Florida Senate - 2017                        COMMITTEE AMENDMENT
       Bill No. SB 530
       
       
       
       
       
       
                                Ì187710ÇÎ187710                         
       
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
                  Comm: RCS            .                                
                  03/27/2017           .                                
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       The Committee on Banking and Insurance (Steube) recommended the
       following:
       
    1         Senate Amendment (with title amendment)
    2  
    3         Delete everything after the enacting clause
    4  and insert:
    5         Section 1. Section 627.42392, Florida Statutes, is amended
    6  to read:
    7         627.42392 Prior authorization.—
    8         (1) As used in this section, the term:
    9         (a) “Health insurer” means an authorized insurer offering
   10  an individual or group insurance policy that provides major
   11  medical or similar comprehensive coverage or a health
   12  maintenance organization as defined in s. 641.19 health
   13  insurance as defined in s. 624.603, a managed care plan as
   14  defined in s. 409.962(9), or a health maintenance organization
   15  as defined in s. 641.19(12).
   16         (b)“Urgent care situation” has the same meaning as in s.
   17  627.42393.
   18         (2) Notwithstanding any other provision of law, effective
   19  January 1, 2017, or six (6) months after the effective date of
   20  the rule adopting the prior authorization form, whichever is
   21  later, a health insurer, or a pharmacy benefits manager on
   22  behalf of the health insurer, which does not provide an
   23  electronic prior authorization process for use by its contracted
   24  providers, shall only use the prior authorization form that has
   25  been approved by the Financial Services Commission for granting
   26  a prior authorization for a medical procedure, course of
   27  treatment, or prescription drug benefit. Such form may not
   28  exceed two pages in length, excluding any instructions or
   29  guiding documentation, and must include all clinical
   30  documentation necessary for the health insurer to make a
   31  decision. At a minimum, the form must include: (1) sufficient
   32  patient information to identify the member, date of birth, full
   33  name, and Health Plan ID number; (2) provider name, address and
   34  phone number; (3) the medical procedure, course of treatment, or
   35  prescription drug benefit being requested, including the medical
   36  reason therefor, and all services tried and failed; (4) any
   37  laboratory documentation required; and (5) an attestation that
   38  all information provided is true and accurate. The form, whether
   39  in electronic or paper format, may not require information that
   40  is not necessary for the determination of medical necessity of,
   41  or coverage for, the requested medical procedure, course of
   42  treatment, or prescription drug.
   43         (3) The Financial Services Commission in consultation with
   44  the Agency for Health Care Administration shall adopt by rule
   45  guidelines for all prior authorization forms which ensure the
   46  general uniformity of such forms.
   47         (4) Electronic prior authorization approvals do not
   48  preclude benefit verification or medical review by the insurer
   49  under either the medical or pharmacy benefits.
   50         (5)A health insurer or a pharmacy benefits manager on
   51  behalf of the health insurer must provide the following
   52  information in writing or in an electronic format upon request,
   53  and on a publicly accessible Internet website:
   54         (a)Detailed descriptions of requirements and restrictions
   55  to obtain prior authorization for coverage of a medical
   56  procedure, course of treatment, or prescription drug in clear,
   57  easily understandable language. Clinical criteria must be
   58  described in language easily understandable by a health care
   59  provider.
   60         (b)Prior authorization forms.
   61         (6)A health insurer or a pharmacy benefits manager on
   62  behalf of the health insurer may not implement any new
   63  requirements or restrictions or make changes to existing
   64  requirements or restrictions to obtain prior authorization
   65  unless:
   66         (a)The changes have been available on a publicly
   67  accessible Internet website at least 60 days before the
   68  implementation of the changes.
   69         (b)Policyholders and health care providers who are
   70  affected by the new requirements and restrictions or changes to
   71  the requirements and restrictions are provided with a written
   72  notice of the changes at least 60 days before the changes are
   73  implemented. Such notice may be delivered electronically or by
   74  other means as agreed to by the insured or health care provider.
   75  
   76  This subsection does not apply to expansion of health care
   77  services coverage.
   78         (7)A health insurer or a pharmacy benefits manager on
   79  behalf of the health insurer must authorize or deny a prior
   80  authorization request and notify the patient and the patient’s
   81  treating health care provider of the decision within:
   82         (a)Seventy-two hours of obtaining a completed prior
   83  authorization form for nonurgent care situations.
   84         (b)Twenty-four hours of obtaining a completed prior
   85  authorization form for urgent care situations.
   86         Section 2. Section 627.42393, Florida Statutes, is created
   87  to read:
   88         627.42393Fail-first protocols.—
   89         (1)As used in this section, the term:
   90         (a)“Fail-first protocol” means a written protocol that
   91  specifies the order in which a certain medical procedure, course
   92  of treatment, or prescription drug must be used to treat an
   93  insured’s condition.
   94         (b)“Health insurer” has the same meaning as provided in s.
   95  627.42392.
   96         (c)“Preceding prescription drug or medical treatment”
   97  means a medical procedure, course of treatment, or prescription
   98  drug that must be used pursuant to a health insurer’s fail-first
