CS for CS for SB 1354 First Engrossed
20141354e1
1 A bill to be entitled
2 An act relating to health care; amending s. 395.0191,
3 F.S.; defining terms; requiring a certain percent of
4 surgical assistants or surgical technologists employed
5 or contracting with a hospital to be certified;
6 providing exceptions; amending s. 395.003, F.S.;
7 revising provisions relating to the provision of
8 cardiovascular services by a hospital; amending s.
9 400.235, F.S.; revising the criteria for recognition
10 as a Gold Seal Program nursing home facility; amending
11 s. 394.9082, F.S.; requiring the Department of
12 Children and Families to develop standards and
13 protocols for the collection, storage, transmittal,
14 and analysis of utilization data from public receiving
15 facilities; defining the term “public receiving
16 facility”; requiring the department to require
17 compliance by managing entities by a specified date;
18 requiring a managing entity to require public
19 receiving facilities in its provider network to submit
20 certain data within specified timeframes; requiring
21 managing entities to reconcile data to ensure
22 accuracy; requiring managing entities to submit
23 certain data to the department within specified
24 timeframes; requiring the department to create a
25 statewide database; requiring the department to adopt
26 rules; requiring the department to submit an annual
27 report to the Governor and the Legislature; providing
28 that implementation is subject to specific
29 appropriations; amending s. 409.967, F.S.; revising
30 contract requirements for Medicaid managed care
31 programs; providing requirements for plans
32 establishing a drug formulary or preferred drug list;
33 requiring the use of a standardized prior
34 authorization form; providing requirements for the
35 form and for the availability and submission of the
36 form; requiring a pharmacy benefits manager to use and
37 accept the form under certain circumstances;
38 establishing a process for providers to override
39 certain treatment restrictions; providing requirements
40 for approval of such overrides; providing an exception
41 to the override protocol in certain circumstances;
42 amending s. 465.189, F.S.; authorizing a pharmacist to
43 administer meningococcal and shingles vaccines;
44 creating s. 627.42392, F.S.; requiring health insurers
45 to use a standardized prior authorization form;
46 providing requirements for the form and for the
47 availability and submission of the form; requiring a
48 pharmacy benefits manager to use and accept the form
49 under certain circumstances; providing an exemption;
50 creating s. 627.42393, F.S.; establishing a process
51 for providers to override certain treatment
52 restrictions; providing requirements for approval of
53 such overrides; providing an exception to the override
54 protocol in certain circumstances; providing an
55 exemption; amending s. 627.6131, F.S.; prohibiting an
56 insurer from retroactively denying a claim in certain
57 circumstances; amending s. 627.6471, F.S.; requiring
58 insurers to post preferred provider information on a
59 website; specifying that changes to such a website
60 must be made within a certain time; amending s.
61 627.6515, F.S.; applying provisions relating to prior
62 authorization and override protocols to out-of-state
63 groups; amending s. 641.3155, F.S.; prohibiting a
64 health maintenance organization from retroactively
65 denying a claim in certain circumstances; creating s.
66 641.393, F.S.; requiring the use of a standardized
67 prior authorization form by a health maintenance
68 organization; providing requirements for the
69 availability and submission of the form; requiring a
70 pharmacy benefits manager to use and accept the form
71 under certain circumstances; providing an exemption;
72 creating s. 641.394, F.S.; establishing a process for
73 providers to override certain treatment restrictions;
74 providing requirements for approval of such overrides;
75 providing an exception to the override protocol in
76 certain circumstances; providing an exemption;
77 amending s. 395.4001, F.S.; conforming cross
78 references; amending s. 395.401, F.S.; limiting trauma
79 service fees to a certain amount; providing for future
80 expiration; conforming a cross-reference; amending s.
81 395.402, F.S.; requiring the Department of Health to
82 convene the Florida Trauma System Plan Advisory
83 Council by a specified date; requiring the advisory
84 council to review the Trauma System Consultation
85 Report and make recommendations to the Legislature by
86 a specified date; authorizing the advisory council to
87 make recommendations to the State Surgeon General;
88 designating the membership of the advisory council;
89 amending s. 395.4025, F.S.; deleting a provision
90 relating to the procedure for protesting an
91 application decision by the department; conforming
92 cross-references; authorizing certain provisional and
93 verified trauma centers to continue operating and to
94 apply for renewal; restricting the department from
95 verifying, designating, or provisionally approving
96 hospitals as trauma centers; providing for future
97 expiration; providing effective dates.
