Bill Text: FL S0820 | 2020 | Regular Session | Introduced
Bill Title: Health Insurance Prior Authorization
Spectrum: Partisan Bill (Republican 2-0)
Status: (Failed) 2020-03-14 - Died in Banking and Insurance [S0820 Detail]
Download: Florida-2020-S0820-Introduced.html
Florida Senate - 2020 SB 820 By Senator Harrell 25-00241C-20 2020820__ 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)(a)“Medical literature” means scientific studies 90 published in a United States peer-reviewed national professional 91 journal. 92 (c)(b)“Standard reference compendium” means authoritative 93 compendia identified by the Secretary of the United States 94 Department of Health and Human Services and recognized by the 95 federal Centers for Medicare and Medicaid Services. 96 (2) COVERAGE FOR TREATMENT OF CANCER.— 97(a)An insurer or a health maintenance organization may not 98 exclude coverage in any individual or group health insurance 99 policy or health maintenance contract issued, amended, 100 delivered, or renewed in this state which covers the treatment 101 of cancer for any drug prescribed for the treatment of cancer on 102 the ground that the drug is not approved by the United States 103 Food and Drug Administration for a particular indication, if 104 that drug is recognized for treatment of that indication in a 105 standard reference compendium or recommended in the medical 106 literature. 107(b)Coverage for a drug required by this section also108includes the medically necessary services associated with the109administration of the drug.110 (3) COVERAGE FOR TREATMENT OF STAGE 4 METASTATIC CANCER AND 111 ASSOCIATED CONDITIONS.— 112 (a) An insurer or a health maintenance organization may not 113 require in any individual or group health insurance policy or 114 health maintenance contract issued, amended, delivered, or 115 renewed in this state which covers the treatment of stage 4 116 metastatic cancer and its associated conditions that, before a 117 drug prescribed for the treatment is covered, the insured or 118 subscriber fail or have previously failed to respond 119 successfully to a different drug. 120 (b) Paragraph (a) applies to a drug that is recognized for 121 the treatment of such stage 4 metastatic cancer or its 122 associated conditions, as applicable, in a standard reference 123 compendium or that is recommended in the medical literature. The 124 insurer or health maintenance organization may not exclude 125 coverage for such drug on the ground that the drug is not 126 approved by the United States Food and Drug Administration for 127 such stage 4 metastatic cancer or its associated conditions, as 128 applicable. 129 (4) COVERAGE FOR SERVICES ASSOCIATED WITH DRUG 130 ADMINISTRATION.—Coverage for a drug required by this section 131 also includes the medically necessary services associated with 132 the administration of the drug. 133 (5)(3)APPLICABILITY AND SCOPE.—This section may not be 134 construed to: 135 (a) Alter any other law with regard to provisions limiting 136 coverage for drugs that are not approved by the United States 137 Food and Drug Administration, except for drugs for the treatment 138 of stage 4 metastatic cancer or its associated conditions. 139 (b) Require coverage for any drug, except for a drug for 140 the treatment of stage 4 metastatic cancer or its associated 141 conditions, if the United States Food and Drug Administration 142 has determined that the use of the drug is contraindicated. 143 (c) Require coverage for a drug that is not otherwise 144 approved for any indication by the United States Food and Drug 145 Administration, except for a drug for the treatment of stage 4 146 metastatic cancer or its associated conditions. 147 (d) Affect the determination as to whether particular 148 levels, dosages, or usage of a medication associated with bone 149 marrow transplant procedures are covered under an individual or 150 group health insurance policy or health maintenance organization 151 contract. 152 (e) Apply to specified disease or supplemental policies. 153 (f)(4)Nothing in this section is intended,Expressly or by 154 implication,tocreate, impair, alter, limit, modify, enlarge, 155 abrogate, prohibit, or withdraw any authority to provide 156 reimbursement for drugs used in the treatment of any other 157 disease or condition. 158 Section 2. Section 627.42392, Florida Statutes, is amended 159 to read: 160 627.42392 Prior authorization.— 161 (1) As used in this section, the term: 162 (a) “Health insurer” means an authorized insurer offering 163 an individual or group health insurance policy that provides 164 major medical or similar comprehensive coveragehealth insurance165as defined in s. 624.603, a managed care plan as defined in s. 166 409.962(10), or a health maintenance organization as defined in 167 s. 641.19(12). 168 (b) “Urgent care situation” has the same meaning as 169 provided in s. 627.42393(1). 