Florida Senate - 2017                          SENATOR AMENDMENT
       Bill No. HB 7117, 1st Eng.
       
       
       
       
       
       
                                Ì1909909Î190990                         
       
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
                                       .                                
                                       .                                
                                       .                                
               Floor: 1c/RE/2R         .                                
             05/03/2017 07:06 PM       .                                
       —————————————————————————————————————————————————————————————————




       —————————————————————————————————————————————————————————————————
       Senator Steube moved the following:
       
    1         Senate Amendment to Amendment (449058) (with title
    2  amendment)
    3  
    4         Between lines 755 and 756
    5  insert:
    6         Section 17. Subsection (11) of section 627.6131, Florida
    7  Statutes, is amended to read:
    8         627.6131 Payment of claims.—
    9         (11) A health insurer may not retroactively deny a claim
   10  because of insured ineligibility:
   11         (a)At any time, if the health insurer verified the
   12  eligibility of an insured at the time of treatment and provided
   13  an authorization number. This paragraph applies to policies
   14  entered into or renewed on or after January 1, 2018.
   15         (b) More than 1 year after the date of payment of the
   16  claim.
   17         Section 18. Subsection (10) of section 641.3155, Florida
   18  Statutes, is amended to read:
   19         641.3155 Prompt payment of claims.—
   20         (10) A health maintenance organization may not
   21  retroactively deny a claim because of subscriber ineligibility:
   22         (a)At any time, if the health maintenance organization
   23  verified the eligibility of a subscriber at the time of
   24  treatment and provided an authorization number. This paragraph
   25  applies to contracts entered into or renewed on or after January
   26  1, 2018. This paragraph does not apply to Medicaid managed care
   27  plans pursuant to part IV of chapter 409.
   28         (b) More than 1 year after the date of payment of the
   29  claim.
   30         Section 19. Section 627.42392, Florida Statutes, is amended
   31  to read:
   32         627.42392 Prior authorization.—
   33         (1) As used in this section, the term:
   34         (a) “Health insurer” means an authorized insurer offering
   35  an individual or group insurance policy that provides major
   36  medical or similar comprehensive coverage health insurance as
   37  defined in s. 624.603, a managed care plan as defined in s.
   38  409.962(10) s. 409.962(9), or a health maintenance organization
   39  as defined in s. 641.19(12).
   40         (b)“Urgent care situation” has the same meaning as in s.
   41  627.42393.
   42         (2) Notwithstanding any other provision of law, effective
   43  January 1, 2017, or six (6) months after the effective date of
   44  the rule adopting the prior authorization form, whichever is
   45  later, a health insurer, or a pharmacy benefits manager on
   46  behalf of the health insurer, which does not provide an
   47  electronic prior authorization process for use by its contracted
   48  providers, shall only use the prior authorization form that has
   49  been approved by the Financial Services Commission for granting
   50  a prior authorization for a medical procedure, course of
   51  treatment, or prescription drug benefit. Such form may not
   52  exceed two pages in length, excluding any instructions or
   53  guiding documentation, and must include all clinical
   54  documentation necessary for the health insurer to make a
   55  decision. At a minimum, the form must include: (1) sufficient
   56  patient information to identify the member, date of birth, full
   57  name, and Health Plan ID number; (2) provider name, address and
   58  phone number; (3) the medical procedure, course of treatment, or
   59  prescription drug benefit being requested, including the medical
   60  reason therefor, and all services tried and failed; (4) any
   61  laboratory documentation required; and (5) an attestation that
   62  all information provided is true and accurate. The form, whether
   63  in electronic or paper format, may not require information that
   64  is not necessary for the determination of medical necessity of,
   65  or coverage for, the requested medical procedure, course of
   66  treatment, or prescription drug.
   67         (3) The Financial Services Commission in consultation with
   68  the Agency for Health Care Administration shall adopt by rule