98
99 Be It Enacted by the Legislature of the State of Florida:
100
101 Section 1. Present subsections (1) through (10) of section
102 395.0191, Florida Statutes, are redesignated as subsections (2)
103 through (11), respectively, present subsection (6) is amended,
104 and a new subsection (1) and subsection (12) are added to that
105 section, to read:
106 395.0191 Staff membership and clinical privileges.—
107 (1) As used in this section, the term:
108 (a) “Certified surgical assistant” means a surgical
109 assistant who maintains a valid and active certification under
110 one of the following designations:
111 1. Certified surgical first assistant, from the National
112 Board of Surgical Technology and Surgical Assisting.
113 2. Certified surgical assistant, from the National Surgical
114 Assistant Association.
115 3. Surgical assistant-certified, from the American Board of
116 Surgical Assistants.
117 (b) “Certified surgical technologist” means a surgical
118 technologist who maintains a valid and active certification as a
119 certified surgical technologist from the National Board of
120 Surgical Technology and Surgical Assisting.
121 (c) “Surgeon” means a health care practitioner as defined
122 in s. 456.001 whose scope of practice includes performing
123 surgery and who is listed as the primary surgeon in the
124 operative record.
125 (d) “Surgical assistant” means a person who provides aid in
126 exposure, hemostasis, closures, and other intraoperative
127 technical functions and who assists the surgeon in performing a
128 safe operation with optimal results for the patient.
129 (e) “Surgical technologist” means a person whose duties
130 include, but are not limited to, maintaining sterility during a
131 surgical procedure, handling and ensuring the availability of
132 necessary equipment and supplies, and maintaining visibility of
133 the operative site to ensure that the operating room environment
134 is safe, that proper equipment is available, and that the
135 operative procedure is conducted efficiently.
136 (7)(6) Upon the written request of the applicant, a any
137 licensed facility that has denied staff membership or clinical
138 privileges to an any applicant specified in subsection (2) (1)
139 or subsection (3) (2) shall, within 30 days of such request,
140 provide the applicant with the reasons for such denial in
141 writing. A denial of staff membership or clinical privileges to
142 an any applicant shall be submitted, in writing, to the
143 applicant’s respective licensing board.
144 (12)(a) At least 50 percent of the surgical assistants that
145 a facility employs or contracts must be certified surgical
146 assistants.
147 (b) At least 50 percent of the surgical technologists that
148 a facility employs or contracts must be certified surgical
149 technologists.
150 (c) Paragraphs (a) and (b) do not apply to:
151 1. A person who has completed an appropriate training
152 program for surgical technology in any branch of the Armed
153 Forces or reserve component of the Armed Forces.
154 2. A person who was employed or contracted to perform the
155 duties of a surgical technologist or surgical assistant before
156 July 1, 2014.
157 3. A health care practitioner as defined in s. 456.001 or a
158 student if the duties performed by the practitioner or the
159 student are within the scope of the practitioner’s or the
160 student’s training and practice.
161 4. A person enrolled in a surgical technology or surgical
162 assisting training program accredited by the Commission on
163 Accreditation of Allied Health Education Programs, the
164 Accrediting Bureau of Health Education Schools, or other
165 accrediting body recognized by the United States Department of
166 Education on July 1, 2014. A person may practice as a surgical
167 technologist or a surgical assistant for 2 years after
168 completing such training program before he or she is required to
169 meet the criteria in paragraph (a).
170 Section 2. Paragraph (a) of subsection (6) of section
171 395.003, Florida Statutes, is amended to read:
172 395.003 Licensure; denial, suspension, and revocation.—
173 (6)(a) A specialty hospital may not provide any service or
174 regularly serve any population group beyond those services or
175 groups specified in its license. A specialty-licensed children’s
176 hospital that is authorized to provide pediatric cardiac
177 catheterization and pediatric open-heart surgery services may
178 provide cardiovascular service to adults who, as children, were
179 previously served by the hospital for congenital heart disease,
180 or to those patients who are referred only for a specialized
181 procedure only for congenital heart disease by an adult
182 hospital, without obtaining additional licensure as a provider
183 of adult cardiovascular services. The agency may request
184 documentation as needed to support patient selection and
185 treatment. This subsection does not apply to a specialty
186 licensed children’s hospital that is already licensed to provide
187 adult cardiovascular services.
188 Section 3. Paragraph (f) of subsection (5) of section
189 400.235, Florida Statutes, is amended to read:
190 400.235 Nursing home quality and licensure status; Gold
191 Seal Program.—
192 (5) Facilities must meet the following additional criteria
193 for recognition as a Gold Seal Program facility:
194 (f) Had no evidence of unresolved, verified complaints
195 generated through an outstanding record regarding the number and
196 types of substantiated complaints reported to the State Long
197 Term Care Ombudsman Program Council within the 30 months
198 preceding application for the program.
