Bill Text: FL S0528 | 2021 | Regular Session | Introduced


Bill Title: Health Insurance Prior Authorization

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced) 2021-01-21 - Referred to Banking and Insurance; Health Policy; Appropriations [S0528 Detail]

Download: Florida-2021-S0528-Introduced.html
       Florida Senate - 2021                                     SB 528
       
       
        
       By Senator Harrell
       
       
       
       
       
       25-00636-21                                            2021528__
    1                        A bill to be entitled                      
    2         An act relating to health insurance prior
    3         authorization; amending s. 627.4239, F.S.; defining
    4         the terms “associated condition” and “health care
    5         provider”; prohibiting health maintenance
    6         organizations from excluding coverage for certain
    7         cancer treatment drugs; prohibiting health insurers
    8         and health maintenance organizations from requiring,
    9         before providing prescription drug coverage for the
   10         treatment of stage 4 metastatic cancer and associated
   11         conditions, that treatment has failed with a different
   12         drug; providing applicability; prohibiting insurers
   13         and health maintenance organizations from excluding
   14         coverage for certain drugs on certain grounds;
   15         revising construction; amending s. 627.42392, F.S.;
   16         revising the definition of the term “health insurer”;
   17         defining the term “urgent care situation”; specifying
   18         a requirement for the prior authorization form adopted
   19         by the Financial Services Commission by rule;
   20         authorizing the commission to adopt certain rules;
   21         specifying requirements for, and restrictions on,
   22         health insurers and pharmacy benefits managers
   23         relating to prior authorization information,
   24         requirements, restrictions, and changes; providing
   25         applicability; specifying timeframes in which prior
   26         authorization requests must be authorized or denied
   27         and the patient and the patient’s provider must be
   28         notified; amending s. 627.42393, F.S.; defining terms;
   29         requiring health insurers to provide and disclose
   30         procedures for insureds to request exceptions to step
   31         therapy protocols; specifying requirements for such
   32         procedures and disclosures; requiring health insurers
   33         to authorize or deny protocol exception requests and
   34         respond to certain appeals within specified
   35         timeframes; specifying required information in
   36         authorizations and denials of such requests; requiring
   37         health insurers to grant a protocol exception request
   38         under specified circumstances; authorizing health
   39         insurers to request certain documentation; conforming
   40         provisions to changes made by the act; amending s.
   41         627.6131, F.S.; prohibiting health insurers, under
   42         certain circumstances, from retroactively denying a
   43         claim at any time because of insured ineligibility;
   44         prohibiting health insurers from imposing an
   45         additional prior authorization requirement with
   46         respect to certain surgical or invasive procedures or
   47         certain items; amending s. 641.31, F.S.; defining
   48         terms; requiring health maintenance organizations to
   49         provide and disclose procedures for subscribers to
   50         request exceptions to step-therapy protocols;
   51         specifying requirements for such procedures and
   52         disclosures; requiring health maintenance
   53         organizations to authorize or deny protocol exception
   54         requests and respond to certain appeals within
   55         specified timeframes; specifying required information
   56         in authorizations and denials of such requests;
   57         requiring health maintenance organizations to grant a
   58         protocol exception request under specified
   59         circumstances; authorizing health maintenance
   60         organizations to request certain documentation;
   61         conforming provisions to changes made by the act;
   62         amending s. 641.3155, F.S.; prohibiting health
   63         maintenance organizations, under certain
   64         circumstances, from retroactively denying a claim at
   65         any time because of subscriber ineligibility; amending
   66         s. 641.3156, F.S.; prohibiting health maintenance
   67         organizations from imposing an additional prior
   68         authorization requirement with respect to certain
   69         surgical or invasive procedures or certain items;
   70         providing an effective date.
