HB 591

1	A bill to be entitled
2	An act relating to health insurance; amending s. 409.912,
3	F.S.; requiring certain entities to include all
4	antiretroviral agents on their formularies; prohibiting
5	such entities from using access-limiting procedures to
6	restrict antiretroviral agents prescribed to treat a
7	person with HIV; creating ss. 627.6404, 627.6572, and
8	641.31093, F.S.; requiring all antiretroviral agents to be
9	included on health plan formularies; prohibiting access-
10	limiting procedures used to restrict antiretroviral agents
11	prescribed to treat a person with HIV; amending s.
12	627.6515, F.S.; including reference to such requirements
13	on policies issued by out-of-state groups; providing an
14	effective date.
15
16	Be It Enacted by the Legislature of the State of Florida:
17
18	Section 1.  Subsection (54) is added to section 409.912,
19	Florida Statutes, to read:
20	409.912  Cost-effective purchasing of health care.-The
21	agency shall purchase goods and services for Medicaid recipients
22	in the most cost-effective manner consistent with the delivery
23	of quality medical care. To ensure that medical services are
24	effectively utilized, the agency may, in any case, require a
25	confirmation or second physician's opinion of the correct
26	diagnosis for purposes of authorizing future services under the
27	Medicaid program. This section does not restrict access to
28	emergency services or poststabilization care services as defined
29	in 42 C.F.R. part 438.114. Such confirmation or second opinion
30	shall be rendered in a manner approved by the agency. The agency
31	shall maximize the use of prepaid per capita and prepaid
32	aggregate fixed-sum basis services when appropriate and other
33	alternative service delivery and reimbursement methodologies,
34	including competitive bidding pursuant to s. 287.057, designed
35	to facilitate the cost-effective purchase of a case-managed
36	continuum of care. The agency shall also require providers to
37	minimize the exposure of recipients to the need for acute
38	inpatient, custodial, and other institutional care and the
39	inappropriate or unnecessary use of high-cost services. The
40	agency shall contract with a vendor to monitor and evaluate the
41	clinical practice patterns of providers in order to identify
42	trends that are outside the normal practice patterns of a
43	provider's professional peers or the national guidelines of a
44	provider's professional association. The vendor must be able to
45	provide information and counseling to a provider whose practice
46	patterns are outside the norms, in consultation with the agency,
47	to improve patient care and reduce inappropriate utilization.
48	The agency may mandate prior authorization, drug therapy
49	management, or disease management participation for certain
50	populations of Medicaid beneficiaries, certain drug classes, or
51	particular drugs to prevent fraud, abuse, overuse, and possible
52	dangerous drug interactions. The Pharmaceutical and Therapeutics
53	Committee shall make recommendations to the agency on drugs for
54	which prior authorization is required. The agency shall inform
55	the Pharmaceutical and Therapeutics Committee of its decisions
56	regarding drugs subject to prior authorization. The agency is
57	authorized to limit the entities it contracts with or enrolls as
58	Medicaid providers by developing a provider network through
59	provider credentialing. The agency may competitively bid single-
60	source-provider contracts if procurement of goods or services
61	results in demonstrated cost savings to the state without
62	limiting access to care. The agency may limit its network based
63	on the assessment of beneficiary access to care, provider
64	availability, provider quality standards, time and distance
65	standards for access to care, the cultural competence of the
66	provider network, demographic characteristics of Medicaid
67	beneficiaries, practice and provider-to-beneficiary standards,
68	appointment wait times, beneficiary use of services, provider
69	turnover, provider profiling, provider licensure history,
70	previous program integrity investigations and findings, peer
71	review, provider Medicaid policy and billing compliance records,
72	clinical and medical record audits, and other factors. Providers
73	shall not be entitled to enrollment in the Medicaid provider
74	network. The agency shall determine instances in which allowing
75	Medicaid beneficiaries to purchase durable medical equipment and
76	other goods is less expensive to the Medicaid program than long-
77	term rental of the equipment or goods. The agency may establish
78	rules to facilitate purchases in lieu of long-term rentals in
79	order to protect against fraud and abuse in the Medicaid program
80	as defined in s. 409.913. The agency may seek federal waivers
81	necessary to administer these policies.
82	(54)  Any entity that provides Medicaid services on a
83	prepaid or fixed-sum basis shall include all antiretroviral
84	agents on its formulary and may not restrict antiretroviral
85	agents prescribed to treat a person with HIV through a
86	requirement for prior authorization, step therapy, or other
87	limitation that limits access to any antiretroviral agent.
88	Section 2.  Section 627.6404, Florida Statutes, is created
89	to read:
90	627.6404  HIV treatment.-Antiretroviral agents prescribed
91	to treat a person with HIV must be included on a health plan
92	formulary and may not be restricted through a requirement for
93	prior authorization, step therapy, or other limitation that
94	limits access to any antiretroviral agent.