199
200 A facility assigned a conditional licensure status may not
201 qualify for consideration for the Gold Seal Program until after
202 it has operated for 30 months with no class I or class II
203 deficiencies and has completed a regularly scheduled relicensure
204 survey.
205 Section 4. Present subsections (10) and (11) of section
206 394.9082, Florida Statutes, are redesignated as subsections (11)
207 and (12), respectively, and a new subsection (10) is added to
208 that section, to read:
209 394.9082 Behavioral health managing entities.—
210 (10) CRISIS STABILIZATION SERVICES UTILIZATION DATABASE.
211 The department shall develop, implement, and maintain standards
212 under which a managing entity shall collect utilization data
213 from all public receiving facilities situated within its
214 geographic service area. As used in this subsection, the term
215 “public receiving facility” means an entity that meets the
216 licensure requirements of and is designated by the department to
217 operate as a public receiving facility under s. 394.875 and that
218 is operating as a licensed crisis stabilization unit.
219 (a) The department shall develop standards and protocols
220 for managing entities and public receiving facilities to be used
221 for data collection, storage, transmittal, and analysis. The
222 standards and protocols must allow for compatibility of data and
223 data transmittal between public receiving facilities, managing
224 entities, and the department for the implementation and
225 requirements of this subsection. The department shall require
226 managing entities contracted under this section to comply with
227 this subsection by August 1, 2014.
228 (b) A managing entity shall require a public receiving
229 facility within its provider network to submit data, in real
230 time or at least daily, to the managing entity for:
231 1. All admissions and discharges of clients receiving
232 public receiving facility services who qualify as indigent, as
233 defined in s. 394.4787; and
234 2. Current active census of total licensed beds, the number
235 of beds purchased by the department, the number of clients
236 qualifying as indigent occupying those beds, and the total
237 number of unoccupied licensed beds regardless of funding.
238 (c) A managing entity shall require a public receiving
239 facility within its provider network to submit data, on a
240 monthly basis, to the managing entity that aggregates the daily
241 data submitted under paragraph (b). The managing entity shall
242 reconcile the data in the monthly submission to the data
243 received by the managing entity under paragraph (b) to check for
244 consistency. If the monthly aggregate data submitted by a public
245 receiving facility under this paragraph is inconsistent with the
246 daily data submitted under paragraph (b), the managing entity
247 shall consult with the public receiving facility to make
248 corrections as necessary to ensure accurate data.
249 (d) A managing entity shall require a public receiving
250 facility within its provider network to submit data, on an
251 annual basis, to the managing entity that aggregates the data
252 submitted and reconciled under paragraph (c). The managing
253 entity shall reconcile the data in the annual submission to the
254 data received and reconciled by the managing entity under
255 paragraph (c) to check for consistency. If the annual aggregate
256 data submitted by a public receiving facility under this
257 paragraph is inconsistent with the data received and reconciled
258 under paragraph (c), the managing entity shall consult with the
259 public receiving facility to make corrections as necessary to
260 ensure accurate data.
261 (e) After ensuring accurate data under paragraphs (c) and
262 (d), the managing entity shall submit the data to the department
263 on a monthly and annual basis. The department shall create a
264 statewide database for the data described under paragraph (b)
265 and submitted under this paragraph for the purpose of analyzing
266 the payments for and the use of crisis stabilization services
267 funded by the Baker Act on a statewide basis and on an
268 individual public receiving facility basis.
269 (f) The department shall adopt rules to administer this
270 subsection.
271 (g) The department shall submit a report by January 31,
272 2015, and annually thereafter, to the Governor, the President of
273 the Senate, and the Speaker of the House of Representatives
274 which provides details on the implementation of this subsection,
275 including the status of the data collection process and a
276 detailed analysis of the data collected under this subsection.