   99  protocol as a condition of coverage under a health insurance
  100  policy or a health maintenance contract to treat an insured’s
  101  condition.
  102         (d)“Protocol exception” means a determination by a health
  103  insurer that a fail-first protocol is not medically appropriate
  104  or indicated for treatment of an insured’s condition and the
  105  health insurer authorizes the use of another medical procedure,
  106  course of treatment, or prescription drug prescribed or
  107  recommended by the treating health care provider for the
  108  insured’s condition.
  109         (e)“Urgent care situation” means an injury or condition of
  110  an insured which, if medical care and treatment is not provided
  111  earlier than the time generally considered by the medical
  112  profession to be reasonable for a nonurgent situation, in the
  113  opinion of the insured’s treating physician, would:
  114         1.Seriously jeopardize the insured’s life, health, or
  115  ability to regain maximum function; or
  116         2.Subject the insured to severe pain that cannot be
  117  adequately managed.
  118         (2)A health insurer must publish on its website, and
  119  provide to an insured in writing, a procedure for an insured and
  120  health care provider to request a protocol exception. The
  121  procedure must include:
  122         (a)A description of the manner in which an insured or
  123  health care provider may request a protocol exception.
  124         (b)The manner and timeframe in which the health insurer is
  125  required to authorize or deny a protocol exception request or
  126  respond to an appeal to a health insurer’s authorization or
  127  denial of a request.
  128         (c)The conditions in which the protocol exception request
  129  must be granted.
  130         (3)(a)The health insurer must authorize or deny a protocol
  131  exception request or respond to an appeal to a health insurer’s
  132  authorization or denial of a request within:
  133         1.Seventy-two hours of obtaining a completed prior
  134  authorization form for nonurgent care situations.
  135         2.Twenty-four hours of obtaining a completed prior
  136  authorization form for urgent care situations.
  137         (b)An authorization of the request must specify the
  138  approved medical procedure, course of treatment, or prescription
  139  drug benefits.
  140         (c)A denial of the request must include a detailed,
  141  written explanation of the reason for the denial, the clinical
  142  rationale that supports the denial, and the procedure to appeal
  143  the health insurer’s determination.
  144         (4)A health insurer must grant a protocol exception
  145  request if:
  146         (a)A preceding prescription drug or medical treatment is
  147  contraindicated or will likely cause an adverse reaction or
  148  physical or mental harm to the insured;
  149         (b)A preceding prescription drug is expected to be
  150  ineffective, based on the medical history of the insured and the
  151  clinical evidence of the characteristics of the preceding
  152  prescription drug or medical treatment;
  153         (c)The insured has previously received a preceding
  154  prescription drug or medical treatment that is in the same
  155  pharmacologic class or has the same mechanism of action, and
  156  such drug or treatment lacked efficacy or effectiveness or
  157  adversely affected the insured; or
  158         (d)A preceding prescription drug or medical treatment is
  159  not in the best interest of the insured because the insured’s
  160  use of such drug or treatment is expected to:
  161         1.Cause a significant barrier to the insured’s adherence
  162  to or compliance with the insured’s plan of care;
  163         2.Worsen an insured’s medical condition that exists
  164  simultaneously but independently with the condition under
  165  treatment; or
  166         3.Decrease the insured’s ability to achieve or maintain
  167  his or her ability to perform daily activities.
  168         (5)The health insurer may request a copy of relevant
  169  documentation from the insured’s medical record in support of a
  170  protocol exception request.
  171         Section 3. This act shall take effect July 1, 2017.
  172  
  173  ================= T I T L E  A M E N D M E N T ================
  174  And the title is amended as follows:
  175         Delete everything before the enacting clause
  176  and insert:
  177                        A bill to be entitled                      
  178         An act relating to health insurer authorization;
  179         amending s. 627.42392, F.S.; revising and providing
  180         definitions; revising criteria for prior authorization
  181         forms; requiring health insurers and pharmacy benefits
  182         managers on behalf of health insurers to provide
  183         certain information relating to prior authorization in
  184         a specified manner; prohibiting such insurers and
  185         pharmacy benefits managers from implementing or making
  186         changes to requirements or restrictions to obtain
  187         prior authorization, except under certain
  188         circumstances; providing applicability; requiring such
  189         insurers or pharmacy benefits managers to authorize or
  190         deny prior authorization requests and provide certain
  191         notices within specified timeframes; creating s.
  192         627.42393, F.S.; providing definitions; requiring
  193         health insurers to publish on their websites and
  194         provide in writing to insureds a specified procedure
  195         to obtain protocol exceptions; specifying timeframes
  196         in which health insurers must authorize or deny
  197         protocol exception requests and respond to an appeal
  198         to a health insurer’s authorization or denial of a
  199         request; requiring authorizations or denials to
  200         specify certain information; providing circumstances
  201         in which health insurers must grant a protocol
  202         exception request; authorizing health insurers to
  203         request documentation in support of a protocol
  204         exception request; providing an effective date.