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