170 (2) Notwithstanding any otherprovision oflaw, effective 171 January 1, 2017, or six (6) months after the effective date of 172 the rule adopting the prior authorization form, whichever is 173 later, a health insurer, or a pharmacy benefits manager on 174 behalf of the health insurer, which does not provide an 175 electronic prior authorization process for use by its contracted 176 providers, shall only use the prior authorization form that has 177 been approved by the Financial Services Commission for granting 178 a prior authorization for a medical procedure, course of 179 treatment, or prescription drug benefit. Such form may not 180 exceed two pages in length, excluding any instructions or 181 guiding documentation, and must include all clinical 182 documentation necessary for the health insurer to make a 183 decision. At a minimum, the form must include: 184 (a)(1)Sufficient patient information to identify the 185 member, his or her date of birth, full name, and Health Plan ID 186 number; 187 (b)(2)The provider’sprovidername, address, and phone 188 number; 189 (c)(3)The medical procedure, course of treatment, or 190 prescription drug benefit being requested, including the medical 191 reason therefor, and all services tried and failed; 192 (d)(4)Any laboratory documentation required; and 193 (e)(5)An attestation that all information provided is true 194 and accurate. 195 196 The form, whether in electronic or paper format, must require 197 only information that is necessary for the determination of 198 medical necessity of, or coverage for, the requested medical 199 procedure, course of treatment, or prescription drug benefit. 200 The commission may adopt rules prescribing such necessary 201 information. 202 (3) The Financial Services Commission, in consultation with 203 the Agency for Health Care Administration, shall adopt by rule 204 guidelines for all prior authorization forms which ensure the 205 general uniformity of such forms. 206 (4) Electronic prior authorization approvals do not 207 preclude benefit verification or medical review by the insurer 208 under either the medical or pharmacy benefits. 209 (5) A health insurer, or a pharmacy benefits manager on 210 behalf of the health insurer, shall provide upon request the 211 following information in writing or in an electronic format and 212 publish it on a publicly accessible website: 213 (a) Detailed descriptions in clear, easily understandable 214 language of the requirements for, and restrictions on, obtaining 215 prior authorization for coverage of a medical procedure, course 216 of treatment, or prescription drug. Clinical criteria must be 217 described in language a health care provider can easily 218 understand. 219 (b) Prior authorization forms. 220 (6) A health insurer, or a pharmacy benefits manager on 221 behalf of the health insurer, may not implement any new 222 requirements or restrictions or make changes to existing 223 requirements or restrictions on obtaining prior authorization 224 unless: 225 (a) The changes have been available on a publicly 226 accessible website for at least 60 days before they are 227 implemented; and 228 (b) Policyholders and health care providers who are 229 affected by the new requirements and restrictions or changes to 230 the requirements and restrictions are provided with a written 231 notice of the changes at least 60 days before they are 232 implemented. Such notice may be delivered electronically or by 233 other means as agreed to by the insured or the health care 234 provider. 235 236 This subsection does not apply to the expansion of health care 237 services coverage. 238 (7) A health insurer, or a pharmacy benefits manager on 239 behalf of the health insurer, must authorize or deny a prior 240 authorization request and notify the patient and the patient’s 241 treating health care provider of the decision within: 242 (a) Seventy-two hours after receiving a completed prior 243 authorization form for nonurgent care situations. 244 (b) Twenty-four hours after receiving a completed prior 245 authorization form for urgent care situations. 246 Section 3. Section 627.42393, Florida Statutes, is amended 247 to read: 248 627.42393 Step-therapy protocol restrictions and 249 exceptions.— 250 (1) DEFINITIONS.—As used in this section, the term: 251 (a) “Health coverage plan” means any of the following which 252 is currently or was previously providing major medical or 253 similar comprehensive coverage or benefits to the insured: 254 1. A health insurer or health maintenance organization. 255 2. A plan established or maintained by an individual 256 employer as provided by the Employee Retirement Income Security 257 Act of 1974, Pub. L. No. 93-406. 258 3. A multiple-employer welfare arrangement as defined in s. 259 624.437. 260 4. A governmental entity providing a plan of self 261 insurance. 262 (b) “Health insurer” has the same meaning as provided in s. 263 627.42392. 264 (c) “Preceding prescription drug or medical treatment” 265 means a prescription drug, medical procedure, or course of 266 treatment that must be used pursuant to a health insurer’s step 267 therapy protocol as a condition of coverage under a health 268 insurance policy to treat an insured’s condition. 