   71          
   72  Be It Enacted by the Legislature of the State of Florida:
   73  
   74         Section 1. Section 627.4239, Florida Statutes, is amended
   75  to read:
   76         627.4239 Coverage for use of drugs in treatment of cancer.—
   77         (1) DEFINITIONS.—As used in this section, the term:
   78         (a) “Associated condition” means a symptom or side effect
   79  that:
   80         1.Is associated with a particular cancer at a particular
   81  stage or with the treatment of that cancer; and
   82         2.In the judgment of a health care provider, will further
   83  jeopardize the health of a patient if left untreated. As used in
   84  this subparagraph, the term “health care provider” means a
   85  physician licensed under chapter 458, chapter 459, or chapter
   86  461, a physician assistant licensed under chapter 458 or chapter
   87  459, an advanced practice registered nurse licensed under
   88  chapter 464, or a dentist licensed under chapter 466.
   89         (b) “Medical literature” means scientific studies published
   90  in a United States peer-reviewed national professional journal.
   91         (c)(b) “Standard reference compendium” means authoritative
   92  compendia identified by the Secretary of the United States
   93  Department of Health and Human Services and recognized by the
   94  federal Centers for Medicare and Medicaid Services.
   95         (2) COVERAGE FOR TREATMENT OF CANCER.—
   96         (a) An insurer or a health maintenance organization may not
   97  exclude coverage in any individual or group health insurance
   98  policy or health maintenance contract issued, amended,
   99  delivered, or renewed in this state which covers the treatment
  100  of cancer for any drug prescribed for the treatment of cancer on
  101  the ground that the drug is not approved by the United States
  102  Food and Drug Administration for a particular indication, if
  103  that drug is recognized for treatment of that indication in a
  104  standard reference compendium or recommended in the medical
  105  literature.
  106         (b)Coverage for a drug required by this section also
  107  includes the medically necessary services associated with the
  108  administration of the drug.
  109         (3)COVERAGE FOR TREATMENT OF STAGE 4 METASTATIC CANCER AND
  110  ASSOCIATED CONDITIONS.—
  111         (a)An insurer or a health maintenance organization may not
  112  require in any individual or group health insurance policy or
  113  health maintenance contract issued, amended, delivered, or
  114  renewed in this state which covers the treatment of stage 4
  115  metastatic cancer and its associated conditions that, before a
  116  drug prescribed for the treatment is covered, the insured or
  117  subscriber fail or have previously failed to respond
  118  successfully to a different drug.
  119         (b)Paragraph (a) applies to a drug that is recognized for
  120  the treatment of such stage 4 metastatic cancer or its
  121  associated conditions, as applicable, in a standard reference
  122  compendium or that is recommended in the medical literature. The
  123  insurer or health maintenance organization may not exclude
  124  coverage for such drug on the ground that the drug is not
  125  approved by the United States Food and Drug Administration for
  126  such stage 4 metastatic cancer or its associated conditions, as
  127  applicable.
  128         (4)COVERAGE FOR SERVICES ASSOCIATED WITH DRUG
  129  ADMINISTRATION.—Coverage for a drug required by this section
  130  also includes the medically necessary services associated with
  131  the administration of the drug.
  132         (5)(3) APPLICABILITY AND SCOPE.—This section may not be
  133  construed to:
  134         (a) Alter any other law with regard to provisions limiting
  135  coverage for drugs that are not approved by the United States
  136  Food and Drug Administration, except for drugs for the treatment
  137  of stage 4 metastatic cancer or its associated conditions.
  138         (b) Require coverage for any drug, except for a drug for
  139  the treatment of stage 4 metastatic cancer or its associated
  140  conditions, if the United States Food and Drug Administration
  141  has determined that the use of the drug is contraindicated.
  142         (c) Require coverage for a drug that is not otherwise
  143  approved for any indication by the United States Food and Drug
  144  Administration, except for a drug for the treatment of stage 4
  145  metastatic cancer or its associated conditions.
  146         (d) Affect the determination as to whether particular
  147  levels, dosages, or usage of a medication associated with bone
  148  marrow transplant procedures are covered under an individual or
  149  group health insurance policy or health maintenance organization
  150  contract.
