Florida Senate - 2014                        COMMITTEE AMENDMENT
       Bill No. SB 1354
       
       
       
       
       
       
                                Ì798756_Î798756                         
       
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
                  Comm: RCS            .                                
                  04/08/2014           .                                
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       recommended the following:
       
    1         Senate Amendment (with title amendment)
    2  
    3         Delete everything after the enacting clause
    4  and insert:
    5         Section 1. 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 to both the
   34  agency and the public and have the capability of comparing to
   35  compare the 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. Include coverage through prior authorization for each
   48  new drug approved by the United States Food and Drug
   49  Administration until the Medicaid Pharmaceutical and
   50  Therapeutics Committee reviews such drug for inclusion on the
   51  formulary. The timing of the formulary review must comply with
   52  s. 409.91195.
   53         c.Each managed care plan must Publish the any prescribed
   54  drug formulary or preferred drug list on the plan’s website in a
   55  manner that is accessible to and searchable by enrollees and
   56  providers. The plan shall must update the list within 24 hours
   57  after making a change. Each plan must ensure that the prior
   58  authorization process for prescribed drugs is readily accessible
   59  to health care providers, including posting appropriate contact
   60  information on its website and providing timely responses to
   61  providers.
   62         d. If a prescription drug on a plan’s formulary is removed
   63  or changed, permit an enrollee who was receiving the drug to
   64  continue to receive the drug if the prescribing provider submits
   65  a written request that demonstrates that the drug is medically
   66  necessary and that the enrollee meets clinical criteria to
   67  receive the drug.
   68         3. For enrollees Medicaid recipients diagnosed with
   69  hemophilia who have been prescribed anti-hemophilic-factor
   70  replacement products, the agency shall provide for those
   71  products and hemophilia overlay services through the agency’s
   72  hemophilia disease management program.
   73         4. Notwithstanding any other law, in order to establish
   74  uniformity in the submission of prior authorization forms, after
   75  January 1, 2015, a managed care plan shall use only the
   76  standardized prior authorization form adopted by the Financial
   77  Services Commission pursuant to s. 627.42392 for obtaining prior
   78  authorization for a medical procedure, a course of treatment, or
   79  prescription drug benefits.
   80         a. If a managed care plan contracts with a pharmacy
   81  benefits manager to perform prior authorization services for
   82  prescription drug benefits, the pharmacy benefits manager shall
   83  use and accept the standardized prior authorization form. The
   84  Office of Insurance Regulation and the managed care plan shall
   85  make the form electronically available on their respective
   86  websites.
   87         b.3. Managed care plans, and their fiscal agents or
   88  intermediaries, must accept prior authorization requests for any
   89  service electronically.
   90         c. A completed prior authorization request submitted by a
   91  health care provider using the standardized prior authorization
   92  form required under this subparagraph is deemed approved upon
   93  receipt by the managed care plan unless the managed care plan
   94  responds otherwise within 2 business days.
   95         5. If medications for the treatment of a medical condition
   96  are restricted for use by a managed care plan by a step-therapy
   97  or fail-first protocol, the prescribing provider must have
   98  access to a clear and convenient process to request an override
   99  of the protocol from the managed care plan.
  100         a. The managed care plan shall grant an override within 24
  101  hours if the prescribing provider believes that:
  102         (I) Based on sound clinical evidence, the preferred
  103  treatment required under the step-therapy or fail-first protocol
  104  has been ineffective in the treatment of the enrollee’s disease
  105  or medical condition; or
  106         (II) Based on sound clinical evidence or medical and
  107  scientific evidence, the preferred treatment required under the
  108  step-therapy or fail-first protocol:
  109         (A) Is expected or likely to be ineffective based on known
  110  relevant physical or mental characteristics of the enrollee and
  111  known characteristics of the drug regimen; or
  112         (B) Will cause or will likely cause an adverse reaction or
  113  other physical harm to the enrollee.
