Florida Senate - 2017 SENATOR AMENDMENT
Bill No. CS for HB 161
Senate . House
Floor: 1/AD/2R .
05/04/2017 08:31 PM .
Senator Steube moved the following:
1 Senate Amendment (with title amendment)
3 Before line 17
5 Section 1. Subsection (11) of section 627.6131, Florida
6 Statutes, is amended to read:
7 627.6131 Payment of claims.—
8 (11) A health insurer may not retroactively deny a claim
9 because of insured ineligibility:
10 (a) At any time, if the health insurer verified the
11 eligibility of an insured at the time of treatment and provided
12 an authorization number. This paragraph applies to policies
13 entered into or renewed on or after January 1, 2018.
14 (b) More than 1 year after the date of payment of the
16 Section 2. Subsection (10) of section 641.3155, Florida
17 Statutes, is amended to read:
18 641.3155 Prompt payment of claims.—
19 (10) A health maintenance organization may not
20 retroactively deny a claim because of subscriber ineligibility:
21 (a) At any time, if the health maintenance organization
22 verified the eligibility of a subscriber at the time of
23 treatment and provided an authorization number. This paragraph
24 applies to contracts entered into or renewed on or after January
25 1, 2018. This paragraph does not apply to Medicaid managed care
26 plans pursuant to part IV of chapter 409.
27 (b) More than 1 year after the date of payment of the
29 Section 3. Section 627.42392, Florida Statutes, is amended
30 to read:
31 627.42392 Prior authorization.—
32 (1) As used in this section, the term:
33 (a) “Health insurer” means an authorized insurer offering
34 an individual or group insurance policy that provides major
35 medical or similar comprehensive coverage
health insurance as
36 defined in s. 624.603, a managed care plan as defined in s.
37 409.962(10) s. 409.962(9), or a health maintenance organization
38 as defined in s. 641.19(12).
39 (b) “Urgent care situation” has the same meaning as s.
41 (2) Notwithstanding any other provision of law, effective
42 January 1, 2017, or six (6) months after the effective date of
43 the rule adopting the prior authorization form, whichever is
44 later, a health insurer, or a pharmacy benefits manager on
45 behalf of the health insurer, which does not provide an
46 electronic prior authorization process for use by its contracted
47 providers, shall only use the prior authorization form that has
48 been approved by the Financial Services Commission for granting
49 a prior authorization for a medical procedure, course of
50 treatment, or prescription drug benefit. Such form may not
51 exceed two pages in length, excluding any instructions or
52 guiding documentation, and must include all clinical
53 documentation necessary for the health insurer to make a
54 decision. At a minimum, the form must include: (1) sufficient
55 patient information to identify the member, date of birth, full
56 name, and Health Plan ID number; (2) provider name, address and
57 phone number; (3) the medical procedure, course of treatment, or
58 prescription drug benefit being requested, including the medical
59 reason therefor, and all services tried and failed; (4) any
60 laboratory documentation required; and (5) an attestation that
61 all information provided is true and accurate. The form, whether
62 in electronic or paper format, may not require information that
63 is not necessary for the determination of medical necessity of,
64 or coverage for, the requested medical procedure, course of
65 treatment, or prescription drug.
66 (3) The Financial Services Commission in consultation with
67 the Agency for Health Care Administration shall adopt by rule
68 guidelines for all prior authorization forms which ensure the
69 general uniformity of such forms.
70 (4) Electronic prior authorization approvals do not
71 preclude benefit verification or medical review by the insurer
72 under either the medical or pharmacy benefits.
73 (5) A health insurer or a pharmacy benefits manager on
74 behalf of the health insurer must provide the following
75 information in writing or in an electronic format upon request,
76 and on a publicly accessible Internet website:
77 (a) Detailed descriptions of requirements and restrictions
78 to obtain prior authorization for coverage of a medical
79 procedure, course of treatment, or prescription drug in clear,
80 easily understandable language. Clinical criteria must be
81 described in language easily understandable by a health care
83 (b) Prior authorization forms.
84 (6) A health insurer or a pharmacy benefits manager on
85 behalf of the health insurer may not implement any new
86 requirements or restrictions or make changes to existing
87 requirements or restrictions to obtain prior authorization
89 (a) The changes have been available on a publicly
90 accessible Internet website at least 60 days before the
91 implementation of the changes.
92 (b) Policyholders and health care providers who are
93 affected by the new requirements and restrictions or changes to
94 the requirements and restrictions are provided with a written
95 notice of the changes at least 60 days before the changes are
96 implemented. Such notice may be delivered electronically or by
97 other means as agreed to by the insured or health care provider.
99 This subsection does not apply to expansion of health care
100 services coverage.
101 (7) A health insurer or a pharmacy benefits manager on
102 behalf of the health insurer must authorize or deny a prior
103 authorization request and notify the patient and the patient’s
104 treating health care provider of the decision within:
105 (a) Seventy-two hours of obtaining a completed prior
106 authorization form for nonurgent care situations.
107 (b) Twenty-four hours of obtaining a completed prior
108 authorization form for urgent care situations.
109 Section 4. Section 627.42393, Florida Statutes, is created
110 to read:
111 627.42393 Fail-first protocols.—
112 (1) As used in this section, the term:
113 (a) “Fail-first protocol” means a written protocol that
114 specifies the order in which a certain medical procedure, course
115 of treatment, or prescription drug must be used to treat an
116 insured’s condition.