269 (d) “Protocol exception” means a determination by a health 270 insurer that a step-therapy protocol is not medically 271 appropriate or indicated for treatment of an insured’s 272 condition, and the health insurer authorizes the use of another 273 medical procedure, course of treatment, or prescription drug 274 prescribed or recommended by the treating health care provider 275 for the insured’s condition. 276 (e) “Step-therapy protocol” means a written protocol that 277 specifies the order in which certain medical procedures, courses 278 of treatment, or prescription drugs must be used to treat an 279 insured’s condition. 280 (f) “Urgent care situation” means an injury or condition of 281 an insured which, if medical care and treatment are not provided 282 earlier than the time the medical profession generally considers 283 reasonable for a nonurgent situation, in the opinion of the 284 insured’s treating physician, physician assistant, or advanced 285 practice registered nurse, would: 286 1. Seriously jeopardize the insured’s life, health, or 287 ability to regain maximum function; or 288 2. Subject the insured to severe pain that cannot be 289 adequately managed. 290 (2) STEP-THERAPY PROTOCOL RESTRICTIONS.—In addition to 291 protocol exceptions granted under subsection (3) and the 292 restriction under s. 627.4239(3), a health insurer issuing a 293 major medical individual or group policy may not require a step 294 therapy protocol under the policy for a covered prescription 295 drug requested by an insured if: 296 (a) The insured has previously been approved to receive the 297 prescription drug through the completion of a step-therapy 298 protocol required by a separate health coverage plan; and 299 (b) The insured provides documentation originating from the 300 health coverage plan that approved the prescription drug as 301 described in paragraph (a) indicating that the health coverage 302 plan paid for the drug on the insured’s behalf during the 90 303 days immediately before the request. 304 (3) STEP-THERAPY PROTOCOL EXCEPTIONS; REQUIREMENTS AND 305 PROCEDURES.— 306 (a) A health insurer shall publish on its website and 307 provide to an insured in writing a procedure for the insured and 308 his or her health care provider to request a protocol exception. 309 The procedure must include: 310 1. The manner in which an insured or health care provider 311 may request a protocol exception. 312 2. The manner and timeframe in which the health insurer is 313 required to authorize or deny a protocol exception request or to 314 respond to an appeal of the health insurer’s authorization or 315 denial of a request. 316 3. The conditions under which the protocol exception 317 request must be granted. 318 (b)1. A health insurer must authorize or deny a protocol 319 exception request or respond to an appeal of a health insurer’s 320 authorization or denial of a request within: 321 a. Seventy-two hours after receiving a completed prior 322 authorization form for nonurgent care situations. 323 b. Twenty-four hours after receiving a completed prior 324 authorization form for urgent care situations. 325 2. An authorization of the request must specify the 326 approved medical procedure, course of treatment, or prescription 327 drug benefits. 328 3. A denial of the request must include a detailed written 329 explanation of the reason for the denial, the clinical rationale 330 that supports the denial, and the procedure for appealing the 331 health insurer’s determination. 332 (c) A health insurer must grant a protocol exception 333 request if any of the following applies: 334 1. A preceding prescription drug or medical treatment is 335 contraindicated or will likely cause an adverse reaction or 336 physical or mental harm to the insured. 337 2. A preceding prescription drug or medical treatment is 338 expected to be ineffective based on the insured’s medical 339 history and the clinical evidence of the characteristics of the 340 preceding prescription drug or medical treatment. 341 3. The insured has previously received a preceding 342 prescription drug or medical treatment that is in the same 343 pharmacologic class or has the same mechanism of action and such 344 drug or treatment lacked efficacy or effectiveness or adversely 345 affected the insured. 346 4. A preceding prescription drug or medical treatment is 347 not in the insured’s best interest because his or her use of the 348 drug or treatment is expected to: 349 a. Cause a significant barrier to the insured’s adherence 350 to or compliance with his or her plan of care; 351 b. Worsen the insured’s medical condition that exists 352 simultaneously with, but independently of, the condition under 353 treatment; or 354 c. Decrease the insured’s ability to achieve or maintain 355 his or her ability to perform daily activities. 356 5. A preceding prescription drug is an opioid and the 357 protocol exception request is for a nonopioid prescription drug 358 or treatment with a likelihood of similar or better results. 359 (d) A health insurer may request a copy of relevant 360 documentation from an insured’s medical record in support of a 361 protocol exception request. 