Bill Text: FL S0098 | 2018 | Regular Session | Comm Sub

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Health Insurer Authorization

Spectrum: Bipartisan Bill

Status: (Failed) 2018-03-10 - Died in Messages [S0098 Detail]

Download: Florida-2018-S0098-Comm_Sub.html

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       Florida Senate - 2018                               CS for SB 98
       
       
        
       By the Committee on Judiciary; and Senator Steube
       
       
       
       
       
       590-01814-18                                            201898c1
    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”; defining the term “urgent care
    5         situation”; prohibiting prior authorization forms from
    6         requiring certain information; requiring health
    7         insurers and pharmacy benefits managers on behalf of
    8         health insurers to provide certain information
    9         relating to prior authorization by specified means;
   10         prohibiting such insurers and pharmacy benefits
   11         managers from implementing or making changes to
   12         requirements or restrictions to obtain prior
   13         authorization except under certain circumstances;
   14         providing applicability; requiring such insurers and
   15         pharmacy benefits managers to authorize or deny prior
   16         authorization requests and provide certain notices
   17         within specified timeframes; creating s. 627.42393,
   18         F.S.; defining terms; requiring health insurers to
   19         publish on their websites and provide to insureds in
   20         writing a procedure for insureds and health care
   21         providers to request protocol exceptions; specifying
   22         requirements for such procedure; requiring health
   23         insurers, within specified timeframes, to authorize or
   24         deny a protocol exception request or respond to
   25         appeals of their authorizations or denials; requiring
   26         authorizations or denials to specify certain
   27         information; requiring health insurers to grant
   28         protocol exception requests under certain
   29         circumstances; authorizing health insurers to request
   30         documentation in support of a protocol exception
   31         request; providing an effective date.
   32          
   33  Be It Enacted by the Legislature of the State of Florida:
   34  
   35         Section 1. Section 627.42392, Florida Statutes, is amended
   36  to read:
   37         627.42392 Prior authorization.—
   38         (1) As used in this section, the term:
   39         (a) “Health insurer” means an authorized insurer offering
   40  an individual or group insurance policy that provides major
   41  medical or similar comprehensive coverage health insurance as
   42  defined in s. 624.603, a managed care plan as defined in s.
   43  409.962(10), or a health maintenance organization as defined in
   44  s. 641.19(12).
   45         (b) “Urgent care situation” has the same meaning as in s.
   46  627.42393.
   47         (2) Notwithstanding any other provision of law, effective
   48  January 1, 2017, or six (6) months after the effective date of
   49  the rule adopting the prior authorization form, whichever is
   50  later, a health insurer, or a pharmacy benefits manager on
   51  behalf of the health insurer, which does not provide an
   52  electronic prior authorization process for use by its contracted
   53  providers, shall only use the prior authorization form that has
   54  been approved by the Financial Services Commission for granting
   55  a prior authorization for a medical procedure, course of
   56  treatment, or prescription drug benefit. Such form may not
   57  exceed two pages in length, excluding any instructions or
   58  guiding documentation, and must include all clinical
   59  documentation necessary for the health insurer to make a
   60  decision. At a minimum, the form must include: (1) sufficient
   61  patient information to identify the member, date of birth, full
   62  name, and Health Plan ID number; (2) provider name, address and
   63  phone number; (3) the medical procedure, course of treatment, or
   64  prescription drug benefit being requested, including the medical
   65  reason therefor, and all services tried and failed; (4) any
   66  laboratory documentation required; and (5) an attestation that
   67  all information provided is true and accurate. The form, whether
   68  in electronic or paper format, may not require information that
   69  is not necessary for the determination of medical necessity of,
   70  or coverage for, the requested medical procedure, course of
   71  treatment, or prescription drug.
   72         (3) The Financial Services Commission in consultation with
   73  the Agency for Health Care Administration shall adopt by rule
   74  guidelines for all prior authorization forms which ensure the
   75  general uniformity of such forms.
   76         (4) Electronic prior authorization approvals do not
   77  preclude benefit verification or medical review by the insurer
   78  under either the medical or pharmacy benefits.
   79         (5) A health insurer or a pharmacy benefits manager on
   80  behalf of the health insurer must provide the following
   81  information in writing or in an electronic format upon request,
   82  and on a publicly accessible Internet website:
   83         (a) Detailed descriptions of requirements and restrictions
   84  to obtain prior authorization for coverage of a medical
   85  procedure, course of treatment, or prescription drug in clear,
   86  easily understandable language. Clinical criteria must be
   87  described in language easily understandable by a health care
   88  provider.
   89         (b) Prior authorization forms.
   90         (6) A health insurer or a pharmacy benefits manager on
   91  behalf of the health insurer may not implement any new
   92  requirements or restrictions or make changes to existing
   93  requirements or restrictions to obtain prior authorization
   94  unless:
   95         (a) The changes have been available on a publicly
