Bill Text: FL S1354 | 2014 | Regular Session | Comm Sub
NOTE: There are more recent revisions of this legislation. Read Latest Draft
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
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
Florida Senate - 2014 CS for CS for SB 1354 By the Committees on Appropriations; and Banking and Insurance; and Senator Grimsley 576-04535A-14 20141354c2 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 use of a standardized prior 7 authorization form; providing requirements for the 8 form and for the availability and submission of the 9 form; requiring a pharmacy benefits manager to use and 10 accept the form under certain circumstances; 11 establishing a process for providers to override 12 certain treatment restrictions; providing requirements 13 for approval of such overrides; providing an exception 14 to the override protocol in certain circumstances; 15 creating s. 627.42392, F.S.; requiring health insurers 16 to use a standardized prior authorization form; 17 providing requirements for the form and for the 18 availability and submission of the form; requiring a 19 pharmacy benefits manager to use and accept the form 20 under certain circumstances; providing an exemption; 21 creating s. 627.42393, F.S.; establishing a process 22 for providers to override certain treatment 23 restrictions; providing requirements for approval of 24 such overrides; providing an exception to the override 25 protocol in certain circumstances; providing an 26 exemption; amending s. 627.6131, F.S.; prohibiting an 27 insurer from retroactively denying a claim in certain 28 circumstances; amending s. 627.6471, F.S.; requiring 29 insurers to post preferred provider information on a 30 website; specifying that changes to such a website 31 must be made within a certain time; amending s. 32 627.6515, F.S.; applying provisions relating to prior 33 authorization and override protocols to out-of-state 34 groups; amending s. 641.3155, F.S.; prohibiting a 35 health maintenance organization from retroactively 36 denying a claim in certain circumstances; creating s. 37 641.393, F.S.; requiring the use of a standardized 38 prior authorization form by a health maintenance 39 organization; providing requirements for the 40 availability and submission of the form; requiring a 41 pharmacy benefits manager to use and accept the form 42 under certain circumstances; providing an exemption; 43 creating s. 641.394, F.S.; establishing a process for 44 providers to override certain treatment restrictions; 45 providing requirements for approval of such overrides; 46 providing an exception to the override protocol in 47 certain circumstances; providing an exemption; 48 providing an effective date. 49 50 Be It Enacted by the Legislature of the State of Florida: 51 52 Section 1. Paragraph (c) of subsection (2) of section 53 409.967, Florida Statutes, is amended to read: 54 409.967 Managed care plan accountability.— 55 (2) The agency shall establish such contract requirements 56 as are necessary for the operation of the statewide managed care 57 program. In addition to any other provisions the agency may deem 58 necessary, the contract must require: 59 (c) Access.— 60 1. The agency shall establish specific standards for the 61 number, type, and regional distribution of providers in managed 62 care plan networks to ensure access to care for both adults and 63 children. Each plan must maintain a regionwide network of 64 providers in sufficient numbers to meet the access standards for 65 specific medical services for all recipients enrolled in the 66 plan. The exclusive use of mail-order pharmacies may not be 67 sufficient to meet network access standards. Consistent with the 68 standards established by the agency, provider networks may 69 include providers located outside the region. A plan may 70 contract with a new hospital facility before the date the 71 hospital becomes operational if the hospital has commenced 72 construction, will be licensed and operational by January 1, 73 2013, and a final order has issued in any civil or 74 administrative challenge. Each plan shall establish and maintain 75 an accurate and complete electronic database of contracted 76 providers, including information about licensure or 77 registration, locations and hours of operation, specialty 78 credentials and other certifications, specific performance 79 indicators, and such other information as the agency deems 80 necessary. The database must be available online toboththe 81 agency and the public and have the capability of comparingto82comparethe availability of providers to network adequacy 83 standards and to accept and display feedback from each 84 provider’s patients. Each plan shall submit quarterly reports to 85 the agency identifying the number of enrollees assigned to each 86 primary care provider. 