  114         b. If the prescribing provider allows the enrollee to enter
  115  the step-therapy or fail-first protocol recommended by the
  116  managed care plan, the duration of the step-therapy or fail
  117  first protocol may not exceed a period deemed appropriate by the
  118  provider. If the prescribing provider deems the treatment
  119  clinically ineffective, the enrollee is entitled to receive the
  120  recommended course of therapy without requiring the prescribing
  121  provider to seek approval for an override of the step-therapy or
  122  fail-first protocol.
  123         Section 2. Section 627.42392, Florida Statutes, is created
  124  to read:
  125         627.42392 Prior authorization.—Notwithstanding any other
  126  law, in order to establish uniformity in the submission of prior
  127  authorization forms, after January 1, 2015, a health insurer
  128  that delivers, issues for delivery, renews, amends, or continues
  129  an individual or group health insurance policy in this state,
  130  including a policy issued to a small employer as defined in s.
  131  627.6699, shall use only the standardized prior authorization
  132  form adopted by the commission for obtaining prior authorization
  133  for a medical procedure, course of treatment, or prescription
  134  drug benefits.
  135         (1) If a health insurer contracts with a pharmacy benefits
  136  manager to perform prior authorization services for prescription
  137  drug benefits, the pharmacy benefits manager shall use and
  138  accept the standardized prior authorization form. The commission
  139  shall adopt rules prescribing the prior authorization form on or
  140  before January 1, 2015, and the office may consult with health
  141  insurers or other organizations as necessary in the development
  142  of the form. The form may not exceed two pages in length,
  143  excluding any instructions or guiding documentation. The office
  144  and the health insurer shall make the form electronically
  145  available on their respective websites. The prescribing provider
  146  may electronically submit the completed form to the health
  147  insurer. The adoption of the form by the commission does not
  148  constitute a determination that affects the substantial
  149  interests of a party under chapter 120.
  150         (2) A completed prior authorization request submitted by a
  151  prescribing provider using the standardized prior authorization
  152  form required under subsection (1) is deemed approved upon
  153  receipt by the health insurer unless the health insurer responds
  154  otherwise within 2 business days.
  155         (3) This section does not apply to a grandfathered health
  156  plan as defined in s. 627.402.
  157         Section 3. Section 627.42393, Florida Statutes, is created
  158  to read:
  159         627.42393 Medication protocol override.—If an individual or
  160  group health insurance policy, including a policy issued by a
  161  small employer, as defined in s. 627.6699, restricts medications
  162  for the treatment of a medical condition by a step-therapy or
  163  fail-first protocol, the prescribing provider must have access
  164  to a clear and convenient process to request an override of the
  165  protocol from the health insurer.
  166         (1) The health insurer shall authorize an override of the
  167  protocol within 24 hours if the prescribing provider believes
  168  that:
  169         (a) Based on sound clinical evidence, the preferred
  170  treatment required under the step-therapy or fail-first protocol
  171  has been ineffective in the treatment of the insured’s disease
  172  or medical condition; or
  173         (b) Based on sound clinical evidence or medical and
  174  scientific evidence, the preferred treatment required under the
  175  step-therapy or fail-first protocol:
  176         1. Is expected or likely to be ineffective based on known
  177  relevant physical or mental characteristics of the insured and
  178  known characteristics of the drug regimen; or
  179         2.Will cause or is likely to cause an adverse reaction or
  180  other physical harm to the insured.
  181         (2) If the prescribing provider allows the insured to enter
  182  the step-therapy or fail-first protocol recommended by the
  183  health insurer, the duration of the step-therapy or fail-first
  184  protocol may not exceed a period deemed appropriate by the
  185  provider. If the prescribing provider deems the treatment
  186  clinically ineffective, the insured is entitled to receive the
  187  recommended course of therapy without requiring the prescribing
  188  provider to seek approval for an override of the step-therapy or
  189  fail-first protocol.
  190         (3) This section does not apply to grandfathered health
  191  plans, as defined in s. 627.402.
  192         Section 4. Subsection (11) of section 627.6131, Florida
  193  Statutes, is amended to read:
  194         627.6131 Payment of claims.—
  195         (11) A health insurer may not retroactively deny a claim
  196  because of insured ineligibility:
  197         (a) More than 1 year after the date of payment of the
  198  claim;.
