Bill Text: FL S1084 | 2016 | Regular Session | Introduced

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

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Bill Title: Health Care Protocols

Spectrum: Bipartisan Bill

Status: (Failed) 2016-03-11 - Died in Appropriations [S1084 Detail]

Download: Florida-2016-S1084-Introduced.html

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       Florida Senate - 2016                                    SB 1084
       
       
        
       By Senator Gaetz
       
       1-00098B-16                                           20161084__
    1                        A bill to be entitled                      
    2         An act relating to health care protocols; providing a
    3         short title; amending s. 409.967, F.S.; requiring a
    4         managed care plan to establish a process by which a
    5         prescribing physician may request an override of
    6         certain restrictions in certain circumstances;
    7         providing the circumstances under which an override
    8         must be granted; defining the term “fail-first
    9         protocol”; creating s. 627.6466, F.S.; requiring an
   10         insurer to establish a process by which a prescribing
   11         physician may request an override of certain
   12         restrictions in certain circumstances; providing the
   13         circumstances under which an override must be granted;
   14         defining the term “fail-first protocol”; amending s.
   15         641.31, F.S.; prohibiting a health maintenance
   16         organization from requiring that a health care
   17         provider use a clinical decision support system or a
   18         laboratory benefits management program in certain
   19         circumstances; defining terms; providing for
   20         construction; creating s. 641.394, F.S.; requiring a
   21         health maintenance organization to establish a process
   22         by which a prescribing physician may request an
   23         override of certain restrictions in certain
   24         circumstances; providing the circumstances under which
   25         an override must be granted; defining the term “fail
   26         first protocol”; providing an effective date.
   27          
   28  Be It Enacted by the Legislature of the State of Florida:
   29  
   30         Section 1. This act may be known as the “Right Medicine
   31  Right Time Act.”
   32         Section 2. Paragraph (c) of subsection (2) of section
   33  409.967, Florida Statutes, is amended to read:
   34         409.967 Managed care plan accountability.—
   35         (2) The agency shall establish such contract requirements
   36  as are necessary for the operation of the statewide managed care
   37  program. In addition to any other provisions the agency may deem
   38  necessary, the contract must require:
   39         (c) Access.—
   40         1. The agency shall establish specific standards for the
   41  number, type, and regional distribution of providers in managed
   42  care plan networks to ensure access to care for both adults and
   43  children. Each plan must maintain a regionwide network of
   44  providers in sufficient numbers to meet the access standards for
   45  specific medical services for all recipients enrolled in the
   46  plan. The exclusive use of mail-order pharmacies may not be
   47  sufficient to meet network access standards. Consistent with the
   48  standards established by the agency, provider networks may
   49  include providers located outside the region. A plan may
   50  contract with a new hospital facility before the date the
   51  hospital becomes operational if the hospital has commenced
   52  construction, will be licensed and operational by January 1,
   53  2013, and a final order has issued in any civil or
   54  administrative challenge. Each plan shall establish and maintain
   55  an accurate and complete electronic database of contracted
   56  providers, including information about licensure or
   57  registration, locations and hours of operation, specialty
   58  credentials and other certifications, specific performance
   59  indicators, and such other information as the agency deems
   60  necessary. The database must be available online to both the
   61  agency and the public and have the capability to compare the
   62  availability of providers to network adequacy standards and to
   63  accept and display feedback from each provider’s patients. Each
   64  plan shall submit quarterly reports to the agency identifying
   65  the number of enrollees assigned to each primary care provider.
   66         2.a. Each managed care plan must publish any prescribed
   67  drug formulary or preferred drug list on the plan’s website in a
   68  manner that is accessible to and searchable by enrollees and
   69  providers. The plan must update the list within 24 hours after
   70  making a change. Each plan must ensure that the prior
   71  authorization process for prescribed drugs is readily accessible
