Bill Amendment: FL S0240 | 2017 | Regular Session

NOTE: For additional amemendments please see the Bill Drafting List

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Bill Title: Direct Primary Care

Status: 2017-05-04 - Laid on Table [S0240 Detail]

Download: Florida-2017-S0240-Senate_Floor_Amendment_620636.html

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       Florida Senate - 2017                          SENATOR AMENDMENT
       Bill No. CS for CS for CS for SB 240
       
       
       
       
       
       
                                Ì620636*Î620636                         
       
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
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       Senator Steube moved the following:
       
    1         Senate Amendment (with title amendment)
    2  
    3         Before line 24
    4  insert:
    5         Section 1. Section 627.42392, Florida Statutes, is amended
    6  to read:
    7         627.42392 Prior authorization.—
    8         (1) As used in this section, the term:
    9         (a) “Health insurer” means an authorized insurer offering
   10  an individual or group insurance policy that provides major
   11  medical or similar comprehensive coverage health insurance as
   12  defined in s. 624.603, a managed care plan as defined in s.
   13  409.962(10) s. 409.962(9), or a health maintenance organization
   14  as defined in s. 641.19(12).
   15         (b) “Urgent care situation” has the same meaning as in s.
   16  627.42393.
   17         (2) Notwithstanding any other provision of law, effective
   18  January 1, 2017, or six (6) months after the effective date of
   19  the rule adopting the prior authorization form, whichever is
   20  later, a health insurer, or a pharmacy benefits manager on
   21  behalf of the health insurer, which does not provide an
   22  electronic prior authorization process for use by its contracted
   23  providers, shall only use the prior authorization form that has
   24  been approved by the Financial Services Commission for granting
   25  a prior authorization for a medical procedure, course of
   26  treatment, or prescription drug benefit. Such form may not
   27  exceed two pages in length, excluding any instructions or
   28  guiding documentation, and must include all clinical
   29  documentation necessary for the health insurer to make a
   30  decision. At a minimum, the form must include: (1) sufficient
   31  patient information to identify the member, date of birth, full
   32  name, and Health Plan ID number; (2) provider name, address and
   33  phone number; (3) the medical procedure, course of treatment, or
   34  prescription drug benefit being requested, including the medical
   35  reason therefor, and all services tried and failed; (4) any
   36  laboratory documentation required; and (5) an attestation that
   37  all information provided is true and accurate. The form, whether
   38  in electronic or paper format, may not require information that
   39  is not necessary for the determination of medical necessity of,
   40  or coverage for, the requested medical procedure, course of
   41  treatment, or prescription drug.
   42         (3) The Financial Services Commission in consultation with
   43  the Agency for Health Care Administration shall adopt by rule
   44  guidelines for all prior authorization forms which ensure the
   45  general uniformity of such forms.
   46         (4) Electronic prior authorization approvals do not
   47  preclude benefit verification or medical review by the insurer
   48  under either the medical or pharmacy benefits.
   49         (5) A health insurer or a pharmacy benefits manager on
   50  behalf of the health insurer must provide the following
   51  information in writing or in an electronic format upon request,
   52  and on a publicly accessible Internet website:
   53         (a) Detailed descriptions of requirements and restrictions
   54  to obtain prior authorization for coverage of a medical
   55  procedure, course of treatment, or prescription drug in clear,
   56  easily understandable language. Clinical criteria must be
   57  described in language easily understandable by a health care
   58  provider.
   59         (b) Prior authorization forms.
   60         (6) A health insurer or a pharmacy benefits manager on
   61  behalf of the health insurer may not implement any new
   62  requirements or restrictions or make changes to existing
   63  requirements or restrictions to obtain prior authorization
   64  unless:
   65         (a) The changes have been available on a publicly
   66  accessible Internet website at least 60 days before the
   67  implementation of the changes.
   68         (b) Policyholders and health care providers who are