95	Section 3.  Subsection (2) of section 627.6515, Florida
96	Statutes, is amended to read:
97	627.6515  Out-of-state groups.-
98	(2)  Except as otherwise provided in this part, this part
99	does not apply to a group health insurance policy issued or
100	delivered outside this state under which a resident of this
101	state is provided coverage if:
102	(a)  The policy is issued to an employee group the
103	composition of which is substantially as described in s.
104	627.653; a labor union group or association group the
105	composition of which is substantially as described in s.
106	627.654; an additional group the composition of which is
107	substantially as described in s. 627.656; a group insured under
108	a blanket health policy when the composition of the group is
109	substantially in compliance with s. 627.659; a group insured
110	under a franchise health policy when the composition of the
111	group is substantially in compliance with s. 627.663; an
112	association group to cover persons associated in any other
113	common group, which common group is formed primarily for
114	purposes other than providing insurance; a group that is
115	established primarily for the purpose of providing group
116	insurance, provided the benefits are reasonable in relation to
117	the premiums charged thereunder and the issuance of the group
118	policy has resulted, or will result, in economies of
119	administration; or a group of insurance agents of an insurer,
120	which insurer is the policyholder.;
121	(b)  Certificates evidencing coverage under the policy are
122	issued to residents of this state and contain in contrasting
123	color and not less than 10-point type the following statement:
124	"The benefits of the policy providing your coverage are governed
125	primarily by the law of a state other than Florida".; and
126	(c)  The policy provides the benefits specified in ss.
127	627.419, 627.6572, 627.6574, 627.6575, 627.6579, 627.6612,
128	627.66121, 627.66122, 627.6613, 627.667, 627.6675, 627.6691, and
129	627.66911.
130	(d)  Applications for certificates of coverage offered to
131	residents of this state must contain, in contrasting color and
132	not less than 12-point type, the following statement on the same
133	page as the applicant's signature:
134
135	"This policy is primarily governed by the laws of ...insert
136	state where the master policy if filed.... As a result, all of
137	the rating laws applicable to policies filed in this state do
138	not apply to this coverage, which may result in increases in
139	your premium at renewal that would not be permissible under a
140	Florida-approved policy. Any purchase of individual health
141	insurance should be considered carefully, as future medical
142	conditions may make it impossible to qualify for another
143	individual health policy. For information concerning individual
144	health coverage under a Florida-approved policy, consult your
145	agent or the Florida Department of Financial Services."
146
147	This paragraph applies only to group certificates providing
148	health insurance coverage which require individualized
149	underwriting to determine coverage eligibility for an individual
150	or premium rates to be charged to an individual except for the
151	following:
152	1.  Policies issued to provide coverage to groups of
153	persons all of whom are in the same or functionally related
154	licensed professions, and providing coverage only to such
155	licensed professionals, their employees, or their dependents;
156	2.  Policies providing coverage to small employers as
157	defined by s. 627.6699. Such policies shall be subject to, and
158	governed by, the provisions of s. 627.6699;
159	3.  Policies issued to a bona fide association, as defined
160	by s. 627.6571(5), provided that there is a person or board
161	acting as a fiduciary for the benefit of the members, and such
162	association is not owned, controlled by, or otherwise associated
163	with the insurance company; or
164	4.  Any accidental death, accidental death and
165	dismemberment, accident-only, vision-only, dental-only, hospital
166	indemnity-only, hospital accident-only, cancer, specified
167	disease, Medicare supplement, products that supplement Medicare,
168	long-term care, or disability income insurance, or similar
169	supplemental plans provided under a separate policy,
170	certificate, or contract of insurance, which cannot duplicate
171	coverage under an underlying health plan, coinsurance, or
172	deductibles or coverage issued as a supplement to workers'
173	compensation or similar insurance, or automobile medical-payment
174	insurance.
175	Section 4.  Section 627.6572, Florida Statutes, is created
176	to read:
177	627.6572  HIV treatment.-Antiretroviral agents prescribed
178	to treat a person with HIV must be included on a health plan
179	formulary and may not be restricted through a requirement for
180	prior authorization, step therapy, or other limitation that
181	limits access to any antiretroviral agent.
182	Section 5.  Section 641.31093, Florida Statutes, is created
183	to read:
184	641.31093  HIV treatment.-Antiretroviral agents prescribed
185	to treat a person with HIV must be included on a health plan
186	formulary and may not be restricted through a requirement for
187	prior authorization, step therapy, or other limitation that
188	limits access to any antiretroviral agent.
189	Section 6.  This act shall take effect July 1, 2010.

CODING: Words stricken are deletions; words underlined are additions.