Bill Text: FL S1354 | 2014 | Regular Session | Comm Sub

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Health Care

Spectrum: Slight Partisan Bill (? 2-1)

Status: (Failed) 2014-05-02 - Died in Messages, companion bill(s) passed, see CS/HB 323 (Ch. 2014-113) [S1354 Detail]

Download: Florida-2014-S1354-Comm_Sub.html

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       Florida Senate - 2014                             CS for SB 1354
       
       
        
       By the Committee on Banking and Insurance; and Senator Grimsley
       
       
       
       
       
       597-04029-14                                          20141354c1
    1                        A bill to be entitled                      
    2         An act relating to health care; amending s. 409.967,
    3         F.S.; revising contract requirements for Medicaid
    4         managed care programs; providing requirements for
    5         plans establishing a drug formulary or preferred drug
    6         list; requiring the plan to authorize an enrollee to
    7         continue a drug that is removed or changed, under
    8         certain circumstances; requiring the use of a
    9         standardized prior authorization form; requiring a
   10         pharmacy benefits manager to use and accept the form
   11         under certain circumstances; providing requirements
   12         for the form and for the availability and submission
   13         of the form; establishing a process for providers to
   14         override certain treatment restrictions; providing
   15         requirements for approval of such overrides; providing
   16         an exception to the override protocol in certain
   17         circumstances; creating s. 627.42392, F.S.; requiring
   18         health insurers to use a standardized prior
   19         authorization form; requiring a pharmacy benefits
   20         manager to use and accept the form under certain
   21         circumstances; providing requirements for the form and
   22         for the availability and submission of the form;
   23         providing an exemption; creating s. 627.42393, F.S.;
   24         establishing a process for providers to override
   25         certain treatment restrictions; providing requirements
   26         for approval of such overrides; providing an exception
   27         to the override protocol in certain circumstances;
   28         providing an exemption; amending s. 627.6131, F.S.;
   29         prohibiting an insurer from retroactively denying a
   30         claim in certain circumstances; amending s. 627.6471,
   31         F.S.; requiring insurers to post preferred provider
   32         information on a website; amending s. 627.6515, F.S.;
   33         applying provisions relating to prior authorization
   34         and override protocols to out-of-state groups;
   35         amending s. 641.3155, F.S.; prohibiting a health
   36         maintenance organization from retroactively denying a
   37         claim in certain circumstances; creating s. 641.393,
   38         F.S.; requiring the use of a standardized prior
   39         authorization form by a health maintenance
   40         organization; requiring a pharmacy benefits manager to
   41         use and accept the form under certain circumstances;
   42         providing requirements for the availability and
   43         submission of the form; providing an exemption;
   44         creating s. 641.394, F.S.; establishing a process for
   45         providers to override certain treatment restrictions;
   46         providing requirements for approval of such overrides;
   47         providing an exception to the override protocol in
   48         certain circumstances; providing an exemption;
   49         providing an effective date.
   50          
   51  Be It Enacted by the Legislature of the State of Florida:
   52  
   53         Section 1. Paragraph (c) of subsection (2) of section
   54  409.967, Florida Statutes, is amended to read:
   55         409.967 Managed care plan accountability.—
   56         (2) The agency shall establish such contract requirements
   57  as are necessary for the operation of the statewide managed care
   58  program. In addition to any other provisions the agency may deem
   59  necessary, the contract must require:
   60         (c) Access.—
   61         1. The agency shall establish specific standards for the
   62  number, type, and regional distribution of providers in managed
   63  care plan networks to ensure access to care for both adults and
   64  children. Each plan must maintain a regionwide network of
   65  providers in sufficient numbers to meet the access standards for
   66  specific medical services for all recipients enrolled in the
   67  plan. The exclusive use of mail-order pharmacies may not be
   68  sufficient to meet network access standards. Consistent with the
   69  standards established by the agency, provider networks may
   70  include providers located outside the region. A plan may
   71  contract with a new hospital facility before the date the
   72  hospital becomes operational if the hospital has commenced
   73  construction, will be licensed and operational by January 1,
   74  2013, and a final order has issued in any civil or
   75  administrative challenge. Each plan shall establish and maintain
   76  an accurate and complete electronic database of contracted
   77  providers, including information about licensure or
   78  registration, locations and hours of operation, specialty
   79  credentials and other certifications, specific performance
   80  indicators, and such other information as the agency deems