277 (h) The implementation of this subsection is subject to
278 specific appropriations provided to the department in the
279 General Appropriations Act.
280 Section 5. Paragraph (c) of subsection (2) of section
281 409.967, Florida Statutes, is amended to read:
282 409.967 Managed care plan accountability.—
283 (2) The agency shall establish such contract requirements
284 as are necessary for the operation of the statewide managed care
285 program. In addition to any other provisions the agency may deem
286 necessary, the contract must require:
287 (c) Access.—
288 1. The agency shall establish specific standards for the
289 number, type, and regional distribution of providers in managed
290 care plan networks to ensure access to care for both adults and
291 children. Each plan must maintain a regionwide network of
292 providers in sufficient numbers to meet the access standards for
293 specific medical services for all recipients enrolled in the
294 plan. The exclusive use of mail-order pharmacies may not be
295 sufficient to meet network access standards. Consistent with the
296 standards established by the agency, provider networks may
297 include providers located outside the region. A plan may
298 contract with a new hospital facility before the date the
299 hospital becomes operational if the hospital has commenced
300 construction, will be licensed and operational by January 1,
301 2013, and a final order has issued in any civil or
302 administrative challenge. Each plan shall establish and maintain
303 an accurate and complete electronic database of contracted
304 providers, including information about licensure or
305 registration, locations and hours of operation, specialty
306 credentials and other certifications, specific performance
307 indicators, and such other information as the agency deems
308 necessary. The database must be available online to both the
309 agency and the public and have the capability of comparing to
310 compare the availability of providers to network adequacy
311 standards and to accept and display feedback from each
312 provider’s patients. Each plan shall submit quarterly reports to
313 the agency identifying the number of enrollees assigned to each
314 primary care provider.
315 2. If establishing a prescribed drug formulary or preferred
316 drug list, a managed care plan shall:
317 a. Provide a broad range of therapeutic options for the
318 treatment of disease states which are consistent with the
319 general needs of an outpatient population. If feasible, the
320 formulary or preferred drug list must include at least two
321 products in a therapeutic class.
322 b. Each managed care plan must Publish the any prescribed
323 drug formulary or preferred drug list on the plan’s website in a
324 manner that is accessible to and searchable by enrollees and
325 providers. The plan shall must update the list within 24 hours
326 after making a change. Each plan must ensure that the prior
327 authorization process for prescribed drugs is readily accessible
328 to health care providers, including posting appropriate contact
329 information on its website and providing timely responses to
330 providers.
331 3. For enrollees Medicaid recipients diagnosed with
332 hemophilia who have been prescribed anti-hemophilic-factor
333 replacement products, the agency shall provide for those
334 products and hemophilia overlay services through the agency’s
335 hemophilia disease management program.
336 3. Managed care plans, and their fiscal agents or
337 intermediaries, must accept prior authorization requests for any
338 service electronically.
339 4. Notwithstanding any other law, in order to establish
340 uniformity in the submission of prior authorization forms,
341 effective January 1, 2015, a managed care plan shall use a
342 single standardized form for obtaining prior authorization for a
343 medical procedure, course of treatment, or prescription drug
344 benefit. The form may not exceed two pages in length, excluding
345 any instructions or guiding documentation.
346 a. The managed care plan shall make the form available
347 electronically and online to practitioners. The prescribing
348 provider may electronically submit the completed prior
349 authorization form to the managed care plan.
350 b. If the managed care plan contracts with a pharmacy
351 benefits manager to perform prior authorization services for a
352 medical procedure, course of treatment, or prescription drug
353 benefit, the pharmacy benefits manager must use and accept the
354 standardized prior authorization form.
355 c. A completed prior authorization request submitted by a
356 health care provider using the standardized prior authorization
357 form is deemed approved upon receipt by the managed care plan
358 unless the managed care plan responds otherwise within 3
359 business days.
360 5. If medications for the treatment of a medical condition
361 are restricted for use by a managed care plan by a step-therapy
362 or fail-first protocol, the prescribing provider must have
363 access to a clear and convenient process to request an override
364 of the protocol from the managed care plan.
365 a. The managed care plan shall grant an override within 72
366 hours if the prescribing provider documents that:
367 (I) Based on sound clinical evidence, the preferred
368 treatment required under the step-therapy or fail-first protocol
369 has been ineffective in the treatment of the enrollee’s disease
370 or medical condition; or
371 (II) Based on sound clinical evidence or medical and
372 scientific evidence, the preferred treatment required under the
373 step-therapy or fail-first protocol:
374 (A) Is expected or is likely to be ineffective based on
375 known relevant physical or mental characteristics of the
376 enrollee and known characteristics of the drug regimen; or
377 (B) Will cause or will likely cause an adverse reaction or
378 other physical harm to the enrollee.
379 b. If the prescribing provider allows the enrollee to enter
380 the step-therapy or fail-first protocol recommended by the
381 managed care plan, the duration of the step-therapy or fail
382 first protocol may not exceed the customary period for use of
383 the medication if the prescribing provider demonstrates such
384 treatment to be clinically ineffective. If the managed care plan
385 can, through sound clinical evidence, demonstrate that the
386 originally prescribed medication is likely to require more than
387 the customary period to provide any relief or amelioration to
388 the enrollee, the step-therapy or fail-first protocol may be
389 extended for an additional period, but no longer than the
390 original customary period for use of the medication.