362(2) As used in this section, the term “health coverage363plan” means any of the following which is currently or was364previously providing major medical or similar comprehensive365coverage or benefits to the insured:366(a) A health insurer or health maintenance organization.367(b) A plan established or maintained by an individual368employer as provided by the Employee Retirement Income Security369Act of 1974, Pub. L. No. 93-406.370(c) A multiple-employer welfare arrangement as defined in371s. 624.437.372(d) A governmental entity providing a plan of self373insurance.374 (4)(3)CONSTRUCTION.—This section does not require a health 375 insurer to add a drug to its prescription drug formulary or to 376 cover a prescription drug that the insurer does not otherwise 377 cover. 378 Section 4. Subsection (11) of section 627.6131, Florida 379 Statutes, is amended, and subsection (20) is added to that 380 section, to read: 381 627.6131 Payment of claims.— 382 (11) A health insurer may not retroactively deny a claim 383 because of insured ineligibility: 384 (a) More than 1 year after the date of payment of the 385 claim; or 386 (b) At any time, if the health insurer verified the 387 insured’s eligibility at the time of treatment or provided an 388 authorization number. 389 (20) A health insurer may not impose an additional prior 390 authorization requirement with respect to a surgical or 391 otherwise invasive procedure, or any item furnished as part of 392 the surgical or invasive procedure, if the procedure or item is 393 furnished during the perioperative period of another procedure 394 for which prior authorization was granted by the health insurer. 395 Section 5. Subsection (46) of section 641.31, Florida 396 Statutes, is amended to read: 397 641.31 Health maintenance contracts.— 398 (46)(a) Definitions.—As used in this subsection, the term: 399 1. “Health coverage plan” means any of the following which 400 is currently or was previously providing major medical or 401 similar comprehensive coverage or benefits to the subscriber: 402 a. A health insurer or health maintenance organization. 403 b. A plan established or maintained by an individual 404 employer as provided by the Employee Retirement Income Security 405 Act of 1974, Pub. L. No. 93-406. 406 c. A multiple-employer welfare arrangement as defined in s. 407 624.437. 408 d. A governmental entity providing a plan of self 409 insurance. 410 2. “Preceding prescription drug or medical treatment” means 411 a prescription drug, medical procedure, or course of treatment 412 that must be used pursuant to a health maintenance 413 organization’s step-therapy protocol as a condition of coverage 414 under a health maintenance contract to treat a subscriber’s 415 condition. 416 3. “Protocol exception” means a determination by a health 417 maintenance organization that a step-therapy protocol is not 418 medically appropriate or indicated for treatment of a 419 subscriber’s condition, and the health maintenance organization 420 authorizes the use of another medical procedure, course of 421 treatment, or prescription drug prescribed or recommended by the 422 treating health care provider for the subscriber’s condition. 423 4. “Step-therapy protocol” means a written protocol that 424 specifies the order in which certain medical procedures, courses 425 of treatment, or prescription drugs must be used to treat a 426 subscriber’s condition. 427 5. “Urgent care situation” means an injury or condition of 428 a subscriber which, if medical care and treatment are not 429 provided earlier than the time the medical profession generally 430 considers reasonable for a nonurgent situation, in the opinion 431 of the subscriber’s treating physician, physician assistant, or 432 advanced practice registered nurse, would: 433 a. Seriously jeopardize the subscriber’s life, health, or 434 ability to regain maximum function; or 435 b. Subject the subscriber to severe pain that cannot be 436 adequately managed. 437 (b) Step-therapy protocol restrictions.—In addition to 438 protocol exceptions granted under paragraph (c) and the 439 restriction under s. 627.4239(3), a health maintenance 440 organization issuing major medical coverage through an 441 individual or group contract may not require a step-therapy 442 protocol under the contract for a covered prescription drug 443 requested by a subscriber if: 444 1. The subscriber has previously been approved to receive 445 the prescription drug through the completion of a step-therapy 446 protocol required by a separate health coverage plan; and 447 2. The subscriber provides documentation originating from 448 the health coverage plan that approved the prescription drug as 449 described in subparagraph 1. indicating that the health coverage 450 plan paid for the drug on the subscriber’s behalf during the 90 451 days immediately before the request. 452 (c) Step-therapy protocol exceptions; requirements and 453 procedures.