Florida Senate - 2021                                    SB 1846
       
       
        
       By Senator Polsky
       
       
       
       
       
       29-01491-21                                           20211846__
    1                        A bill to be entitled                      
    2         An act relating to health insurance prior
    3         authorization; amending s. 627.42392, F.S.; defining
    4         the terms “pharmacy benefit manager” and “urgent
    5         health care service”; requiring health insurers and
    6         pharmacy benefit managers to establish an online
    7         electronic prior authorization process by a certain
    8         date; specifying requirements for, and restrictions
    9         on, such online electronic prior authorization
   10         process; requiring all prior authorization requests to
   11         health insurers and pharmacy benefit managers to be
   12         made using such online electronic prior authorization
   13         process by a certain date; deleting provisions
   14         requiring prior authorization forms to be approved by
   15         the Financial Services Commission under certain
   16         circumstances; specifying requirements for, and
   17         restrictions on, health insurers and pharmacy benefit
   18         managers relating to prior authorization information,
   19         requirements, restrictions, and changes; providing
   20         applicability; specifying timeframes within which
   21         prior authorization requests must be authorized or
   22         denied and the patient and the patient’s provider must
   23         be notified; amending ss. 627.6131 and 641.3156, F.S.;
   24         prohibiting health insurers and health maintenance
   25         organizations, respectively, from imposing an
   26         additional prior authorization requirement with
   27         respect to certain surgical or invasive procedures or
   28         certain items; providing an effective date.
   29          
   30  Be It Enacted by the Legislature of the State of Florida:
   31  
   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  health insurance as defined in s. 624.603, a managed care plan
   38  as defined in s. 409.962(10), or a health maintenance
   39  organization as defined in s. 641.19(12).
   40         (b)“Pharmacy benefit manager” has the same meaning as
   41  provided in s. 624.490.
   42         (c)Urgent health care service” means a health care
   43  service that, if not provided earlier than the time the medical
   44  profession generally considers reasonable for making a nonurgent
   45  prior authorization, in the opinion of a physician with
   46  knowledge of the patient’s medical condition, could:
   47         1.Seriously jeopardize the life or health of the patient
   48  or the ability of the patient to regain maximum function; or
   49         2.Subject the patient to severe pain that cannot be
   50  adequately managed without the care or treatment that is the
   51  subject of the prior authorization request.
   52         (2)Beginning January 1, 2022, a health insurer, or a
   53  pharmacy benefit manager on behalf of the health insurer, must
   54  establish and offer a secure, interactive online electronic
   55  prior authorization process for accepting electronic prior
   56  authorization requests. The process must allow a person seeking
   57  the prior authorization to upload documentation if such
   58  documentation is required by the health insurer or pharmacy
   59  benefit manager to adjudicate the prior authorization request.
   60  The electronic prior authorization process may not include
   61  transmissions through a facsimile machine.
   62         (3)Beginning January 1, 2022, all prior authorization
   63  requests to a health insurer or to a pharmacy benefit manager by
   64  a health care provider for medical procedures, surgical
   65  procedures, prescription drugs, or any other medical service
   66  must be made using the interactive online prior authorization
   67  process required in subsection (2).
   68         (2) Notwithstanding any other provision of law, effective
   69  January 1, 2017, or six (6) months after the effective date of
   70  the rule adopting the prior authorization form, whichever is
   71  later, a health insurer, or a pharmacy benefits manager on
   72  behalf of the health insurer, which does not provide an
   73  electronic prior authorization process for use by its contracted
   74  providers, shall only use the prior authorization form that has
   75  been approved by the Financial Services Commission for granting
   76  a prior authorization for a medical procedure, course of
   77  treatment, or prescription drug benefit. Such form may not
   78  exceed two pages in length, excluding any instructions or
   79  guiding documentation, and must include all clinical
   80  documentation necessary for the health insurer to make a
   81  decision. At a minimum, the form must include: (1) sufficient
   82  patient information to identify the member, date of birth, full
   83  name, and Health Plan ID number; (2) provider name, address and
   84  phone number; (3) the medical procedure, course of treatment, or
   85  prescription drug benefit being requested, including the medical
   86  reason therefor, and all services tried and failed; (4) any
   87  laboratory documentation required; and (5) an attestation that
   88  all information provided is true and accurate.
   89         (3) The Financial Services Commission in consultation with
   90  the Agency for Health Care Administration shall adopt by rule
   91  guidelines for all prior authorization forms which ensure the
   92  general uniformity of such forms.
   93         (4) Electronic prior authorization approvals do not
   94  preclude benefit verification or medical review by the insurer
   95  under either the medical or pharmacy benefits.
   96         (5)The prior authorization process may not require
   97  information that is not needed to make a determination or
   98  facilitate a determination of medical necessity of the requested
   99  medical procedure, course of treatment, or prescription drug
  100  benefit.
  101         (6)A health insurer, or a pharmacy benefit manager on
  102  behalf of the health insurer, shall make any current prior
  103  authorization requirements and restrictions readily accessible
  104  on its website.
  105         (7)A health insurer, or a pharmacy benefit manager on
  106  behalf of the health insurer, may not implement any new
  107  requirements or restrictions or make changes to existing
  108  requirements for or restrictions on obtaining prior
  109  authorization unless:
  110         (a)The changes have been available on a publicly
  111  accessible website for at least 60 days before they are
  112  implemented; and
  113         (b)Policyholders and health care providers who are
  114  affected by the new requirements and restrictions or changes to
  115  the requirements and restrictions are provided with a written
  116  notice of the changes at least 60 days before they are
  117  implemented. Such notice must be delivered electronically or by
  118  other means as agreed to by the insured or the health care
  119  provider.
  120  
  121  This subsection does not apply to the expansion of health care
  122  services coverage.
  123         (8)A health insurer, or a pharmacy benefit manager on
  124  behalf of the health insurer, must authorize or deny a prior
  125  authorization request and notify the patient and the patient’s
  126  treating health care provider of the decision within:
  127         (a)Three calendar days after receiving all necessary
  128  information to make the decision on the prior authorization
  129  request for nonurgent care situations.
  130         (b)Twenty-four hours after receiving all necessary
  131  information to make the decision on the prior authorization
  132  request for urgent care situations.
  133         Section 2. Subsection (20) is added to section 627.6131,
  134  Florida Statutes, to read:
  135         627.6131 Payment of claims.—
  136         (20)A health insurer may not impose an additional prior
  137  authorization requirement with respect to a surgical or
  138  otherwise invasive procedure, or any item furnished as part of
  139  the surgical or invasive procedure, if the procedure or item is
  140  furnished during the perioperative period of another procedure
  141  for which prior authorization was granted by the health insurer.
  142         Section 3. Subsection (4) is added to section 641.3156,
  143  Florida Statutes, to read:
  144         641.3156 Treatment authorization; payment of claims.—
  145         (4)A health maintenance organization may not impose an
  146  additional prior authorization requirement with respect to a
  147  surgical or otherwise invasive procedure, or any item furnished
  148  as part of the surgical or invasive procedure, if the procedure
  149  or item is furnished during the perioperative period of another
  150  procedure for which prior authorization was granted by the
  151  health maintenance organization.
  152         Section 4. This act shall take effect July 1, 2021.