Florida Senate - 2019 SB 650
By Senator Mayfield
17-00769-19 2019650__
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” and defining the term “urgent care
5 situation”; providing that prior authorization forms
6 may not require 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, by
10 specified means, certain information relating to prior
11 authorization; prohibiting such insurers and pharmacy
12 benefits managers from implementing or making changes
13 to requirements or restrictions to obtain prior
14 authorization, except under certain circumstances;
15 providing applicability; requiring such insurers and
16 pharmacy benefits managers to authorize or deny prior
17 authorization requests and provide certain notices
18 within specified timeframes; creating s. 627.42393,
19 F.S.; defining terms; requiring health insurers to
20 publish on their websites and provide to insureds in
21 writing a procedure for insureds and health care
22 providers to request protocol exceptions; specifying
23 requirements for such a procedure; requiring health
24 insurers, within specified timeframes, to authorize or
25 deny a protocol exception request or respond to
26 appeals of such authorizations or denials; requiring
27 that authorizations or denials 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 a 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, shall 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, in clear, easily understandable
86 language, of the requirements for and restrictions on obtaining
87 prior authorization for coverage of a medical procedure, course
88 of treatment, or prescription drug. 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 for 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 the health care
106 provider.
107
108 This subsection does not apply to the expansion of health care
109 services coverage.
110 (7) A health insurer, or a pharmacy benefits manager on
111 behalf of the health insurer, shall authorize or deny a prior
112 authorization request and notify the patient and the patient’s
113 treating health care provider of the decision within:
114 (a) Seventy-two hours after obtaining a completed prior
115 authorization form for nonurgent care situations.
116 (b) Twenty-four hours after obtaining a completed prior
117 authorization form for urgent care situations.
118 Section 2. Section 627.42393, Florida Statutes, is created
119 to read:
120 627.42393 Fail-first protocols.—
121 (1) As used in this section, the term:
122 (a) “Fail-first protocol” means a written protocol that
123 specifies the order in which a certain medical procedure, course
124 of treatment, or prescription drug must be used to treat an
125 insured’s condition.
126 (b) “Health insurer” has the same meaning as provided in s.
127 627.42392.
128 (c) “Preceding prescription drug or medical treatment”
129 means a medical procedure, course of treatment, or prescription
130 drug that must be used pursuant to a health insurer’s fail-first
131 protocol as a condition of coverage under a health insurance
132 policy or a health maintenance contract to treat an insured’s
133 condition.
134 (d) “Protocol exception” means a determination by a health
135 insurer that a fail-first protocol is not medically appropriate
136 or indicated for treatment of an insured’s condition and the
137 health insurer authorizes the use of another medical procedure,
138 course of treatment, or prescription drug prescribed or
139 recommended by the treating health care provider for the
140 insured’s condition.
141 (e) “Urgent care situation” means an injury or condition of
142 an insured which, if medical care and treatment were not
143 provided earlier than the time generally considered by the
144 medical profession to be reasonable for a nonurgent situation,
145 in the opinion of the insured’s treating physician, physician
146 assistant, or advanced practice registered nurse, would:
147 1. Seriously jeopardize the insured’s life, health, or
148 ability to regain maximum function; or
149 2. Subject the insured to severe pain that cannot be
150 adequately managed.
151 (2) A health insurer shall publish on its website and
152 provide to an insured in writing a procedure for an insured and
153 a health care provider to request a protocol exception. The
154 procedure must include:
155 (a) A description of the manner in which an insured or
156 health care provider may request a protocol exception.
157 (b) The manner and timeframe in which the health insurer is
158 required to authorize or deny a protocol exception request or to
159 respond to an appeal of a health insurer’s authorization or
160 denial of a request.
161 (c) The conditions under which the protocol exception
162 request must be granted.
163 (3)(a) The health insurer shall authorize or deny a
164 protocol exception request or respond to an appeal of a health
165 insurer’s authorization or denial of a request within:
166 1. Seventy-two hours after obtaining a completed prior
167 authorization form for nonurgent care situations.
168 2. Twenty-four hours after obtaining a completed prior
169 authorization form for urgent care situations.
170 (b) An authorization of the request must specify the
171 approved medical procedure, course of treatment, or prescription
172 drug benefits.
173 (c) A denial of the request must include a detailed,
174 written explanation of the reason for the denial, the clinical
175 rationale that supports the denial, and the procedure for
176 appealing the health insurer’s determination.
177 (4) A health insurer shall grant a protocol exception
178 request if any of the following applies:
179 (a) A preceding prescription drug or medical treatment is
180 contraindicated or will likely cause an adverse reaction or
181 physical or mental harm to the insured.
182 (b) A preceding prescription drug is expected to be
183 ineffective, based on the medical history of the insured and the
184 clinical evidence of the characteristics of the preceding
185 prescription drug or medical treatment.
186 (c) The insured has previously received a preceding
187 prescription drug or medical treatment that is in the same
188 pharmacologic class or has the same mechanism of action, and
189 such drug or treatment lacked efficacy or effectiveness or
190 adversely affected the insured.
191 (d) A preceding prescription drug or medical treatment is
192 not in the best interest of the insured because the insured’s
193 use of such drug or treatment is expected to:
194 1. Cause a significant barrier to the insured’s adherence
195 to or compliance with the insured’s plan of care;
196 2. Worsen an insured’s medical condition that exists
197 simultaneously but independently with the condition under
198 treatment; or
199 3. Decrease the insured’s ability to achieve or maintain
200 his or her ability to perform daily activities.
201 (e) A preceding prescription drug is an opioid, and the
202 protocol exception request is for a nonopioid prescription drug
203 or treatment with a likelihood of similar or better results.
204 (5) The health insurer may request a copy of relevant
205 documentation from the insured’s medical record in support of a
206 protocol exception request.
207 Section 3. This act shall take effect January 1, 2020.