117 (b) “Health insurer” has the same meaning as provided in s.
119 (c) “Preceding prescription drug or medical treatment”
120 means a medical procedure, course of treatment, or prescription
121 drug that must be used pursuant to a health insurer’s fail-first
122 protocol as a condition of coverage under a health insurance
123 policy or a health maintenance contract to treat an insured’s
125 (d) “Protocol exception” means a determination by a health
126 insurer that a fail-first protocol is not medically appropriate
127 or indicated for treatment of an insured’s condition and the
128 health insurer authorizes the use of another medical procedure,
129 course of treatment, or prescription drug prescribed or
130 recommended by the treating health care provider for the
131 insured’s condition.
132 (e) “Urgent care situation” means an injury or condition of
133 an insured which, if medical care and treatment is not provided
134 earlier than the time generally considered by the medical
135 profession to be reasonable for a nonurgent situation, in the
136 opinion of the insured’s treating physician, would:
137 1. Seriously jeopardize the insured’s life, health, or
138 ability to regain maximum function; or
139 2. Subject the insured to severe pain that cannot be
140 adequately managed.
141 (2) A health insurer must publish on its website, and
142 provide to an insured in writing, a procedure for an insured and
143 health care provider to request a protocol exception. The
144 procedure must include:
145 (a) A description of the manner in which an insured or
146 health care provider may request a protocol exception.
147 (b) The manner and timeframe in which the health insurer is
148 required to authorize or deny a protocol exception request or
149 respond to an appeal to a health insurer’s authorization or
150 denial of a request.
151 (c) The conditions in which the protocol exception request
152 must be granted.
153 (3)(a) The health insurer must authorize or deny a protocol
154 exception request or respond to an appeal to a health insurer’s
155 authorization or denial of a request within:
156 1. Seventy-two hours of obtaining a completed prior
157 authorization form for nonurgent care situations.
158 2. Twenty-four hours of obtaining a completed prior
159 authorization form for urgent care situations.
160 (b) An authorization of the request must specify the
161 approved medical procedure, course of treatment, or prescription
162 drug benefits.
163 (c) A denial of the request must include a detailed,
164 written explanation of the reason for the denial, the clinical
165 rationale that supports the denial, and the procedure to appeal
166 the health insurer’s determination.
167 (4) A health insurer must grant a protocol exception
168 request if:
169 (a) A preceding prescription drug or medical treatment is
170 contraindicated or will likely cause an adverse reaction or
171 physical or mental harm to the insured;
172 (b) A preceding prescription drug is expected to be
173 ineffective, based on the medical history of the insured and the
174 clinical evidence of the characteristics of the preceding
175 prescription drug or medical treatment;
176 (c) The insured has previously received a preceding
177 prescription drug or medical treatment that is in the same
178 pharmacologic class or has the same mechanism of action, and
179 such drug or treatment lacked efficacy or effectiveness or
180 adversely affected the insured; or
181 (d) A preceding prescription drug or medical treatment is
182 not in the best interest of the insured because the insured’s
183 use of such drug or treatment is expected to:
184 1. Cause a significant barrier to the insured’s adherence
185 to or compliance with the insured’s plan of care;
186 2. Worsen an insured’s medical condition that exists
187 simultaneously but independently with the condition under
188 treatment; or
189 3. Decrease the insured’s ability to achieve or maintain
190 his or her ability to perform daily activities.
191 (5) The health insurer may request a copy of relevant
192 documentation from the insured’s medical record in support of a
193 protocol exception request.
195 ================= T I T L E A M E N D M E N T ================
196 And the title is amended as follows:
197 Delete line 2
198 and insert:
199 An act relating to health care; amending s. 627.6131,
200 F.S.; prohibiting a health insurer from retroactively
201 denying a claim under specified circumstances;
202 providing applicability; amending s. 641.3155, F.S.;
203 prohibiting a health maintenance organization from
204 retroactively denying a claim under specified
205 circumstances; providing applicability; exempting
206 certain Medicaid managed care plans; amending s.
207 627.42392, F.S.; revising and providing definitions;
208 revising criteria for prior authorization forms;
209 requiring health insurers and pharmacy benefits
210 managers on behalf of health insurers to provide
211 certain information relating to prior authorization in
212 a specified manner; prohibiting such insurers and
213 pharmacy benefits managers from implementing or making
214 changes to requirements or restrictions to obtain
215 prior authorization, except under certain
216 circumstances; providing applicability; requiring such
217 insurers or pharmacy benefits managers to authorize or
218 deny prior authorization requests and provide certain
219 notices within specified timeframes; creating s.
220 627.42393, F.S.; providing definitions; requiring
221 health insurers to publish on their websites and
222 provide in writing to insureds a specified procedure
223 to obtain protocol exceptions; specifying timeframes
224 in which health insurers must authorize or deny
225 protocol exception requests and respond to an appeal
226 to a health insurer’s authorization or denial of a
227 request; requiring authorizations or denials to
228 specify certain information; providing circumstances
229 in which health insurers must grant a protocol
230 exception request; authorizing health insurers to
231 request documentation in support of a protocol
232 exception request;