391 Notwithstanding this provision, a step-therapy or fail-first
392 protocol shall be terminated if the prescribing provider
393 determines that the enrollee is having an adverse reaction or is
394 suffering from other physical harm resulting from the use of the
395 medication.
396 Section 6. Subsections (1) and (2) of section 465.189,
397 Florida Statutes, are amended to read:
398 465.189 Administration of vaccines and epinephrine
399 autoinjection.—
400 (1) In accordance with guidelines of the Centers for
401 Disease Control and Prevention for each recommended immunization
402 or vaccine, a pharmacist may administer the following vaccines
403 to an adult within the framework of an established protocol
404 under a supervising physician licensed under chapter 458 or
405 chapter 459:
406 (a) Influenza vaccine.
407 (b) Pneumococcal vaccine.
408 (c) Meningococcal vaccine.
409 (d) Shingles vaccine.
410 (2) In accordance with guidelines of the Centers for
411 Disease Control and Prevention, a pharmacist may administer the
412 shingles vaccine within the framework of an established protocol
413 and pursuant to a written or electronic prescription issued to
414 the patient by a physician licensed under chapter 458 or chapter
415 459.
416 Section 7. Section 627.42392, Florida Statutes, is created
417 to read:
418 627.42392 Prior authorization.—
419 (1) Notwithstanding any other law, in order to establish
420 uniformity in the submission of prior authorization forms,
421 effective January 1, 2015, a health insurer that delivers,
422 issues for delivery, renews, amends, or continues an individual
423 or group health insurance policy in this state, including a
424 policy issued to a small employer as defined in s. 627.6699,
425 shall use a single standardized form for obtaining prior
426 authorization for a medical procedure, course of treatment, or
427 prescription drug benefit. The form may not exceed two pages in
428 length, excluding any instructions or guiding documentation.
429 (a) The health insurer shall make the form available
430 electronically and online to practitioners. The prescribing
431 provider may submit the completed prior authorization form
432 electronically to the health insurer.
433 (b) If the health insurer contracts with a pharmacy
434 benefits manager to perform prior authorization services for a
435 medical procedure, course of treatment, or prescription drug
436 benefit, the pharmacy benefits manager must use and accept the
437 standardized prior authorization form.
438 (c) A completed prior authorization request submitted by a
439 health care provider using the standardized prior authorization
440 form is deemed approved upon receipt by the health insurer
441 unless the health insurer responds otherwise within 3 business
442 days.
443 (2) This section does not apply to a grandfathered health
444 plan as defined in s. 627.402.
445 Section 8. Section 627.42393, Florida Statutes, is created
446 to read:
447 627.42393 Medication protocol override.—If an individual or
448 group health insurance policy, including a policy issued by a
449 small employer as defined in s. 627.6699, restricts medications
450 for the treatment of a medical condition by a step-therapy or
451 fail-first protocol, the prescribing provider must have access
452 to a clear and convenient process to request an override of the
453 protocol from the health insurer.
454 (1) The health insurer shall authorize an override of the
455 protocol within 72 hours if the prescribing provider documents
456 that:
457 (a) Based on sound clinical evidence, the preferred
458 treatment required under the step-therapy or fail-first protocol
459 has been ineffective in the treatment of the insured’s disease
460 or medical condition; or
461 (b) Based on sound clinical evidence or medical and
462 scientific evidence, the preferred treatment required under the
463 step-therapy or fail-first protocol:
464 1. Is expected or is likely to be ineffective based on
465 known relevant physical or mental characteristics of the insured
466 and known characteristics of the drug regimen; or
467 2. Will cause or is likely to cause an adverse reaction or
468 other physical harm to the insured.
469 (2) If the prescribing provider allows the insured to enter
470 the step-therapy or fail-first protocol recommended by the
471 health insurer, the duration of the step-therapy or fail-first
472 protocol may not exceed the customary period for use of the
473 medication if the prescribing provider demonstrates such
474 treatment to be clinically ineffective. If the health insurer
475 can, through sound clinical evidence, demonstrate that the
476 originally prescribed medication is likely to require more than
477 the customary period for such medication to provide any relief
478 or amelioration to the insured, the step-therapy or fail-first
479 protocol may be extended for an additional period of time, but
480 no longer than the original customary period for the medication.
