Florida Senate - 2018                        CS for CS for SB 98
       
       
        
       By the Committees on Rules; and Judiciary; and Senators Steube
       and Mayfield
       
       
       
       
       595-02013-18                                            201898c2
    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; authorizing the
    7         Financial Services Commission to adopt certain rules;
    8         requiring health insurers and pharmacy benefits
    9         managers on behalf of health insurers to provide
   10         certain information relating to prior authorization by
   11         specified means; prohibiting such insurers and
   12         pharmacy benefits managers from implementing or making
   13         changes to requirements or restrictions to obtain
   14         prior authorization except under certain
   15         circumstances; providing applicability; requiring such
   16         insurers and pharmacy benefits managers to authorize
   17         or deny prior authorization requests and provide
   18         certain notices within specified timeframes; creating
   19         s. 627.42393, F.S.; defining terms; requiring health
   20         insurers to publish on their websites and provide to
   21         insureds in writing a procedure for insureds and
   22         health care providers to request protocol exceptions;
   23         specifying requirements for such procedure; requiring
   24         health insurers, within specified timeframes, to
   25         authorize or deny a protocol exception request or
   26         respond to appeals of their authorizations or denials;
   27         requiring authorizations or denials to specify certain
   28         information; requiring health insurers to grant
   29         protocol exception requests under certain
   30         circumstances; authorizing health insurers to request
   31         documentation in support of a protocol exception
   32         request; providing an effective date.
   33          
   34  Be It Enacted by the Legislature of the State of Florida:
   35  
   36         Section 1. Section 627.42392, Florida Statutes, is amended
   37  to read:
   38         627.42392 Prior authorization.—
   39         (1) As used in this section, the term:
   40         (a) “Health insurer” means an authorized insurer offering
   41  an individual or group health insurance policy that provides
   42  major medical or similar comprehensive coverage health insurance
   43  as defined in s. 624.603, a managed care plan as defined in s.
   44  409.962(10), or a health maintenance organization as defined in
   45  s. 641.19(12).
   46         (b)“Urgent care situation” has the same meaning as in s.
   47  627.42393.
   48         (2) Notwithstanding any other provision of law, effective
   49  January 1, 2017, or six (6) months after the effective date of
   50  the rule adopting the prior authorization form, whichever is
   51  later, a health insurer, or a pharmacy benefits manager on
   52  behalf of the health insurer, which does not provide an
   53  electronic prior authorization process for use by its contracted
   54  providers, shall only use the prior authorization form that has
   55  been approved by the Financial Services Commission for granting
   56  a prior authorization for a medical procedure, course of
   57  treatment, or prescription drug benefit. Such form may not
   58  exceed two pages in length, excluding any instructions or
   59  guiding documentation, and must include all clinical
   60  documentation necessary for the health insurer to make a
   61  decision. At a minimum, the form must include: (1) sufficient
   62  patient information to identify the member, date of birth, full
   63  name, and Health Plan ID number; (2) provider name, address and
   64  phone number; (3) the medical procedure, course of treatment, or
   65  prescription drug benefit being requested, including the medical
   66  reason therefor, and all services tried and failed; (4) any
   67  laboratory documentation required; and (5) an attestation that
   68  all information provided is true and accurate. The form, whether
   69  in electronic or paper format, may not require information that
   70  is not necessary for the determination of medical necessity of,
   71  or coverage for, the requested medical procedure, course of
   72  treatment, or prescription drug. The commission may adopt rules
   73  prescribing such necessary information.
   74         (3) The Financial Services Commission in consultation with
   75  the Agency for Health Care Administration shall adopt by rule
   76  guidelines for all prior authorization forms which ensure the
   77  general uniformity of such forms.
   78         (4) Electronic prior authorization approvals do not
   79  preclude benefit verification or medical review by the insurer
   80  under either the medical or pharmacy benefits.
   81         (5)A health insurer or a pharmacy benefits manager on
   82  behalf of the health insurer must provide the following
   83  information in writing or in an electronic format upon request,
   84  and on a publicly accessible Internet website:
   85         (a)Detailed descriptions of requirements and restrictions
   86  to obtain prior authorization for coverage of a medical
   87  procedure, course of treatment, or prescription drug in clear,
   88  easily understandable language. Clinical criteria must be
   89  described in language easily understandable by a health care
   90  provider.
   91         (b)Prior authorization forms.
   92         (6)A health insurer or a pharmacy benefits manager on
   93  behalf of the health insurer may not implement any new
   94  requirements or restrictions or make changes to existing
   95  requirements or restrictions to obtain prior authorization
   96  unless:
   97         (a)The changes have been available on a publicly
   98  accessible Internet website at least 60 days before the
   99  implementation of the changes.
  100         (b)Policyholders and health care providers who are