   81  necessary. The database must be available online to both the
   82  agency and the public and have the capability of comparing to
   83  compare the availability of providers to network adequacy
   84  standards and to accept and display feedback from each
   85  provider’s patients. Each plan shall submit quarterly reports to
   86  the agency identifying the number of enrollees assigned to each
   87  primary care provider.
   88         2. If establishing a prescribed drug formulary or preferred
   89  drug list, a managed care plan shall:
   90         a. Provide a broad range of therapeutic options for the
   91  treatment of disease states which are consistent with the
   92  general needs of an outpatient population. If feasible, the
   93  formulary or preferred drug list must include at least two
   94  products in a therapeutic class.
   95         b. Include coverage through prior authorization for each
   96  new drug approved by the United States Food and Drug
   97  Administration until the Medicaid Pharmaceutical and
   98  Therapeutics Committee reviews such drug for inclusion on the
   99  formulary. The timing of the formulary review must comply with
  100  s. 409.91195.
  101         c. Each managed care plan must Publish the any prescribed
  102  drug formulary or preferred drug list on the plan’s website in a
  103  manner that is accessible to and searchable by enrollees and
  104  providers. The plan shall must update the list within 24 hours
  105  after making a change. Each plan must ensure that the prior
  106  authorization process for prescribed drugs is readily accessible
  107  to health care providers, including posting appropriate contact
  108  information on its website and providing timely responses to
  109  providers.
  110         d. If a prescription drug on a plan’s formulary is removed
  111  or changed, permit an enrollee who was receiving the drug to
  112  continue to receive the drug if the prescribing provider submits
  113  a written request that demonstrates that the drug is medically
  114  necessary and that the enrollee meets clinical criteria to
  115  receive the drug.
  116         3. For enrollees Medicaid recipients diagnosed with
  117  hemophilia who have been prescribed anti-hemophilic-factor
  118  replacement products, the agency shall provide for those
  119  products and hemophilia overlay services through the agency’s
  120  hemophilia disease management program.
  121         4. Notwithstanding any other law, in order to establish
  122  uniformity in the submission of prior authorization forms, after
  123  January 1, 2015, a managed care plan shall use only the
  124  standardized prior authorization form adopted by the Financial
  125  Services Commission pursuant to s. 627.42392 for obtaining prior
  126  authorization for a medical procedure, a course of treatment, or
  127  prescription drug benefits.
  128         a. If a managed care plan contracts with a pharmacy
  129  benefits manager to perform prior authorization services for
  130  prescription drug benefits, the pharmacy benefits manager shall
  131  use and accept the standardized prior authorization form. The
  132  Office of Insurance Regulation and the managed care plan shall
  133  make the form electronically available on their respective
  134  websites.
  135         b.3. Managed care plans, and their fiscal agents or
  136  intermediaries, must accept prior authorization requests for any
  137  service electronically.
  138         c. A completed prior authorization request submitted by a
  139  health care provider using the standardized prior authorization
  140  form required under this subparagraph is deemed approved upon
  141  receipt by the managed care plan unless the managed care plan
  142  responds otherwise within 2 business days.
  143         5. If medications for the treatment of a medical condition
  144  are restricted for use by a managed care plan by a step-therapy
  145  or fail-first protocol, the prescribing provider must have
  146  access to a clear and convenient process to request an override
  147  of the protocol from the managed care plan.
  148         a. The managed care plan shall grant an override within 24
  149  hours if the prescribing provider believes that:
  150         (I) Based on sound clinical evidence, the preferred
  151  treatment required under the step-therapy or fail-first protocol
  152  has been ineffective in the treatment of the enrollee’s disease
  153  or medical condition; or
  154         (II) Based on sound clinical evidence or medical and
  155  scientific evidence, the preferred treatment required under the
  156  step-therapy or fail-first protocol:
  157         (A) Is expected or likely to be ineffective based on known
  158  relevant physical or mental characteristics of the enrollee and
  159  known characteristics of the drug regimen; or
  160         (B) Will cause or will likely cause an adverse reaction or
  161  other physical harm to the enrollee.
  162         b. If the prescribing provider allows the enrollee to enter
  163  the step-therapy or fail-first protocol recommended by the
  164  managed care plan, the duration of the step-therapy or fail
  165  first protocol may not exceed a period deemed appropriate by the
  166  provider. If the prescribing provider deems the treatment
  167  clinically ineffective, the enrollee is entitled to receive the
  168  recommended course of therapy without requiring the prescribing
  169  provider to seek approval for an override of the step-therapy or
  170  fail-first protocol.
  171         Section 2. Section 627.42392, Florida Statutes, is created
