy provides the benefits specified in ss. 230 627.419, 627.42392, 627.42393, 627.6574, 627.6575, 627.6579, 231 627.6612, 627.66121, 627.66122, 627.6613, 627.667, 627.6675, 232 627.6691, and 627.66911, and complies with the requirements of 233 s. 627.66996. 234 Section 54. Subsection (10) of section 641.3155, Florida 235 Statutes, is amended to read: 236 641.3155 Prompt payment of claims.— 237 (10) A health maintenance organization may not 238 retroactively deny a claim because of subscriber ineligibility: 239 (a) More than 1 year after the date of payment of the 240 claim; or 241 (b) If, under a policy in compliance with the federal 242 Patient Protection and Affordable Care Act, as amended by the 243 Health Care and Education Reconciliation Act of 2010, and the 244 regulations adopted pursuant to those acts, the health 245 maintenance organization verified the eligibility of the 246 subscriber at the time of treatment and provided an 247 authorization number, unless, at the time eligibility was 248 verified, the provider was notified that the subscriber was 249 delinquent in paying the premium. 250 Section 55. Section 641.393, Florida Statutes, is created 251 to read: 252 641.393 Prior authorization.—Notwithstanding any other law, 253 in order to establish uniformity in the submission of prior 254 authorization forms, effective January 1, 2015, a health 255 maintenance organization shall use a single standardized form 256 for obtaining prior authorization for prescription drug 257 benefits. The form may not exceed two pages in length, excluding 258 any instructions or guiding documentation. 259 (1) A health maintenance organization shall make the form 260 available electronically and online to practitioners. A health 261 care provider may electronically submit the completed form to 262 the health maintenance organization. 263 (2) If a health maintenance organization contracts with a 264 pharmacy benefits manager to perform prior authorization 265 services for prescription drug benefits, the pharmacy benefits 266 manager must use and accept the standardized prior authorization 267 form. 268 (3) A completed prior authorization request submitted by a 269 health care provider using the standardized prior authorization 270 form required under this section is deemed approved upon receipt 271 by the health maintenance organization unless the health 272 maintenance organization responds otherwise within 3 business 273 days. 274 (4) This section does not apply to grandfathered health 275 plans, as defined in s. 627.402. 276 Section 56. Section 641.394, Florida Statutes, is created 277 to read: 278 641.394 Medication protocol override.—If a health 279 maintenance organization contract restricts medications for the 280 treatment of a medical condition by a step-therapy or fail-first 281 protocol, the prescribing provider shall have access to a clear 282 and convenient process to request an override of the protocol 283 from the health maintenance organization. 284 (1) The health maintenance organization shall grant an 285 override within 72 hours if the prescribing provider documents 286 that: 287 (a) Based on sound clinical evidence, the preferred 288 treatment required under the step-therapy or fail-first protocol 289 has been ineffective in the treatment of the subscriber’s 290 disease or medical condition; or 291 (b) Based on sound clinical evidence or medical and 292 scientific evidence, the preferred treatment required under the 293 step-therapy or fail-first protocol: 294 1. Is expected or is likely to be ineffective based on 295 known relevant physical or mental characteristics of the 296 subscriber and known characteristics of the drug regimen; or 297 2. Will cause or is likely to cause an adverse reaction or 298 other physical harm to the subscriber. 299 (2) If the prescribing provider allows the subscriber to 300 enter the step-therapy or fail-first protocol recommended by the 301 health maintenance organization, the duration of the step 302 therapy or fail-first protocol may not exceed the customary 303 period for use of the medication if the prescribing provider 304 demonstrates such treatment to be clinically ineffective. If the 305 health maintenance organization can, through sound clinical 306 evidence, demonstrate that the originally prescribed medication 307 is likely to require more than the customary period to provide 308 any relief or amelioration to the subscriber, the step-therapy 309 or fail-first protocol may be extended for an additional period, 310 but no longer than the original customary period for use of the 311 medication. Notwithstanding this provision, a step-therapy or 312 fail-first protocol shall be terminated if the prescribing 313 provider determines that the subscriber is having an adverse 314 reaction or is suffering from other physical harm resulting from 315 the use of the medication. 316 (3) This section does not apply to grandfathered health 317 plans, as defined in s. 627.402. 318 319 ================= T I T L E A M E N D M E N T ================ 320 And the title is amended as follows: 321 Delete line 292 322 and insert: 323 home health agencies; amending s. 409.967, F.S.; 324 revising contract requirements for Medicaid managed 325 care programs; providing requirements for plans 326 establishing a drug formulary or preferred drug list; 327 requiring the use of a standardized prior 328 authorization form; providing requirements for the 329 form and for the availability and submission of the 330 form; requiring a pharmacy benefits manager to use and 331 accept the form under certain circumstances; 332 establishing a process for providers to override 333 certain treatment restrictions; providing requirements 334 for approval of such overrides; providing an exception 335 to the override protocol in certain circumstances; 336 creating s. 627.42392, F.S.; requiring health insurers 337 to use a standardized prior authorization form; 338 providing requirements for the form and for the 339 availability and submission of the form; requiring a 340 pharmacy benefits manager to use and accept the form 341 under certain circumstances; providing an exemption; 342 creating s. 627.42393, F.S.; establishing a process 343 for providers to override certain treatment 344 restrictions; providing requirements for approval of 345 such overrides; providing an exception to the override 346 protocol in certain circumstances; providing an 347 exemption; amending s. 627.6131, F.S.; prohibiting an 348 insurer from retroactively denying a claim in certain 349 circumstances; amending s. 627.6471, F.S.; requiring 350 insurers to post preferred provider information on a 351 website; specifying that changes to such a website 352 must be made within a certain time; amending s. 353 627.6515, F.S.; applying provisions relating to prior 354 authorization and override protocols to out-of-state 355 groups; amending s. 641.3155, F.S.; prohibiting a 356 health maintenance organization from retroactively 357 denying a claim in certain circumstances; creating s. 358 641.393, F.S.; requiring the use of a standardized 359 prior authorization form by a health maintenance 360 organization; providing requirements for the 361 availability and submission of the form; requiring a 362 pharmacy benefits manager to use and accept the form 363 under certain circumstances; providing an exemption; 364 creating s. 641.394, F.S.; establishing a process for 365 providers to override certain treatment restrictions; 366 providing requirements for approval of such overrides; 367 providing an exception to the override protocol in 368 certain circumstances; providing an exemption; 369 providing effective dates.