  151         (e) Apply to specified disease or supplemental policies.
  152         (f)(4)Nothing in this section is intended, Expressly or by
  153  implication, to create, impair, alter, limit, modify, enlarge,
  154  abrogate, prohibit, or withdraw any authority to provide
  155  reimbursement for drugs used in the treatment of any other
  156  disease or condition.
  157         Section 2. Section 627.42392, Florida Statutes, is amended
  158  to read:
  159         627.42392 Prior authorization.—
  160         (1) As used in this section, the term:
  161         (a) “Health insurer” means an authorized insurer offering
  162  an individual or group health insurance policy that provides
  163  major medical or similar comprehensive coverage health insurance
  164  as defined in s. 624.603, a managed care plan as defined in s.
  165  409.962(10), or a health maintenance organization as defined in
  166  s. 641.19(12).
  167         (b)“Urgent care situation” has the same meaning as
  168  provided in s. 627.42393(1).
  169         (2) Notwithstanding any other provision of law, effective
  170  January 1, 2017, or six (6) months after the effective date of
  171  the rule adopting the prior authorization form, whichever is
  172  later, a health insurer, or a pharmacy benefits manager on
  173  behalf of the health insurer, which does not provide an
  174  electronic prior authorization process for use by its contracted
  175  providers, shall only use the prior authorization form that has
  176  been approved by the Financial Services Commission for granting
  177  a prior authorization for a medical procedure, course of
  178  treatment, or prescription drug benefit. Such form may not
  179  exceed two pages in length, excluding any instructions or
  180  guiding documentation, and must include all clinical
  181  documentation necessary for the health insurer to make a
  182  decision. At a minimum, the form must include:
  183         (a)(1) Sufficient patient information to identify the
  184  member, his or her date of birth, full name, and Health Plan ID
  185  number;
  186         (b)(2)The provider’s provider name, address, and phone
  187  number;
  188         (c)(3) The medical procedure, course of treatment, or
  189  prescription drug benefit being requested, including the medical
  190  reason therefor, and all services tried and failed;
  191         (d)(4) Any laboratory documentation required; and
  192         (e)(5) An attestation that all information provided is true
  193  and accurate.
  194  
  195  The form, whether in electronic or paper format, must require
  196  only information that is necessary for the determination of
  197  medical necessity of, or coverage for, the requested medical
  198  procedure, course of treatment, or prescription drug benefit.
  199  The commission may adopt rules prescribing such necessary
  200  information.
  201         (3) The Financial Services Commission, in consultation with
  202  the Agency for Health Care Administration, shall adopt by rule
  203  guidelines for all prior authorization forms which ensure the
  204  general uniformity of such forms.
  205         (4) Electronic prior authorization approvals do not
  206  preclude benefit verification or medical review by the insurer
  207  under either the medical or pharmacy benefits.
  208         (5)A health insurer, or a pharmacy benefits manager on
  209  behalf of the health insurer, shall provide upon request the
  210  following information in writing or in an electronic format and
  211  publish it on a publicly accessible website:
  212         (a)Detailed descriptions in clear, easily understandable
  213  language of the requirements for, and restrictions on, obtaining
  214  prior authorization for coverage of a medical procedure, course
  215  of treatment, or prescription drug. Clinical criteria must be
  216  described in language a health care provider can easily
  217  understand.
  218         (b)Prior authorization forms.
  219         (6)A health insurer, or a pharmacy benefits manager on
  220  behalf of the health insurer, may not implement any new
  221  requirements or restrictions or make changes to existing
  222  requirements or restrictions on obtaining prior authorization
  223  unless:
  224         (a)The changes have been available on a publicly
  225  accessible website for at least 60 days before they are
  226  implemented; and
  227         (b)Policyholders and health care providers who are
  228  affected by the new requirements and restrictions or changes to
  229  the requirements and restrictions are provided with a written
  230  notice of the changes at least 60 days before they are
  231  implemented. Such notice may be delivered electronically or by
  232  other means as agreed to by the insured or the health care
  233  provider.