   69  guidelines for all prior authorization forms which ensure the
   70  general uniformity of such forms.
   71         (4) Electronic prior authorization approvals do not
   72  preclude benefit verification or medical review by the insurer
   73  under either the medical or pharmacy benefits.
   74         (5)A health insurer or a pharmacy benefits manager on
   75  behalf of the health insurer must provide the following
   76  information in writing or in an electronic format upon request,
   77  and on a publicly accessible Internet website:
   78         (a)Detailed descriptions of requirements and restrictions
   79  to obtain prior authorization for coverage of a medical
   80  procedure, course of treatment, or prescription drug in clear,
   81  easily understandable language. Clinical criteria must be
   82  described in language easily understandable by a health care
   83  provider.
   84         (b)Prior authorization forms.
   85         (6)A health insurer or a pharmacy benefits manager on
   86  behalf of the health insurer may not implement any new
   87  requirements or restrictions or make changes to existing
   88  requirements or restrictions to obtain prior authorization
   89  unless:
   90         (a)The changes have been available on a publicly
   91  accessible Internet website at least 60 days before the
   92  implementation of the changes.
   93         (b)Policyholders and health care providers who are
   94  affected by the new requirements and restrictions or changes to
   95  the requirements and restrictions are provided with a written
   96  notice of the changes at least 60 days before the changes are
   97  implemented. Such notice may be delivered electronically or by
   98  other means as agreed to by the insured or health care provider.
   99  
  100  This subsection does not apply to expansion of health care
  101  services coverage.
  102         (7)A health insurer or a pharmacy benefits manager on
  103  behalf of the health insurer must authorize or deny a prior
  104  authorization request and notify the patient and the patient’s
  105  treating health care provider of the decision within:
  106         (a)Seventy-two hours of obtaining a completed prior
  107  authorization form for nonurgent care situations.
  108         (b)Twenty-four hours of obtaining a completed prior
  109  authorization form for urgent care situations.
  110         Section 20. Section 627.42393, Florida Statutes, is created
  111  to read:
  112         627.42393Fail-first protocols.—
  113         (1)As used in this section, the term:
  114         (a)“Fail-first protocol” means a written protocol that
  115  specifies the order in which a certain medical procedure, course
  116  of treatment, or prescription drug must be used to treat an
  117  insured’s condition.
  118         (b)“Health insurer” has the same meaning as provided in s.
  119  627.42392.
  120         (c)“Preceding prescription drug or medical treatment”
  121  means a medical procedure, course of treatment, or prescription
  122  drug that must be used pursuant to a health insurer’s fail-first
  123  protocol as a condition of coverage under a health insurance
  124  policy or a health maintenance contract to treat an insured’s
  125  condition.
  126         (d)“Protocol exception” means a determination by a health
  127  insurer that a fail-first protocol is not medically appropriate
  128  or indicated for treatment of an insured’s condition and the
  129  health insurer authorizes the use of another medical procedure,
  130  course of treatment, or prescription drug prescribed or
  131  recommended by the treating health care provider for the
  132  insured’s condition.
  133         (e)“Urgent care situation” means an injury or condition of
  134  an insured which, if medical care and treatment is not provided
  135  earlier than the time generally considered by the medical
  136  profession to be reasonable for a nonurgent situation, in the
  137  opinion of the insured’s treating physician, would:
  138         1.Seriously jeopardize the insured’s life, health, or
  139  ability to regain maximum function; or
  140         2.Subject the insured to severe pain that cannot be
  141  adequately managed.
  142         (2)A health insurer must publish on its website, and
  143  provide to an insured in writing, a procedure for an insured and
  144  health care provider to request a protocol exception. The
  145  procedure must include:
  146         (a)A description of the manner in which an insured or
  147  health care provider may request a protocol exception.
  148         (b)The manner and timeframe in which the health insurer is
  149  required to authorize or deny a protocol exception request or
  150  respond to an appeal to a health insurer’s authorization or
  151  denial of a request.