  172  to read:
  173         627.42392 Prior authorization.—Notwithstanding any other
  174  law, in order to establish uniformity in the submission of prior
  175  authorization forms, after January 1, 2015, a health insurer
  176  that delivers, issues for delivery, renews, amends, or continues
  177  an individual or group health insurance policy in this state,
  178  including a policy issued to a small employer as defined in s.
  179  627.6699, shall use only the standardized prior authorization
  180  form adopted by the commission for obtaining prior authorization
  181  for a medical procedure, course of treatment, or prescription
  182  drug benefits.
  183         (1) If a health insurer contracts with a pharmacy benefits
  184  manager to perform prior authorization services for prescription
  185  drug benefits, the pharmacy benefits manager shall use and
  186  accept the standardized prior authorization form. The commission
  187  shall adopt rules prescribing the prior authorization form on or
  188  before January 1, 2015, and the office may consult with health
  189  insurers or other organizations as necessary in the development
  190  of the form. The form may not exceed two pages in length,
  191  excluding any instructions or guiding documentation. The office
  192  and the health insurer shall make the form electronically
  193  available on their respective websites. The prescribing provider
  194  may electronically submit the completed form to the health
  195  insurer. The adoption of the form by the commission does not
  196  constitute a determination that affects the substantial
  197  interests of a party under chapter 120.
  198         (2) A completed prior authorization request submitted by a
  199  prescribing provider using the standardized prior authorization
  200  form required under subsection (1) is deemed approved upon
  201  receipt by the health insurer unless the health insurer responds
  202  otherwise within 2 business days.
  203         (3) This section does not apply to a grandfathered health
  204  plan as defined in s. 627.402.
  205         Section 3. Section 627.42393, Florida Statutes, is created
  206  to read:
  207         627.42393 Medication protocol override.—If an individual or
  208  group health insurance policy, including a policy issued by a
  209  small employer, as defined in s. 627.6699, restricts medications
  210  for the treatment of a medical condition by a step-therapy or
  211  fail-first protocol, the prescribing provider must have access
  212  to a clear and convenient process to request an override of the
  213  protocol from the health insurer.
  214         (1) The health insurer shall authorize an override of the
  215  protocol within 24 hours if the prescribing provider believes
  216  that:
  217         (a) Based on sound clinical evidence, the preferred
  218  treatment required under the step-therapy or fail-first protocol
  219  has been ineffective in the treatment of the insured’s disease
  220  or medical condition; or
  221         (b) Based on sound clinical evidence or medical and
  222  scientific evidence, the preferred treatment required under the
  223  step-therapy or fail-first protocol:
  224         1. Is expected or likely to be ineffective based on known
  225  relevant physical or mental characteristics of the insured and
  226  known characteristics of the drug regimen; or
  227         2. Will cause or is likely to cause an adverse reaction or
  228  other physical harm to the insured.
  229         (2) If the prescribing provider allows the insured to enter
  230  the step-therapy or fail-first protocol recommended by the
  231  health insurer, the duration of the step-therapy or fail-first
  232  protocol may not exceed a period deemed appropriate by the
  233  provider. If the prescribing provider deems the treatment
  234  clinically ineffective, the insured is entitled to receive the
  235  recommended course of therapy without requiring the prescribing
  236  provider to seek approval for an override of the step-therapy or
  237  fail-first protocol.
  238         (3) This section does not apply to grandfathered health
  239  plans, as defined in s. 627.402.
  240         Section 4. Subsection (11) of section 627.6131, Florida
  241  Statutes, is amended to read:
  242         627.6131 Payment of claims.—
  243         (11) A health insurer may not retroactively deny a claim
  244  because of insured ineligibility:
  245         (a) More than 1 year after the date of payment of the
  246  claim; or
  247         (b) If, under a policy compliant with the federal Patient
  248  Protection and Affordable Care Act, as amended by the Health
  249  Care and Education Reconciliation Act of 2010, and regulations
  250  adopted pursuant to those acts, the health insurer verified the
  251  eligibility of the insured at the time of treatment and provided
  252  an authorization number unless, at the time eligibility was
  253  verified, the provider was notified that the insured was
  254  delinquent in paying the premium.
  255         Section 5. Subsection (2) of section 627.6471, Florida
  256  Statutes, is amended to read:
  257         627.6471 Contracts for reduced rates of payment;
  258  limitations; coinsurance and deductibles.—
  259         (2) An Any insurer issuing a policy of health insurance in
  260  this state, which insurance includes coverage for the services
  261  of a preferred provider, shall must provide each policyholder
  262  and certificateholder with a current list of preferred
  263  providers, shall and must make the list available for public