  101  affected by the new requirements and restrictions or changes to
  102  the requirements and restrictions are provided with a written
  103  notice of the changes at least 60 days before the changes are
  104  implemented. Such notice may be delivered electronically or by
  105  other means as agreed to by the insured or health care provider.
  106  
  107  This subsection does not apply to expansion of health care
  108  services coverage.
  109         (7)A health insurer or a pharmacy benefits manager on
  110  behalf of the health insurer must authorize or deny a prior
  111  authorization request and notify the patient and the patient’s
  112  treating health care provider of the decision within:
  113         (a)Seventy-two hours of obtaining a completed prior
  114  authorization form for nonurgent care situations.
  115         (b)Twenty-four hours of obtaining a completed prior
  116  authorization form for urgent care situations.
  117         Section 2. Section 627.42393, Florida Statutes, is created
  118  to read:
  119         627.42393Fail-first protocols.—
  120         (1)As used in this section, the term:
  121         (a)“Fail-first protocol” means a written protocol that
  122  specifies the order in which a certain medical procedure, course
  123  of treatment, or prescription drug must be used to treat an
  124  insured’s condition.
  125         (b)“Health insurer” has the same meaning as provided in s.
  126  627.42392.
  127         (c)“Preceding prescription drug or medical treatment”
  128  means a medical procedure, course of treatment, or prescription
  129  drug that must be used pursuant to a health insurer’s fail-first
  130  protocol as a condition of coverage under a health insurance
  131  policy or a health maintenance contract to treat an insured’s
  132  condition.
  133         (d)“Protocol exception” means a determination by a health
  134  insurer that a fail-first protocol is not medically appropriate
  135  or indicated for treatment of an insured’s condition and the
  136  health insurer authorizes the use of another medical procedure,
  137  course of treatment, or prescription drug prescribed or
  138  recommended by the treating health care provider for the
  139  insured’s condition.
  140         (e)“Urgent care situation” means an injury or condition of
  141  an insured which, if medical care and treatment are not provided
  142  earlier than the time generally considered by the medical
  143  profession to be reasonable for a nonurgent situation, in the
  144  opinion of the insured’s treating physician, physician
  145  assistant, or advanced registered nurse practitioner, would:
  146         1.Seriously jeopardize the insured’s life, health, or
  147  ability to regain maximum function; or
  148         2.Subject the insured to severe pain that cannot be
  149  adequately managed.
  150         (2)A health insurer must publish on its website and
  151  provide to an insured in writing a procedure for an insured and
  152  health care provider to request a protocol exception. The
  153  procedure must include:
  154         (a)A description of the manner in which an insured or
  155  health care provider may request a protocol exception.
  156         (b)The manner and timeframe in which the health insurer is
  157  required to authorize or deny a protocol exception request or
  158  respond to an appeal of a health insurer’s authorization or
  159  denial of a request.
  160         (c)The conditions under which the protocol exception
  161  request must be granted.
  162         (3)(a)The health insurer must authorize or deny a protocol
  163  exception request or respond to an appeal of a health insurer’s
  164  authorization or denial of a request within:
  165         1.Seventy-two hours of obtaining a completed prior
  166  authorization form for nonurgent care situations.
  167         2.Twenty-four hours of obtaining a completed prior
  168  authorization form for urgent care situations.
  169         (b)An authorization of the request must specify the
  170  approved medical procedure, course of treatment, or prescription
  171  drug benefits.
  172         (c)A denial of the request must include a detailed,
  173  written explanation of the reason for the denial, the clinical
  174  rationale that supports the denial, and the procedure to appeal
  175  the health insurer’s determination.
  176         (4)A health insurer must grant a protocol exception
  177  request if:
  178         (a)A preceding prescription drug or medical treatment is
  179  contraindicated or will likely cause an adverse reaction or
  180  physical or mental harm to the insured;
  181         (b)A preceding prescription drug is expected to be
  182  ineffective, based on the medical history of the insured and the
  183  clinical evidence of the characteristics of the preceding
  184  prescription drug or medical treatment;
  185         (c)The insured has previously received a preceding
  186  prescription drug or medical treatment that is in the same
  187  pharmacologic class or has the same mechanism of action, and
  188  such drug or treatment lacked efficacy or effectiveness or
  189  adversely affected the insured; or
  190         (d)A preceding prescription drug or medical treatment is
  191  not in the best interest of the insured because the insured’s
  192  use of such drug or treatment is expected to:
  193         1.Cause a significant barrier to the insured’s adherence
  194  to or compliance with the insured’s plan of care;
  195         2.Worsen an insured’s medical condition that exists
  196  simultaneously but independently with the condition under
  197  treatment; or
  198         3.Decrease the insured’s ability to achieve or maintain
  199  his or her ability to perform daily activities.
  200         (5)The health insurer may request a copy of relevant
  201  documentation from the insured’s medical record in support of a
  202  protocol exception request.
  203         Section 3. This act shall take effect January 1, 2019.