  152         (c)The conditions in which the protocol exception request
  153  must be granted.
  154         (3)(a)The health insurer must authorize or deny a protocol
  155  exception request or respond to an appeal to a health insurer’s
  156  authorization or denial of a request within:
  157         1.Seventy-two hours of obtaining a completed prior
  158  authorization form for nonurgent care situations.
  159         2.Twenty-four hours of obtaining a completed prior
  160  authorization form for urgent care situations.
  161         (b)An authorization of the request must specify the
  162  approved medical procedure, course of treatment, or prescription
  163  drug benefits.
  164         (c)A denial of the request must include a detailed,
  165  written explanation of the reason for the denial, the clinical
  166  rationale that supports the denial, and the procedure to appeal
  167  the health insurer’s determination.
  168         (4)A health insurer must grant a protocol exception
  169  request if:
  170         (a)A preceding prescription drug or medical treatment is
  171  contraindicated or will likely cause an adverse reaction or
  172  physical or mental harm to the insured;
  173         (b)A preceding prescription drug is expected to be
  174  ineffective, based on the medical history of the insured and the
  175  clinical evidence of the characteristics of the preceding
  176  prescription drug or medical treatment;
  177         (c)The insured has previously received a preceding
  178  prescription drug or medical treatment that is in the same
  179  pharmacologic class or has the same mechanism of action, and
  180  such drug or treatment lacked efficacy or effectiveness or
  181  adversely affected the insured; or
  182         (d)A preceding prescription drug or medical treatment is
  183  not in the best interest of the insured because the insured’s
  184  use of such drug or treatment is expected to:
  185         1.Cause a significant barrier to the insured’s adherence
  186  to or compliance with the insured’s plan of care;
  187         2.Worsen an insured’s medical condition that exists
  188  simultaneously but independently with the condition under
  189  treatment; or
  190         3.Decrease the insured’s ability to achieve or maintain
  191  his or her ability to perform daily activities.
  192         (5)The health insurer may request a copy of relevant
  193  documentation from the insured’s medical record in support of a
  194  protocol exception request.
  195  
  196  ================= T I T L E  A M E N D M E N T ================
  197  And the title is amended as follows:
  198         Delete line 851
  199  and insert:
  200         under the code under certain circumstances; amending
  201         s. 627.6131, F.S.; prohibiting a health insurer from
  202         retroactively denying a claim under specified
  203         circumstances; providing applicability; amending s.
  204         641.3155, F.S.; prohibiting a health maintenance
  205         organization from retroactively denying a claim under
  206         specified circumstances; providing applicability;
  207         exempting certain Medicaid managed care plans;
  208         amending s. 627.42392, F.S.; revising and providing
  209         definitions; revising criteria for prior authorization
  210         forms; requiring health insurers and pharmacy benefits
  211         managers on behalf of health insurers to provide
  212         certain information relating to prior authorization in
  213         a specified manner; prohibiting such insurers and
  214         pharmacy benefits managers from implementing or making
  215         changes to requirements or restrictions to obtain
  216         prior authorization, except under certain
  217         circumstances; providing applicability; requiring such
  218         insurers and pharmacy benefits managers to authorize
  219         or deny prior authorization requests and provide
  220         certain notices within specified timeframes; creating
  221         s. 627.42393, F.S.; providing definitions; requiring
  222         health insurers to publish on their websites and
  223         provide in writing to insureds a specified procedure
  224         to obtain protocol exceptions; specifying timeframes
  225         in which health insurers must authorize or deny
  226         protocol exception requests and respond to an appeal
  227         to a health insurer’s authorization or denial of a
  228         request; requiring authorizations or denials to
  229         specify certain information; providing circumstances
  230         in which health insurers must grant a protocol
  231         exception request; authorizing health insurers to
  232         request documentation in support of a protocol
  233         exception request; providing