  234  
  235  This subsection does not apply to the expansion of health care
  236  services coverage.
  237         (7)A health insurer, or a pharmacy benefits manager on
  238  behalf of the health insurer, must authorize or deny a prior
  239  authorization request and notify the patient and the patient’s
  240  treating health care provider of the decision within:
  241         (a)Seventy-two hours after receiving a completed prior
  242  authorization form for nonurgent care situations.
  243         (b)Twenty-four hours after receiving a completed prior
  244  authorization form for urgent care situations.
  245         Section 3. Section 627.42393, Florida Statutes, is amended
  246  to read:
  247         627.42393 Step-therapy protocol restrictions and
  248  exceptions.—
  249         (1) DEFINITIONS.—As used in this section, the term:
  250         (a)Health coverage plan” means any of the following which
  251  is currently or was previously providing major medical or
  252  similar comprehensive coverage or benefits to the insured:
  253         1. A health insurer or health maintenance organization.
  254         2. A plan established or maintained by an individual
  255  employer as provided by the Employee Retirement Income Security
  256  Act of 1974, Pub. L. No. 93-406.
  257         3. A multiple-employer welfare arrangement as defined in s.
  258  624.437.
  259         4. A governmental entity providing a plan of self
  260  insurance.
  261         (b)“Health insurer” has the same meaning as provided in s.
  262  627.42392.
  263         (c)“Preceding prescription drug or medical treatment”
  264  means a prescription drug, medical procedure, or course of
  265  treatment that must be used pursuant to a health insurer’s step
  266  therapy protocol as a condition of coverage under a health
  267  insurance policy to treat an insured’s condition.
  268         (d)“Protocol exception” means a determination by a health
  269  insurer that a step-therapy protocol is not medically
  270  appropriate or indicated for treatment of an insured’s
  271  condition, and the health insurer authorizes the use of another
  272  medical procedure, course of treatment, or prescription drug
  273  prescribed or recommended by the treating health care provider
  274  for the insured’s condition.
  275         (e)Step-therapy protocol” means a written protocol that
  276  specifies the order in which certain medical procedures, courses
  277  of treatment, or prescription drugs must be used to treat an
  278  insured’s condition.
  279         (f)“Urgent care situation” means an injury or condition of
  280  an insured which, if medical care and treatment are not provided
  281  earlier than the time the medical profession generally considers
  282  reasonable for a nonurgent situation, in the opinion of the
  283  insured’s treating physician, physician assistant, or advanced
  284  practice registered nurse, would:
  285         1.Seriously jeopardize the insured’s life, health, or
  286  ability to regain maximum function; or
  287         2.Subject the insured to severe pain that cannot be
  288  adequately managed.
  289         (2)STEP-THERAPY PROTOCOL RESTRICTIONS.—In addition to
  290  protocol exceptions granted under subsection (3) and the
  291  restriction under s. 627.4239(3), a health insurer issuing a
  292  major medical individual or group policy may not require a step
  293  therapy protocol under the policy for a covered prescription
  294  drug requested by an insured if:
  295         (a) The insured has previously been approved to receive the
  296  prescription drug through the completion of a step-therapy
  297  protocol required by a separate health coverage plan; and
  298         (b) The insured provides documentation originating from the
  299  health coverage plan that approved the prescription drug as
  300  described in paragraph (a) indicating that the health coverage
  301  plan paid for the drug on the insured’s behalf during the 90
  302  days immediately before the request.
  303         (3)STEP-THERAPY PROTOCOL EXCEPTIONS; REQUIREMENTS AND
  304  PROCEDURES.—
  305         (a)A health insurer shall publish on its website and
  306  provide to an insured in writing a procedure for the insured and
  307  his or her health care provider to request a protocol exception.