— 454 1. A health maintenance organization shall publish on its 455 website and provide to a subscriber in writing a procedure for 456 the subscriber and his or her health care provider to request a 457 protocol exception. The procedure must include: 458 a. The manner in which a subscriber or health care provider 459 may request a protocol exception. 460 b. The manner and timeframe in which the health maintenance 461 organization is required to authorize or deny a protocol 462 exception request or to respond to an appeal of the health 463 maintenance organization’s authorization or denial of a request. 464 c. The conditions under which the protocol exception 465 request must be granted. 466 2.a. A health maintenance organization must authorize or 467 deny a protocol exception request or respond to an appeal of a 468 health maintenance organization’s authorization or denial of a 469 request within: 470 (I) Seventy-two hours after receiving a completed prior 471 authorization form for nonurgent care situations. 472 (II) Twenty-four hours after receiving a completed prior 473 authorization form for urgent care situations. 474 b. An authorization of the request must specify the 475 approved medical procedure, course of treatment, or prescription 476 drug benefits. 477 c. A denial of the request must include a detailed written 478 explanation of the reason for the denial, the clinical rationale 479 that supports the denial, and the procedure for appealing the 480 health maintenance organization’s determination. 481 3. A health maintenance organization must grant a protocol 482 exception request if any of the following applies: 483 a. A preceding prescription drug or medical treatment is 484 contraindicated or will likely cause an adverse reaction or 485 physical or mental harm to the subscriber. 486 b. A preceding prescription drug or medical treatment is 487 expected to be ineffective based on the subscriber’s medical 488 history and the clinical evidence of the characteristics of the 489 preceding prescription drug or medical treatment. 490 c. The subscriber has previously received a preceding 491 prescription drug or medical treatment that is in the same 492 pharmacologic class or has the same mechanism of action and such 493 drug or treatment lacked efficacy or effectiveness or adversely 494 affected the subscriber. 495 d. A preceding prescription drug or medical treatment is 496 not in the subscriber’s best interest because his or her use of 497 the drug or treatment is expected to: 498 (I) Cause a significant barrier to the subscriber’s 499 adherence to or compliance with his or her plan of care; 500 (II) Worsen the subscriber’s medical condition that exists 501 simultaneously with, but independently of, the condition under 502 treatment; or 503 (III) Decrease the subscriber’s ability to achieve or 504 maintain his or her ability to perform daily activities. 505 e. A preceding prescription drug is an opioid and the 506 protocol exception request is for a nonopioid prescription drug 507 or treatment with a likelihood of similar or better results. 508 4. A health maintenance organization may request a copy of 509 relevant documentation from a subscriber’s medical record in 510 support of a protocol exception request. 511(b) As used in this subsection, the term “health coverage512plan” means any of the following which previously provided or is513currently providing major medical or similar comprehensive514coverage or benefits to the subscriber:5151. A health insurer or health maintenance organization;5162. A plan established or maintained by an individual517employer as provided by the Employee Retirement Income Security518Act of 1974, Pub. L. No. 93-406;5193. A multiple-employer welfare arrangement as defined in s.520624.437; or5214. A governmental entity providing a plan of self522insurance.523 (d)(c)Construction.—This subsection does not require a 524 health maintenance organization to add a drug to its 525 prescription drug formulary or to cover a prescription drug that 526 the health maintenance organization does not otherwise cover. 527 Section 6. Subsection (10) of section 641.3155, Florida 528 Statutes, is amended to read: 529 641.3155 Prompt payment of claims.— 530 (10) A health maintenance organization may not 531 retroactively deny a claim because of subscriber ineligibility: 532 (a) More than 1 year after the date of payment of the 533 claim; or 534 (b) At any time, if the health maintenance organization 535 verified the subscriber’s eligibility at the time of treatment 536 or provided an authorization number. 537 Section 7. Subsection (4) is added to section 641.3156, 538 Florida Statutes, to read: 539 641.3156 Treatment authorization; payment of claims.— 540 (4) A health maintenance organization may not impose an 541 additional prior authorization requirement with respect to a 542 surgical or otherwise invasive procedure, or any item furnished 543 as part of the surgical or invasive procedure, if the procedure 544 or item is furnished during the perioperative period of another 545 procedure for which prior authorization was granted by the 546 health maintenance organization. 547 Section 8. This act shall take effect January 1, 2021.