481 Notwithstanding this provision, a step-therapy or fail-first
482 protocol shall be terminated if the prescribing provider
483 determines that the insured is having an adverse reaction or is
484 suffering from other physical harm resulting from the use of the
485 medication.
486 (3) This section does not apply to grandfathered health
487 plans, as defined in s. 627.402.
488 Section 9. Subsection (11) of section 627.6131, Florida
489 Statutes, is amended to read:
490 627.6131 Payment of claims.—
491 (11) A health insurer may not retroactively deny a claim
492 because of insured ineligibility:
493 (a) More than 1 year after the date of payment of the
494 claim; or
495 (b) If, under a policy compliant with the federal Patient
496 Protection and Affordable Care Act, as amended by the Health
497 Care and Education Reconciliation Act of 2010, and the
498 regulations adopted pursuant to those acts, the health insurer
499 verified the eligibility of the insured at the time of treatment
500 and provided an authorization number, unless, at the time
501 eligibility was verified, the provider was notified that the
502 insured was delinquent in paying the premium.
503 Section 10. Subsection (2) of section 627.6471, Florida
504 Statutes, is amended to read:
505 627.6471 Contracts for reduced rates of payment;
506 limitations; coinsurance and deductibles.—
507 (2) An Any insurer issuing a policy of health insurance in
508 this state, which insurance includes coverage for the services
509 of a preferred provider shall, must provide each policyholder
510 and certificateholder with a current list of preferred
511 providers, shall and must make the list available for public
512 inspection during regular business hours at the principal office
513 of the insurer within the state, and shall post a link to the
514 list of preferred providers on the home page of the insurer’s
515 website. Changes to the list of preferred providers must be
516 reflected on the insurer’s website within 24 hours.
517 Section 11. Paragraph (c) of subsection (2) of section
518 627.6515, Florida Statutes, is amended to read:
519 627.6515 Out-of-state groups.—
520 (2) Except as otherwise provided in this part, this part
521 does not apply to a group health insurance policy issued or
522 delivered outside this state under which a resident of this
523 state is provided coverage if:
524 (c) The policy provides the benefits specified in ss.
525 627.419, 627.42392, 627.42393, 627.6574, 627.6575, 627.6579,
526 627.6612, 627.66121, 627.66122, 627.6613, 627.667, 627.6675,
527 627.6691, and 627.66911, and complies with the requirements of
528 s. 627.66996.
529 Section 12. Subsection (10) of section 641.3155, Florida
530 Statutes, is amended to read:
531 641.3155 Prompt payment of claims.—
532 (10) A health maintenance organization may not
533 retroactively deny a claim because of subscriber ineligibility:
534 (a) More than 1 year after the date of payment of the
535 claim; or
536 (b) If, under a policy in compliance with the federal
537 Patient Protection and Affordable Care Act, as amended by the
538 Health Care and Education Reconciliation Act of 2010, and the
539 regulations adopted pursuant to those acts, the health
540 maintenance organization verified the eligibility of the
541 subscriber at the time of treatment and provided an
542 authorization number, unless, at the time eligibility was
543 verified, the provider was notified that the subscriber was
544 delinquent in paying the premium.
545 Section 13. Section 641.393, Florida Statutes, is created
546 to read:
547 641.393 Prior authorization.—Notwithstanding any other law,
548 in order to establish uniformity in the submission of prior
549 authorization forms, effective January 1, 2015, a health
550 maintenance organization shall use a single standardized form
551 for obtaining prior authorization for prescription drug
552 benefits. The form may not exceed two pages in length, excluding
553 any instructions or guiding documentation.
554 (1) A health maintenance organization shall make the form
555 available electronically and online to practitioners. A health
556 care provider may electronically submit the completed form to
557 the health maintenance organization.
558 (2) If a health maintenance organization contracts with a
559 pharmacy benefits manager to perform prior authorization
560 services for prescription drug benefits, the pharmacy benefits
561 manager must use and accept the standardized prior authorization
562 form.
563 (3) A completed prior authorization request submitted by a
564 health care provider using the standardized prior authorization
565 form required under this section is deemed approved upon receipt
566 by the health maintenance organization unless the health
567 maintenance organization responds otherwise within 3 business
568 days.
569 (4) This section does not apply to grandfathered health
570 plans, as defined in s. 627.402.
571 Section 14. Section 641.394, Florida Statutes, is created
572 to read:
573 641.394 Medication protocol override.—If a health
574 maintenance organization contract restricts medications for the
575 treatment of a medical condition by a step-therapy or fail-first
576 protocol, the prescribing provider shall have access to a clear
577 and convenient process to request an override of the protocol
578 from the health maintenance organization.