  308  The procedure must include:
  309         1.The manner in which an insured or health care provider
  310  may request a protocol exception.
  311         2.The manner and timeframe in which the health insurer is
  312  required to authorize or deny a protocol exception request or to
  313  respond to an appeal of the health insurer’s authorization or
  314  denial of a request.
  315         3.The conditions under which the protocol exception
  316  request must be granted.
  317         (b)1.A health insurer must authorize or deny a protocol
  318  exception request or respond to an appeal of a health insurer’s
  319  authorization or denial of a request within:
  320         a.Seventy-two hours after receiving a completed prior
  321  authorization form for nonurgent care situations.
  322         b.Twenty-four hours after receiving a completed prior
  323  authorization form for urgent care situations.
  324         2.An authorization of the request must specify the
  325  approved medical procedure, course of treatment, or prescription
  326  drug benefits.
  327         3.A denial of the request must include a detailed written
  328  explanation of the reason for the denial, the clinical rationale
  329  that supports the denial, and the procedure for appealing the
  330  health insurer’s determination.
  331         (c)A health insurer must grant a protocol exception
  332  request if any of the following applies:
  333         1.A preceding prescription drug or medical treatment is
  334  contraindicated or will likely cause an adverse reaction or
  335  physical or mental harm to the insured.
  336         2.A preceding prescription drug or medical treatment is
  337  expected to be ineffective based on the insured’s medical
  338  history and the clinical evidence of the characteristics of the
  339  preceding prescription drug or medical treatment.
  340         3.The insured has previously received a preceding
  341  prescription drug or medical treatment that is in the same
  342  pharmacologic class or has the same mechanism of action and such
  343  drug or treatment lacked efficacy or effectiveness or adversely
  344  affected the insured.
  345         4. A preceding prescription drug or medical treatment is
  346  not in the insured’s best interest because his or her use of the
  347  drug or treatment is expected to:
  348         a. Cause a significant barrier to the insured’s adherence
  349  to or compliance with his or her plan of care;
  350         b. Worsen the insured’s medical condition that exists
  351  simultaneously with, but independently of, the condition under
  352  treatment; or
  353         c. Decrease the insured’s ability to achieve or maintain
  354  his or her ability to perform daily activities.
  355         5. A preceding prescription drug is an opioid and the
  356  protocol exception request is for a nonopioid prescription drug
  357  or treatment with a likelihood of similar or better results.
  358         (d)A health insurer may request a copy of relevant
  359  documentation from an insured’s medical record in support of a
  360  protocol exception request
  361         (2) As used in this section, the term “health coverage
  362  plan” means any of the following which is currently or was
  363  previously providing major medical or similar comprehensive
  364  coverage or benefits to the insured:
  365         (a) A health insurer or health maintenance organization.
  366         (b) A plan established or maintained by an individual
  367  employer as provided by the Employee Retirement Income Security
  368  Act of 1974, Pub. L. No. 93-406.
  369         (c) A multiple-employer welfare arrangement as defined in
  370  s. 624.437.
  371         (d) A governmental entity providing a plan of self
  372  insurance.
  373         (4)(3)CONSTRUCTION.—This section does not require a health
  374  insurer to add a drug to its prescription drug formulary or to
  375  cover a prescription drug that the insurer does not otherwise
  376  cover.
  377         Section 4. Subsection (11) of section 627.6131, Florida
  378  Statutes, is amended, and subsection (20) is added to that
  379  section, to read:
  380         627.6131 Payment of claims.—
  381         (11) A health insurer may not retroactively deny a claim
  382  because of insured ineligibility:
  383         (a) More than 1 year after the date of payment of the
  384  claim; or
  385         (b)At any time, if the health insurer verified the
  386  insured’s eligibility at the time of treatment or provided an
  387  authorization number.