  199         (b) If the health insurer verified the eligibility of the
  200  insured at the time of treatment and provided an authorization
  201  number; or
  202         (c) If the health insurer provided the insured with an
  203  identification card as provided under s. 627.642(3), which at
  204  the time of service identified the insured as eligible to
  205  receive services.
  206         Section 5. Subsection (2) of section 627.6471, Florida
  207  Statutes, is amended to read:
  208         627.6471 Contracts for reduced rates of payment;
  209  limitations; coinsurance and deductibles.—
  210         (2) An Any insurer issuing a policy of health insurance in
  211  this state, which insurance includes coverage for the services
  212  of a preferred provider, shall must provide each policyholder
  213  and certificateholder with a current list of preferred
  214  providers, shall and must make the list available for public
  215  inspection during regular business hours at the principal office
  216  of the insurer within the state, and shall post a link to the
  217  list of preferred providers on the home page of the insurer’s
  218  website. Changes to the list of preferred providers must be
  219  reflected on the insurer’s website within 24 hours.
  220         Section 6. Paragraph (c) of subsection (2) of section
  221  627.6515, Florida Statutes, is amended to read:
  222         627.6515 Out-of-state groups.—
  223         (2) Except as otherwise provided in this part, this part
  224  does not apply to a group health insurance policy issued or
  225  delivered outside this state under which a resident of this
  226  state is provided coverage if:
  227         (c) The policy provides the benefits specified in ss.
  228  627.419, 627.42392, 627.42393, 627.6574, 627.6575, 627.6579,
  229  627.6612, 627.66121, 627.66122, 627.6613, 627.667, 627.6675,
  230  627.6691, and 627.66911, and complies with the requirements of
  231  s. 627.66996.
  232         Section 7. Subsection (10) of section 641.3155, Florida
  233  Statutes, is amended to read:
  234         641.3155 Prompt payment of claims.—
  235         (10) A health maintenance organization may not
  236  retroactively deny a claim because of subscriber ineligibility:
  237         (a) More than 1 year after the date of payment of the
  238  claim;.
  239         (b) If the health maintenance organization verified the
  240  eligibility of the subscriber at the time of treatment and
  241  provided an authorization number; or
  242         (c) If the health maintenance organization provided the
  243  subscriber with an identification card as provided under s.
  244  627.642(3), which at the time of service identified the
  245  subscriber as eligible to receive services.
  246         Section 8. Section 641.393, Florida Statutes, is created to
  247  read:
  248         641.393 Prior authorization.—Notwithstanding any other law,
  249  in order to establish uniformity in the submission of prior
  250  authorization forms, after January 1, 2015, a health maintenance
  251  organization shall use only the standardized prior authorization
  252  form adopted by the Financial Services Commission pursuant to s.
  253  627.42392 for obtaining prior authorization for a medical
  254  procedure, a course of treatment, or prescription drug benefits.
  255         (1) If a health maintenance organization contracts with a
  256  pharmacy benefits manager to perform prior authorization
  257  services for prescription drug benefits, the pharmacy benefits
  258  manager must use and accept the standardized prior authorization
  259  form. The office and health maintenance organization shall make
  260  the form electronically available on their respective websites.
  261         (2) A health care provider may submit the completed form
  262  electronically to the health maintenance organization.
  263         (3) A completed prior authorization request submitted by a
  264  health care provider using the standardized prior authorization
  265  form required under this section is deemed approved upon receipt
  266  by the health maintenance organization unless the health
  267  maintenance organization responds otherwise within 2 business
  268  days.
  269         (4) This section does not apply to grandfathered health
  270  plans, as defined in s. 627.402.
  271         Section 9. Section 641.394, Florida Statutes, is created to
  272  read:
  273         641.394 Medication protocol override.—If a health
  274  maintenance organization contract restricts medications for the
  275  treatment of a medical condition by a step-therapy or fail-first
  276  protocol, the prescribing provider shall have access to a clear
  277  and convenient process to request an override of the protocol
  278  from the health maintenance organization.