579 (1) The health maintenance organization shall grant an
580 override within 72 hours if the prescribing provider documents
581 that:
582 (a) Based on sound clinical evidence, the preferred
583 treatment required under the step-therapy or fail-first protocol
584 has been ineffective in the treatment of the subscriber’s
585 disease or medical condition; or
586 (b) Based on sound clinical evidence or medical and
587 scientific evidence, the preferred treatment required under the
588 step-therapy or fail-first protocol:
589 1. Is expected or is likely to be ineffective based on
590 known relevant physical or mental characteristics of the
591 subscriber and known characteristics of the drug regimen; or
592 2. Will cause or is likely to cause an adverse reaction or
593 other physical harm to the subscriber.
594 (2) If the prescribing provider allows the subscriber to
595 enter the step-therapy or fail-first protocol recommended by the
596 health maintenance organization, the duration of the step
597 therapy or fail-first protocol may not exceed the customary
598 period for use of the medication if the prescribing provider
599 demonstrates such treatment to be clinically ineffective. If the
600 health maintenance organization can, through sound clinical
601 evidence, demonstrate that the originally prescribed medication
602 is likely to require more than the customary period to provide
603 any relief or amelioration to the subscriber, the step-therapy
604 or fail-first protocol may be extended for an additional period,
605 but no longer than the original customary period for use of the
606 medication. Notwithstanding this provision, a step-therapy or
607 fail-first protocol shall be terminated if the prescribing
608 provider determines that the subscriber is having an adverse
609 reaction or is suffering from other physical harm resulting from
610 the use of the medication.
611 (3) This section does not apply to grandfathered health
612 plans, as defined in s. 627.402.
613 Section 15. Effective upon this act becoming a law,
614 paragraph (a) of subsection (7) and subsection (14) of section
615 395.4001, Florida Statutes, are amended to read:
616 395.4001 Definitions.—As used in this part, the term:
617 (7) “Level II trauma center” means a trauma center that:
618 (a) Is verified by the department to be in substantial
619 compliance with Level II trauma center standards and has been
620 approved by the department to operate as a Level II trauma
621 center or is designated pursuant to s. 395.4025(13) s.
622 395.4025(14).
623 (14) “Trauma center” means a hospital that has been
624 verified by the department to be in substantial compliance with
625 the requirements in s. 395.4025 and has been approved by the
626 department to operate as a Level I trauma center, Level II
627 trauma center, or pediatric trauma center, or is designated by
628 the department as a Level II trauma center pursuant to s.
629 395.4025(13) s. 395.4025(14).
630 Section 16. Effective upon this act becoming a law, present
631 paragraphs (k) through (o) of subsection (1) of section 395.401,
632 Florida Statutes, are redesignated as paragraphs (l) through
633 (p), respectively, a new paragraph (k) is added to that
634 subsection, and present paragraph (k) of that subsection is
635 amended, to read:
636 395.401 Trauma services system plans; approval of trauma
637 centers and pediatric trauma centers; procedures; renewal.—
638 (1)
639 (k) A hospital operating a trauma center may not charge a
640 trauma activation fee greater than $15,000. This paragraph
641 expires on July 1, 2015.
642 (l)(k) A It is unlawful for any hospital or other facility
643 may not to hold itself out as a trauma center unless it has been
644 so verified or designated pursuant to s. 395.4025(13) s.
645 395.4025(14).
646 Section 17. Effective upon this act becoming a law,
647 subsection (5) is added to section 395.402, Florida Statutes, to
648 read:
649 395.402 Trauma service areas; number and location of trauma
650 centers.—
651 (5) By October 1, 2014, the department must convene the
652 Florida Trauma System Plan Advisory Council in order to review
653 the Trauma System Consultation Report issued by the American
654 College of Surgeons Committee on Trauma dated February 2-5,
655 2013. Based on this review, the advisory council must submit
656 recommendations, including recommended statutory changes, to the
657 President of the Senate and the Speaker of the House of
658 Representatives by February 1, 2015. The advisory council may
659 make recommendations to the State Surgeon General regarding the
660 continuing development of the state trauma system. The advisory
661 council shall consist of nine representatives of an inclusive
662 trauma system appointed by the State Surgeon General as follows:
663 (a) A trauma patient, or a family member of a trauma
664 patient, who has sustained and recovered from severe injuries;
665 (b) A member of the Florida Committee on Trauma;
666 (c) A member of the Association of Florida Trauma
667 Coordinators;
668 (d) A chief executive officer of a nontrauma acute care
669 hospital who is a member of the Florida Hospital Association;