   96  accessible Internet website at least 60 days before the
   97  implementation of the changes.
   98         (b) Policyholders and health care providers who are
   99  affected by the new requirements and restrictions or changes to
  100  the requirements and restrictions are provided with a written
  101  notice of the changes at least 60 days before the changes are
  102  implemented. Such notice may be delivered electronically or by
  103  other means as agreed to by the insured or health care provider.
  104  
  105  This subsection does not apply to expansion of health care
  106  services coverage.
  107         (7) A health insurer or a pharmacy benefits manager on
  108  behalf of the health insurer must authorize or deny a prior
  109  authorization request and notify the patient and the patient’s
  110  treating health care provider of the decision within:
  111         (a) Seventy-two hours of obtaining a completed prior
  112  authorization form for nonurgent care situations.
  113         (b) Twenty-four hours of obtaining a completed prior
  114  authorization form for urgent care situations.
  115         Section 2. Section 627.42393, Florida Statutes, is created
  116  to read:
  117         627.42393 Fail-first protocols.—
  118         (1) As used in this section, the term:
  119         (a) “Fail-first protocol” means a written protocol that
  120  specifies the order in which a certain medical procedure, course
  121  of treatment, or prescription drug must be used to treat an
  122  insured’s condition.
  123         (b) “Health insurer” has the same meaning as provided in s.
  124  627.42392.
  125         (c) “Preceding prescription drug or medical treatment”
  126  means a medical procedure, course of treatment, or prescription
  127  drug that must be used pursuant to a health insurer’s fail-first
  128  protocol as a condition of coverage under a health insurance
  129  policy or a health maintenance contract to treat an insured’s
  130  condition.
  131         (d) “Protocol exception” means a determination by a health
  132  insurer that a fail-first protocol is not medically appropriate
  133  or indicated for treatment of an insured’s condition and the
  134  health insurer authorizes the use of another medical procedure,
  135  course of treatment, or prescription drug prescribed or
  136  recommended by the treating health care provider for the
  137  insured’s condition.
  138         (e) “Urgent care situation” means an injury or condition of
  139  an insured which, if medical care and treatment are not provided
  140  earlier than the time generally considered by the medical
  141  profession to be reasonable for a nonurgent situation, in the
  142  opinion of the insured’s treating physician, physician
  143  assistant, or advanced registered nurse practitioner, would:
  144         1. Seriously jeopardize the insured’s life, health, or
  145  ability to regain maximum function; or
  146         2. Subject the insured to severe pain that cannot be
  147  adequately managed.
  148         (2) A health insurer must publish on its website and
  149  provide to an insured in writing a procedure for an insured and
  150  health care provider to request a protocol exception. The
  151  procedure must include:
  152         (a) A description of the manner in which an insured or
  153  health care provider may request a protocol exception.
  154         (b) The manner and timeframe in which the health insurer is
  155  required to authorize or deny a protocol exception request or
  156  respond to an appeal of a health insurer’s authorization or
  157  denial of a request.
  158         (c) The conditions under which the protocol exception
  159  request must be granted.
  160         (3)(a) The health insurer must authorize or deny a protocol
  161  exception request or respond to an appeal of a health insurer’s
  162  authorization or denial of a request within:
  163         1. Seventy-two hours of obtaining a completed prior
  164  authorization form for nonurgent care situations.
  165         2. Twenty-four hours of obtaining a completed prior
  166  authorization form for urgent care situations.
  167         (b) An authorization of the request must specify the
  168  approved medical procedure, course of treatment, or prescription
  169  drug benefits.
  170         (c) A denial of the request must include a detailed,
  171  written explanation of the reason for the denial, the clinical
  172  rationale that supports the denial, and the procedure to appeal
  173  the health insurer’s determination.
  174         (4) A health insurer must grant a protocol exception
  175  request if:
  176         (a) A preceding prescription drug or medical treatment is
  177  contraindicated or will likely cause an adverse reaction or
  178  physical or mental harm to the insured;
  179         (b) A preceding prescription drug is expected to be
  180  ineffective, based on the medical history of the insured and the
  181  clinical evidence of the characteristics of the preceding
  182  prescription drug or medical treatment;
  183         (c) The insured has previously received a preceding
  184  prescription drug or medical treatment that is in the same
  185  pharmacologic class or has the same mechanism of action, and
  186  such drug or treatment lacked efficacy or effectiveness or
  187  adversely affected the insured; or
  188         (d) A preceding prescription drug or medical treatment is
  189  not in the best interest of the insured because the insured’s
  190  use of such drug or treatment is expected to:
  191         1. Cause a significant barrier to the insured’s adherence
  192  to or compliance with the insured’s plan of care;
  193         2. Worsen an insured’s medical condition that exists
  194  simultaneously but independently with the condition under
  195  treatment; or
  196         3. Decrease the insured’s ability to achieve or maintain
  197  his or her ability to perform daily activities.
  198         (5) The health insurer may request a copy of relevant
  199  documentation from the insured’s medical record in support of a
  200  protocol exception request.
  201         Section 3. This act shall take effect July 1, 2018.