   69  affected by the new requirements and restrictions or changes to
   70  the requirements and restrictions are provided with a written
   71  notice of the changes at least 60 days before the changes are
   72  implemented. Such notice may be delivered electronically or by
   73  other means as agreed to by the insured or health care provider.
   74  
   75  This subsection does not apply to expansion of health care
   76  services coverage.
   77         (7) A health insurer or a pharmacy benefits manager on
   78  behalf of the health insurer must authorize or deny a prior
   79  authorization request and notify the patient and the patient’s
   80  treating health care provider of the decision within:
   81         (a) Seventy-two hours of obtaining a completed prior
   82  authorization form for nonurgent care situations.
   83         (b) Twenty-four hours of obtaining a completed prior
   84  authorization form for urgent care situations.
   85         Section 2. Section 627.42393, Florida Statutes, is created
   86  to read:
   87         627.42393 Fail-first protocols.—
   88         (1) As used in this section, the term:
   89         (a) “Fail-first protocol” means a written protocol that
   90  specifies the order in which a certain medical procedure, course
   91  of treatment, or prescription drug must be used to treat an
   92  insured’s condition.
   93         (b) “Health insurer” has the same meaning as provided in s.
   94  627.42392.
   95         (c) “Preceding prescription drug or medical treatment”
   96  means a medical procedure, course of treatment, or prescription
   97  drug that must be used pursuant to a health insurer’s fail-first
   98  protocol as a condition of coverage under a health insurance
   99  policy or a health maintenance contract to treat an insured’s
  100  condition.
  101         (d) “Protocol exception” means a determination by a health
  102  insurer that a fail-first protocol is not medically appropriate
  103  or indicated for treatment of an insured’s condition and the
  104  health insurer authorizes the use of another medical procedure,
  105  course of treatment, or prescription drug prescribed or
  106  recommended by the treating health care provider for the
  107  insured’s condition.
  108         (e) “Urgent care situation” means an injury or condition of
  109  an insured which, if medical care and treatment is not provided
  110  earlier than the time generally considered by the medical
  111  profession to be reasonable for a nonurgent situation, in the
  112  opinion of the insured’s treating physician, would:
  113         1. Seriously jeopardize the insured’s life, health, or
  114  ability to regain maximum function; or
  115         2. Subject the insured to severe pain that cannot be
  116  adequately managed.
  117         (2) A health insurer must publish on its website, and
  118  provide to an insured in writing, a procedure for an insured and
  119  health care provider to request a protocol exception. The
  120  procedure must include:
  121         (a) A description of the manner in which an insured or
  122  health care provider may request a protocol exception.
  123         (b) The manner and timeframe in which the health insurer is
  124  required to authorize or deny a protocol exception request or
  125  respond to an appeal to a health insurer’s authorization or
  126  denial of a request.
  127         (c) The conditions in which the protocol exception request
  128  must be granted.
  129         (3)(a) The health insurer must authorize or deny a protocol
  130  exception request or respond to an appeal to a health insurer’s
  131  authorization or denial of a request within:
  132         1. Seventy-two hours of obtaining a completed prior
  133  authorization form for nonurgent care situations.
  134         2. Twenty-four hours of obtaining a completed prior
  135  authorization form for urgent care situations.
  136         (b) An authorization of the request must specify the
  137  approved medical procedure, course of treatment, or prescription
  138  drug benefits.
  139         (c) A denial of the request must include a detailed,
  140  written explanation of the reason for the denial, the clinical
  141  rationale that supports the denial, and the procedure to appeal
  142  the health insurer’s determination.
  143         (4) A health insurer must grant a protocol exception
  144  request if:
  145         (a) A preceding prescription drug or medical treatment is
  146  contraindicated or will likely cause an adverse reaction or
  147  physical or mental harm to the insured;
  148         (b) A preceding prescription drug is expected to be
  149  ineffective, based on the medical history of the insured and the
  150  clinical evidence of the characteristics of the preceding