670 (e) A member of the Florida Emergency Medical Services
671 Advisory Council;
672 (f) A member of the Florida Injury Prevention Advisory
673 Council;
674 (g) A member of the Brain and Spinal Cord Injury Program
675 Advisory Council;
676 (h) A member of the Florida Chamber of Commerce; and
677 (i) A member of the Florida Health Insurance Advisory
678 Board.
679 Section 18. Effective upon this act becoming a law, present
680 subsections (8) through (12) of section 395.4025, Florida
681 Statutes, are redesignated as subsections (7) through (11),
682 respectively, paragraph (d) of subsection (2) and present
683 subsection (7) of that section are amended, present subsections
684 (13) and (14) of that section are redesignated as subsections
685 (12) and (13), respectively, and amended, and a new subsection
686 (14) and subsection (15) are added to that section, to read:
687 395.4025 Trauma centers; selection; quality assurance;
688 records.—
689 (2)
690 (d)1. Notwithstanding other provisions in this section, the
691 department may grant up to an additional 18 months to a hospital
692 applicant that is unable to meet all requirements as provided in
693 paragraph (c) at the time of application if the number of
694 applicants in the service area in which the applicant is located
695 is equal to or less than the service area allocation, as
696 provided by rule of the department. An applicant that is granted
697 additional time under pursuant to this paragraph shall submit a
698 plan for departmental approval which includes timelines and
699 activities that the applicant proposes to complete in order to
700 meet application requirements. An Any applicant that
701 demonstrates an ongoing effort to complete the activities within
702 the timelines outlined in the plan shall be included in the
703 number of trauma centers at such time that the department has
704 conducted a provisional review of the application and has
705 determined that the application is complete and that the
706 hospital has the critical elements required for a trauma center.
707 2. Timeframes provided in subsections (1)-(7) (1)-(8) shall
708 be stayed until the department determines that the application
709 is complete and that the hospital has the critical elements
710 required for a trauma center.
711 (7) Any hospital that wishes to protest a decision made by
712 the department based on the department’s preliminary or in-depth
713 review of applications or on the recommendations of the site
714 visit review team pursuant to this section shall proceed as
715 provided in chapter 120. Hearings held under this subsection
716 shall be conducted in the same manner as provided in ss. 120.569
717 and 120.57. Cases filed under chapter 120 may combine all
718 disputes between parties.
719 (12)(13) The department may adopt, by rule, the procedures
720 and process by which it will select trauma centers. Such
721 procedures and process must be used in annually selecting trauma
722 centers and must be consistent with subsections (1)-(7) (1)-(8)
723 except in those situations in which it is in the best interest
724 of, and mutually agreed to by, all applicants within a service
725 area and the department to reduce the timeframes.
726 (13)(14) Notwithstanding the procedures established
727 pursuant to subsections (1)-(12) (1) through (13), hospitals
728 located in areas with limited access to trauma center services
729 shall be designated by the department as Level II trauma centers
730 based on documentation of a valid certificate of trauma center
731 verification from the American College of Surgeons. Areas with
732 limited access to trauma center services are defined by the
733 following criteria:
734 (a) The hospital is located in a trauma service area with a
735 population greater than 600,000 persons but a population density
736 of less than 225 persons per square mile;
737 (b) The hospital is located in a county with no verified
738 trauma center; and
739 (c) The hospital is located at least 15 miles or 20 minutes
740 travel time by ground transport from the nearest verified trauma
741 center.
742 (14) Notwithstanding any other law, a hospital designated
743 as a provisional or verified as a Level I, Level II, or
744 pediatric trauma center after the enactment of chapter 2004-259,
745 Laws of Florida, whose approval has not been revoked may
746 continue to operate at the same trauma center level as a Level
747 I, Level II, or pediatric trauma center until the approval
748 period in subsection (6) expires, as long as the hospital
749 continues to meet the other requirements of part II of this
750 chapter related to trauma center standards and patient outcomes.
751 Any hospital that meets the requirements of this section is
752 eligible for renewal of its 7-year approval period pursuant to
753 subsection (6).
754 (15) The department may not verify, designate, or
755 provisionally approve any hospital to operate as a trauma center
756 through the procedures established in subsections (1)-(13). This
757 subsection expires July 1, 2015.
758 Section 19. Except as otherwise expressly provided in this
759 act and except for this section, which shall take effect upon
760 becoming a law, this act shall take effect July 1, 2014.