  279         (1) The health maintenance organization shall grant an
  280  override within 24 hours if the prescribing provider believes
  281  that:
  282         (a) Based on sound clinical evidence, the preferred
  283  treatment required under the step-therapy or fail-first protocol
  284  has been ineffective in the treatment of the subscriber’s
  285  disease or medical condition; or
  286         (b) Based on sound clinical evidence or medical and
  287  scientific evidence, the preferred treatment required under the
  288  step-therapy or fail-first protocol:
  289         1. Is expected or likely to be ineffective based on known
  290  relevant physical or mental characteristics of the subscriber
  291  and known characteristics of the drug regimen; or
  292         2.Will cause or is likely to cause an adverse reaction or
  293  other physical harm to the subscriber.
  294         (2) If the prescribing provider allows the subscriber to
  295  enter the step-therapy or fail-first protocol recommended by the
  296  health maintenance organization, the duration of the step
  297  therapy or fail-first protocol may not exceed a period deemed
  298  appropriate by the provider. If the prescribing provider deems
  299  the treatment clinically ineffective, the subscriber is entitled
  300  to receive the recommended course of therapy without requiring
  301  the prescribing provider to seek approval for an override of the
  302  step-therapy or fail-first protocol.
  303         (3)This section does not apply to grandfathered health
  304  plans, as defined in s. 627.402.
  305         Section 10. This act shall take effect July 1, 2014.
  306  
  307  ================= T I T L E  A M E N D M E N T ================
  308  And the title is amended as follows:
  309         Delete everything before the enacting clause
  310  and insert:
  311                        A bill to be entitled                      
  312         An act relating to health care; amending s. 409.967,
  313         F.S.; revising contract requirements for Medicaid
  314         managed care programs; providing requirements for
  315         plans establishing a drug formulary or preferred drug
  316         list; requiring the plan to authorize an enrollee to
  317         continue a drug that is removed or changed, under
  318         certain circumstances; requiring the use of a
  319         standardized prior authorization form; requiring a
  320         pharmacy benefits manage to use and accept the form
  321         under certain circumstances; providing requirements
  322         for the form and for the availability and submission
  323         of the form; establishing a process for providers to
  324         override certain treatment restrictions; providing
  325         requirements for approval of such overrides; providing
  326         an exception to the override protocol in certain
  327         circumstances; creating s. 627.42392, F.S.; requiring
  328         health insurers to use a standardized prior
  329         authorization form; requiring a pharmacy benefits
  330         manage to use and accept the form under certain
  331         circumstances; providing requirements for the form and
  332         for the availability and submission of the form;
  333         providing an exemption; creating s. 627.42393, F.S.;
  334         establishing a process for providers to override
  335         certain treatment restrictions; providing requirements
  336         for approval of such overrides; providing an exception
  337         to the override protocol in certain circumstances;
  338         providing an exemption; amending s. 627.6131, F.S.;
  339         prohibiting an insurer from retroactively denying a
  340         claim in certain circumstances; amending s. 627.6471,
  341         F.S.; requiring insurers to post preferred provider
  342         information on a website; amending s. 627.6515, F.S.;
  343         applying provisions relating to prior authorization
  344         and override protocols to out-of-state groups;
  345         amending s. 641.3155, F.S.; prohibiting a health
  346         maintenance organization from retroactively denying a
  347         claim in certain circumstances; creating s. 641.393,
  348         F.S.; requiring the use of a standardized prior
  349         authorization form by a health maintenance
  350         organization; requiring a pharmacy benefits manager to
  351         use and accept the form under certain circumstances;
  352         providing requirements for the availability and
  353         submission of the form; providing an exemption;
  354         creating s. 641.394, F.S.; establishing a process for
  355         providers to override certain treatment restrictions;
  356         providing requirements for approval of such overrides;
  357         providing an exception to the override protocol in
  358         certain circumstances; providing an exemption;
  359         providing an effective date.