   72  to health care providers, including posting appropriate contact
   73  information on its website and providing timely responses to
   74  providers. For Medicaid recipients diagnosed with hemophilia who
   75  have been prescribed anti-hemophilic-factor replacement
   76  products, the agency shall provide for those products and
   77  hemophilia overlay services through the agency’s hemophilia
   78  disease management program.
   79         b. If a managed care plan restricts the use of prescribed
   80  drugs through a fail-first protocol, it must establish a clear
   81  and convenient process that a prescribing physician may use to
   82  request an override of the restriction from the managed care
   83  plan. The managed care plan shall grant an override of the
   84  protocol within 24 hours if:
   85         (I) Based on sound clinical evidence, the prescribing
   86  provider concludes that the preferred treatment required under
   87  the fail-first protocol has been ineffective in the treatment of
   88  the enrollee’s disease or medical condition; or
   89         (II) Based on sound clinical evidence or medical and
   90  scientific evidence, the prescribing provider believes that the
   91  preferred treatment required under the fail-first protocol:
   92         (A) Is likely to be ineffective given the known relevant
   93  physical or mental characteristics and medical history of the
   94  enrollee and the known characteristics of the drug regimen; or
   95         (B) Will cause or is likely to cause an adverse reaction or
   96  other physical harm to the enrollee.
   97  
   98  If the prescribing provider follows the fail-first protocol
   99  recommended by the managed care plan for an enrollee, the
  100  duration of treatment under the fail-first protocol may not
  101  exceed a period deemed appropriate by the prescribing provider.
  102  Following such period, if the prescribing provider deems the
  103  treatment provided under the protocol clinically ineffective,
  104  the enrollee is entitled to receive the course of therapy that
  105  the prescribing provider recommends, and the provider is not
  106  required to seek approval of an override of the fail-first
  107  protocol. As used in this subparagraph, the term “fail-first
  108  protocol” means a prescription practice that begins medication
  109  for a medical condition with the most cost-effective drug
  110  therapy and progresses to other more costly or risky therapies
  111  only if necessary.
  112         3. Managed care plans, and their fiscal agents or
  113  intermediaries, must accept prior authorization requests for any
  114  service electronically.
  115         4. Managed care plans serving children in the care and
  116  custody of the Department of Children and Families shall must
  117  maintain complete medical, dental, and behavioral health
  118  encounter information and participate in making such information
  119  available to the department or the applicable contracted
  120  community-based care lead agency for use in providing
  121  comprehensive and coordinated case management. The agency and
  122  the department shall establish an interagency agreement to
  123  provide guidance for the format, confidentiality, recipient,
  124  scope, and method of information to be made available and the
  125  deadlines for submission of the data. The scope of information
  126  available to the department are shall be the data that managed
  127  care plans are required to submit to the agency. The agency
  128  shall determine the plan’s compliance with standards for access
  129  to medical, dental, and behavioral health services; the use of
  130  medications; and followup on all medically necessary services
  131  recommended as a result of early and periodic screening,
  132  diagnosis, and treatment.
  133         Section 3. Section 627.6466, Florida Statutes, is created
  134  to read:
  135         627.6466 Fail-first protocols.—If an insurer restricts the
  136  use of prescribed drugs through a fail-first protocol, it must
  137  establish a clear and convenient process that a prescribing
  138  physician may use to request an override of the restriction from
  139  the insurer. The insurer shall grant an override of the protocol
  140  within 24 hours if:
  141         (1) Based on sound clinical evidence, the prescribing
  142  provider concludes that the preferred treatment required under
  143  the fail-first protocol has been ineffective in the treatment of
  144  the insured’s disease or medical condition; or
  145         (2) Based on sound clinical evidence or medical and
  146  scientific evidence, the prescribing provider believes that the
  147  preferred treatment required under the fail-first protocol:
  148         (a) Is likely to be ineffective given the known relevant
  149  physical or mental characteristics and medical history of the
  150  insured and the known characteristics of the drug regimen; or
  151         (b) Will cause or is likely to cause an adverse reaction or