  388         (20)A health insurer may not impose an additional prior
  389  authorization requirement with respect to a surgical or
  390  otherwise invasive procedure, or any item furnished as part of
  391  the surgical or invasive procedure, if the procedure or item is
  392  furnished during the perioperative period of another procedure
  393  for which prior authorization was granted by the health insurer.
  394         Section 5. Subsection (46) of section 641.31, Florida
  395  Statutes, is amended to read:
  396         641.31 Health maintenance contracts.—
  397         (46)(a) Definitions.As used in this subsection, the term:
  398         1.Health coverage plan” means any of the following which
  399  is currently or was previously providing major medical or
  400  similar comprehensive coverage or benefits to the subscriber:
  401         a. A health insurer or health maintenance organization.
  402         b. A plan established or maintained by an individual
  403  employer as provided by the Employee Retirement Income Security
  404  Act of 1974, Pub. L. No. 93-406.
  405         c. A multiple-employer welfare arrangement as defined in s.
  406  624.437.
  407         d. A governmental entity providing a plan of self
  408  insurance.
  409         2.“Preceding prescription drug or medical treatment” means
  410  a prescription drug, medical procedure, or course of treatment
  411  that must be used pursuant to a health maintenance
  412  organization’s step-therapy protocol as a condition of coverage
  413  under a health maintenance contract to treat a subscriber’s
  414  condition.
  415         3.“Protocol exception” means a determination by a health
  416  maintenance organization that a step-therapy protocol is not
  417  medically appropriate or indicated for treatment of a
  418  subscriber’s condition, and the health maintenance organization
  419  authorizes the use of another medical procedure, course of
  420  treatment, or prescription drug prescribed or recommended by the
  421  treating health care provider for the subscriber’s condition.
  422         4.Step-therapy protocol” means a written protocol that
  423  specifies the order in which certain medical procedures, courses
  424  of treatment, or prescription drugs must be used to treat a
  425  subscriber’s condition.
  426         5.“Urgent care situation” means an injury or condition of
  427  a subscriber which, if medical care and treatment are not
  428  provided earlier than the time the medical profession generally
  429  considers reasonable for a nonurgent situation, in the opinion
  430  of the subscriber’s treating physician, physician assistant, or
  431  advanced practice registered nurse, would:
  432         a.Seriously jeopardize the subscriber’s life, health, or
  433  ability to regain maximum function; or
  434         b.Subject the subscriber to severe pain that cannot be
  435  adequately managed.
  436         (b)Step-therapy protocol restrictions.In addition to
  437  protocol exceptions granted under paragraph (c) and the
  438  restriction under s. 627.4239(3), a health maintenance
  439  organization issuing major medical coverage through an
  440  individual or group contract may not require a step-therapy
  441  protocol under the contract for a covered prescription drug
  442  requested by a subscriber if:
  443         1. The subscriber has previously been approved to receive
  444  the prescription drug through the completion of a step-therapy
  445  protocol required by a separate health coverage plan; and
  446         2. The subscriber provides documentation originating from
  447  the health coverage plan that approved the prescription drug as
  448  described in subparagraph 1. indicating that the health coverage
  449  plan paid for the drug on the subscriber’s behalf during the 90
  450  days immediately before the request.
  451         (c)Step-therapy protocol exceptions; requirements and
  452  procedures.
  453         1.A health maintenance organization shall publish on its
  454  website and provide to a subscriber in writing a procedure for
  455  the subscriber and his or her health care provider to request a
  456  protocol exception. The procedure must include:
  457         a.The manner in which a subscriber or health care provider
  458  may request a protocol exception.
  459         b.The manner and timeframe in which the health maintenance
  460  organization is required to authorize or deny a protocol
  461  exception request or to respond to an appeal of the health
  462  maintenance organization’s authorization or denial of a request.
  463         c.The conditions under which the protocol exception
  464  request must be granted.
  465         2.a.A health maintenance organization must authorize or
  466  deny a protocol exception request or respond to an appeal of a
  467  health maintenance organization’s authorization or denial of a
  468  request within:
  469         (I)Seventy-two hours after receiving a completed prior
  470  authorization form for nonurgent care situations.