  151  prescription drug or medical treatment;
  152         (c) The insured has previously received a preceding
  153  prescription drug or medical treatment that is in the same
  154  pharmacologic class or has the same mechanism of action, and
  155  such drug or treatment lacked efficacy or effectiveness or
  156  adversely affected the insured; or
  157         (d) A preceding prescription drug or medical treatment is
  158  not in the best interest of the insured because the insured’s
  159  use of such drug or treatment is expected to:
  160         1. Cause a significant barrier to the insured’s adherence
  161  to or compliance with the insured’s plan of care;
  162         2. Worsen an insured’s medical condition that exists
  163  simultaneously but independently with the condition under
  164  treatment; or
  165         3. Decrease the insured’s ability to achieve or maintain
  166  his or her ability to perform daily activities.
  167         (5) The health insurer may request a copy of relevant
  168  documentation from the insured’s medical record in support of a
  169  protocol exception request.
  170         Section 3. Subsection (11) of section 627.6131, Florida
  171  Statutes, is amended to read:
  172         627.6131 Payment of claims.—
  173         (11) A health insurer may not retroactively deny a claim
  174  because of insured ineligibility:
  175         (a) At any time, if the health insurer verified the
  176  eligibility of an insured at the time of treatment and provided
  177  an authorization number. This paragraph applies to policies
  178  entered into or renewed on or after January 1, 2018.
  179         (b) More than 1 year after the date of payment of the
  180  claim.
  181         Section 4. Subsection (10) of section 641.3155, Florida
  182  Statutes, is amended to read:
  183         641.3155 Prompt payment of claims.—
  184         (10) A health maintenance organization may not
  185  retroactively deny a claim because of subscriber ineligibility:
  186         (a) At any time, if the health maintenance organization
  187  verified the eligibility of a subscriber at the time of
  188  treatment and provided an authorization number. This paragraph
  189  applies to contracts entered into or renewed on or after January
  190  1, 2018. This paragraph does not apply to Medicaid managed care
  191  plans pursuant to part IV of chapter 409.
  192         (b) More than 1 year after the date of payment of the
  193  claim.
  194  
  195  ================= T I T L E  A M E N D M E N T ================
  196  And the title is amended as follows:
  197         Delete line 2
  198  and insert:
  199         An act relating to health care; amending s. 627.42392,
  200         F.S.; revising and providing definitions; revising
  201         criteria for prior authorization forms; requiring
  202         health insurers and pharmacy benefits managers on
  203         behalf of health insurers to provide certain
  204         information relating to prior authorization in a
  205         specified manner; prohibiting such insurers and
  206         pharmacy benefits managers from implementing or making
  207         changes to requirements or restrictions to obtain
  208         prior authorization, except under certain
  209         circumstances; providing applicability; requiring such
  210         insurers and pharmacy benefits managers to authorize
  211         or deny prior authorization requests and provide
  212         certain notices within specified timeframes; creating
  213         s. 627.42393, F.S.; providing definitions; requiring
  214         health insurers to publish on their websites and
  215         provide in writing to insureds a specified procedure
  216         to obtain protocol exceptions; specifying timeframes
  217         in which health insurers must authorize or deny
  218         protocol exception requests and respond to an appeal
  219         to a health insurer’s authorization or denial of a
  220         request; requiring authorizations or denials to
  221         specify certain information; providing circumstances
  222         in which health insurers must grant a protocol
  223         exception request; authorizing health insurers to
  224         request documentation in support of a protocol
  225         exception request; amending s. 627.6131, F.S.;
  226         prohibiting a health insurer from retroactively
  227         denying a claim under specified circumstances;
  228         providing applicability; amending s. 641.3155, F.S.;
  229         prohibiting a health maintenance organization from
  230         retroactively denying a claim under specified
  231         circumstances; providing applicability; exempting
  232         certain Medicaid managed care plans; amending s.