  152  other physical harm to the insured.
  153  
  154  If the prescribing provider follows the fail-first protocol
  155  recommended by the insurer for an insured, the duration of
  156  treatment under the fail-first protocol may not exceed a period
  157  deemed appropriate by the prescribing provider. Following such
  158  period, if the prescribing provider deems the treatment provided
  159  under the protocol clinically ineffective, the insured is
  160  entitled to receive the course of therapy that the prescribing
  161  provider recommends, and the provider is not required to seek
  162  approval of an override of the fail-first protocol. As used in
  163  this section, the term “fail-first protocol” means a
  164  prescription practice that begins medication for a medical
  165  condition with the most cost-effective drug therapy and
  166  progresses to other more costly or risky therapies only if
  167  necessary.
  168         Section 4. Subsection (44) is added to section 641.31,
  169  Florida Statutes, to read:
  170         641.31 Health maintenance contracts.—
  171         (44) A health maintenance organization may not require a
  172  health care provider, by contract with another health care
  173  provider, a patient, or another individual or entity, to use a
  174  clinical decision support system or a laboratory benefits
  175  management program before the provider may order clinical
  176  laboratory services or in an attempt to direct or limit the
  177  provider’s medical decisionmaking relating to the use of such
  178  services. This subsection may not be construed to prohibit any
  179  prior authorization requirements that the health maintenance
  180  organization may have regarding the provision of clinical
  181  laboratory services. As used in this subsection, the term:
  182         (a) “Clinical decision support system” means software
  183  designed to direct or assist clinical decisionmaking by matching
  184  the characteristics of an individual patient to a computerized
  185  clinical knowledge base and providing patient-specific
  186  assessments or recommendations based on the match.
  187         (b) “Clinical laboratory services” means the examination of
  188  fluids or other materials taken from the human body, which
  189  examination is ordered by a health care provider for use in the
  190  diagnosis, prevention, or treatment of a disease or in the
  191  identification or assessment of a medical or physical condition.
  192         (c) “Laboratory benefits management program” means a health
  193  maintenance organization protocol that dictates or limits health
  194  care provider decisionmaking relating to the use of clinical
  195  laboratory services.
  196         Section 5. Section 641.394, Florida Statutes, is created to
  197  read:
  198         641.394 Fail-first protocols.—If a health maintenance
  199  organization restricts the use of prescribed drugs through a
  200  fail-first protocol, it must establish a clear and convenient
  201  process that a prescribing physician may use to request an
  202  override of the restriction from the health maintenance
  203  organization. The health maintenance organization shall grant an
  204  override of the protocol within 24 hours if:
  205         (1) Based on sound clinical evidence, the prescribing
  206  provider concludes that the preferred treatment required under
  207  the fail-first protocol has been ineffective in the treatment of
  208  the subscriber’s disease or medical condition; or
  209         (2) Based on sound clinical evidence or medical and
  210  scientific evidence, the prescribing provider believes that the
  211  preferred treatment required under the fail-first protocol:
  212         (a) Is likely to be ineffective given the known relevant
  213  physical or mental characteristics and medical history of the
  214  subscriber and the known characteristics of the drug regimen; or
  215         (b) Will cause or is likely to cause an adverse reaction or
  216  other physical harm to the subscriber.
  217  
  218  If the prescribing provider follows the fail-first protocol
  219  recommended by the health maintenance organization for a
  220  subscriber, the duration of treatment under the fail-first
  221  protocol may not exceed a period deemed appropriate by the
  222  prescribing provider. Following such period, if the prescribing
  223  provider deems the treatment provided under the protocol
  224  clinically ineffective, the subscriber is entitled to receive
  225  the course of therapy that the prescribing provider recommends,
  226  and the provider is not required to seek approval of an override
  227  of the fail-first protocol. As used in this section, the term
  228  “fail-first protocol” means a prescription practice that begins
  229  medication for a medical condition with the most cost-effective
  230  drug therapy and progresses to other more costly or risky
  231  therapies only if necessary.
  232         Section 6. This act shall take effect July 1, 2016.