  471         (II)Twenty-four hours after receiving a completed prior
  472  authorization form for urgent care situations.
  473         b.An authorization of the request must specify the
  474  approved medical procedure, course of treatment, or prescription
  475  drug benefits.
  476         c.A denial of the request must include a detailed written
  477  explanation of the reason for the denial, the clinical rationale
  478  that supports the denial, and the procedure for appealing the
  479  health maintenance organization’s determination.
  480         3.A health maintenance organization must grant a protocol
  481  exception request if any of the following applies:
  482         a.A preceding prescription drug or medical treatment is
  483  contraindicated or will likely cause an adverse reaction or
  484  physical or mental harm to the subscriber.
  485         b.A preceding prescription drug or medical treatment is
  486  expected to be ineffective based on the subscriber’s medical
  487  history and the clinical evidence of the characteristics of the
  488  preceding prescription drug or medical treatment.
  489         c.The subscriber has previously received a preceding
  490  prescription drug or medical treatment that is in the same
  491  pharmacologic class or has the same mechanism of action and such
  492  drug or treatment lacked efficacy or effectiveness or adversely
  493  affected the subscriber.
  494         d. A preceding prescription drug or medical treatment is
  495  not in the subscriber’s best interest because his or her use of
  496  the drug or treatment is expected to:
  497         (I) Cause a significant barrier to the subscriber’s
  498  adherence to or compliance with his or her plan of care;
  499         (II) Worsen the subscriber’s medical condition that exists
  500  simultaneously with, but independently of, the condition under
  501  treatment; or
  502         (III) Decrease the subscriber’s ability to achieve or
  503  maintain his or her ability to perform daily activities.
  504         e. A preceding prescription drug is an opioid and the
  505  protocol exception request is for a nonopioid prescription drug
  506  or treatment with a likelihood of similar or better results.
  507         4.A health maintenance organization may request a copy of
  508  relevant documentation from a subscriber’s medical record in
  509  support of a protocol exception request
  510         (b) As used in this subsection, the term “health coverage
  511  plan” means any of the following which previously provided or is
  512  currently providing major medical or similar comprehensive
  513  coverage or benefits to the subscriber:
  514         1. A health insurer or health maintenance organization;
  515         2. A plan established or maintained by an individual
  516  employer as provided by the Employee Retirement Income Security
  517  Act of 1974, Pub. L. No. 93-406;
  518         3. A multiple-employer welfare arrangement as defined in s.
  519  624.437; or
  520         4. A governmental entity providing a plan of self
  521  insurance.
  522         (d)(c)Construction.This subsection does not require a
  523  health maintenance organization to add a drug to its
  524  prescription drug formulary or to cover a prescription drug that
  525  the health maintenance organization does not otherwise cover.
  526         Section 6. Subsection (10) of section 641.3155, Florida
  527  Statutes, is amended to read:
  528         641.3155 Prompt payment of claims.—
  529         (10) A health maintenance organization may not
  530  retroactively deny a claim because of subscriber ineligibility:
  531         (a) More than 1 year after the date of payment of the
  532  claim; or
  533         (b)At any time, if the health maintenance organization
  534  verified the subscriber’s eligibility at the time of treatment
  535  or provided an authorization number.
  536         Section 7. Subsection (4) is added to section 641.3156,
  537  Florida Statutes, to read:
  538         641.3156 Treatment authorization; payment of claims.—
  539         (4)A health maintenance organization may not impose an
  540  additional prior authorization requirement with respect to a
  541  surgical or otherwise invasive procedure, or any item furnished
  542  as part of the surgical or invasive procedure, if the procedure
  543  or item is furnished during the perioperative period of another
  544  procedure for which prior authorization was granted by the
  545  health maintenance organization.
  546         Section 8. This act shall take effect January 1, 2022.

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