  264  inspection during regular business hours at the principal office
  265  of the insurer within the state, and shall post a link to the
  266  list of preferred providers on the home page of the insurer’s
  267  website. Changes to the list of preferred providers must be
  268  reflected on the insurer’s website within 24 hours.
  269         Section 6. Paragraph (c) of subsection (2) of section
  270  627.6515, Florida Statutes, is amended to read:
  271         627.6515 Out-of-state groups.—
  272         (2) Except as otherwise provided in this part, this part
  273  does not apply to a group health insurance policy issued or
  274  delivered outside this state under which a resident of this
  275  state is provided coverage if:
  276         (c) The policy provides the benefits specified in ss.
  277  627.419, 627.42392, 627.42393, 627.6574, 627.6575, 627.6579,
  278  627.6612, 627.66121, 627.66122, 627.6613, 627.667, 627.6675,
  279  627.6691, and 627.66911, and complies with the requirements of
  280  s. 627.66996.
  281         Section 7. Subsection (10) of section 641.3155, Florida
  282  Statutes, is amended to read:
  283         641.3155 Prompt payment of claims.—
  284         (10) A health maintenance organization may not
  285  retroactively deny a claim because of subscriber ineligibility:
  286         (a) More than 1 year after the date of payment of the
  287  claim; or
  288         (b) If, under a policy compliant with the federal Patient
  289  Protection and Affordable Care Act, as amended by the Health
  290  Care and Education Reconciliation Act of 2010, and regulations
  291  adopted pursuant to those acts, the health maintenance
  292  organization verified the eligibility of the subscriber at the
  293  time of treatment and provided an authorization number unless,
  294  at the time eligibility was verified, the provider was notified
  295  that the subscriber was delinquent in paying the premium.
  296         Section 8. Section 641.393, Florida Statutes, is created to
  297  read:
  298         641.393 Prior authorization.—Notwithstanding any other law,
  299  in order to establish uniformity in the submission of prior
  300  authorization forms, after January 1, 2015, a health maintenance
  301  organization shall use only the standardized prior authorization
  302  form adopted by the Financial Services Commission pursuant to s.
  303  627.42392 for obtaining prior authorization for a medical
  304  procedure, a course of treatment, or prescription drug benefits.
  305         (1) If a health maintenance organization contracts with a
  306  pharmacy benefits manager to perform prior authorization
  307  services for prescription drug benefits, the pharmacy benefits
  308  manager must use and accept the standardized prior authorization
  309  form. The office and health maintenance organization shall make
  310  the form electronically available on their respective websites.
  311         (2) A health care provider may submit the completed form
  312  electronically to the health maintenance organization.
  313         (3) A completed prior authorization request submitted by a
  314  health care provider using the standardized prior authorization
  315  form required under this section is deemed approved upon receipt
  316  by the health maintenance organization unless the health
  317  maintenance organization responds otherwise within 2 business
  318  days.
  319         (4) This section does not apply to grandfathered health
  320  plans, as defined in s. 627.402.
  321         Section 9. Section 641.394, Florida Statutes, is created to
  322  read:
  323         641.394 Medication protocol override.—If a health
  324  maintenance organization contract restricts medications for the
  325  treatment of a medical condition by a step-therapy or fail-first
  326  protocol, the prescribing provider shall have access to a clear
  327  and convenient process to request an override of the protocol
  328  from the health maintenance organization.
  329         (1) The health maintenance organization shall grant an
  330  override within 24 hours if the prescribing provider believes
  331  that:
  332         (a) Based on sound clinical evidence, the preferred
  333  treatment required under the step-therapy or fail-first protocol
  334  has been ineffective in the treatment of the subscriber’s
  335  disease or medical condition; or
  336         (b) Based on sound clinical evidence or medical and
  337  scientific evidence, the preferred treatment required under the
  338  step-therapy or fail-first protocol:
  339         1. Is expected or likely to be ineffective based on known
  340  relevant physical or mental characteristics of the subscriber
  341  and known characteristics of the drug regimen; or
  342         2. Will cause or is likely to cause an adverse reaction or
  343  other physical harm to the subscriber.
  344         (2) If the prescribing provider allows the subscriber to
  345  enter the step-therapy or fail-first protocol recommended by the
  346  health maintenance organization, the duration of the step
  347  therapy or fail-first protocol may not exceed a period deemed
  348  appropriate by the provider. If the prescribing provider deems
  349  the treatment clinically ineffective, the subscriber is entitled
  350  to receive the recommended course of therapy without requiring
  351  the prescribing provider to seek approval for an override of the
  352  step-therapy or fail-first protocol.
  353         (3) This section does not apply to grandfathered health
  354  plans, as defined in s. 627.402.
  355         Section 10. This act shall take effect July 1, 2014.