87 2. If establishing a prescribed drug formulary or preferred 88 drug list, a managed care plan shall: 89 a. Provide a broad range of therapeutic options for the 90 treatment of disease states which are consistent with the 91 general needs of an outpatient population. If feasible, the 92 formulary or preferred drug list must include at least two 93 products in a therapeutic class. 94 b.Each managed care plan mustPublish theanyprescribed 95 drug formulary or preferred drug list on the plan’s website in a 96 manner that is accessible to and searchable by enrollees and 97 providers. The plan shallmustupdate the list within 24 hours 98 after making a change.Each plan must ensure that the prior99authorization process for prescribed drugs is readily accessible100to health care providers, including posting appropriate contact101information on its website and providing timely responses to102providers.103 3. For enrolleesMedicaid recipientsdiagnosed with 104 hemophilia who have been prescribed anti-hemophilic-factor 105 replacement products, the agency shall provide for those 106 products and hemophilia overlay services through the agency’s 107 hemophilia disease management program. 1083. Managed care plans, and their fiscal agents or109intermediaries, must accept prior authorization requests for any110service electronically.111 4. Notwithstanding any other law, in order to establish 112 uniformity in the submission of prior authorization forms, 113 effective January 1, 2015, a managed care plan shall use a 114 single standardized form for obtaining prior authorization for a 115 medical procedure, course of treatment, or prescription drug 116 benefit. The form may not exceed two pages in length, excluding 117 any instructions or guiding documentation. 118 a. The managed care plan shall make the form available 119 electronically and online to practitioners. The prescribing 120 provider may electronically submit the completed prior 121 authorization form to the managed care plan. 122 b. If the managed care plan contracts with a pharmacy 123 benefits manager to perform prior authorization services for a 124 medical procedure, course of treatment, or prescription drug 125 benefit, the pharmacy benefits manager must use and accept the 126 standardized prior authorization form. 127 c. A completed prior authorization request submitted by a 128 health care provider using the standardized prior authorization 129 form is deemed approved upon receipt by the managed care plan 130 unless the managed care plan responds otherwise within 3 131 business days. 132 5. If medications for the treatment of a medical condition 133 are restricted for use by a managed care plan by a step-therapy 134 or fail-first protocol, the prescribing provider must have 135 access to a clear and convenient process to request an override 136 of the protocol from the managed care plan. 137 a. The managed care plan shall grant an override within 72 138 hours if the prescribing provider documents that: 139 (I) Based on sound clinical evidence, the preferred 140 treatment required under the step-therapy or fail-first protocol 141 has been ineffective in the treatment of the enrollee’s disease 142 or medical condition; or 143 (II) Based on sound clinical evidence or medical and 144 scientific evidence, the preferred treatment required under the 145 step-therapy or fail-first protocol: 146 (A) Is expected or is likely to be ineffective based on 147 known relevant physical or mental characteristics of the 148 enrollee and known characteristics of the drug regimen; or 149 (B) Will cause or will likely cause an adverse reaction or 150 other physical harm to the enrollee. 151 b. If the prescribing provider allows the enrollee to enter 152 the step-therapy or fail-first protocol recommended by the 153 managed care plan, the duration of the step-therapy or fail 154 first protocol may not exceed the customary period for use of 155 the medication if the prescribing provider demonstrates such 156 treatment to be clinically ineffective. If the managed care plan 157 can, through sound clinical evidence, demonstrate that the 158 originally prescribed medication is likely to require more than 159 the customary period to provide any relief or amelioration to 160 the enrollee, the step-therapy or fail-first protocol may be 161 extended for an additional period, but no longer than the 162 original customary period for use of the medication. 163 Notwithstanding this provision, a step-therapy or fail-first 164 protocol shall be terminated if the prescribing provider 165 determines that the enrollee is having an adverse reaction or is 166 suffering from other physical harm resulting from the use of the 167 medication. 168 Section 2. Section 627.42392, Florida Statutes, is created 169 to read: 170 627.42392 Prior authorization.— 171 (1) Notwithstanding any other law, in order to establish 172 uniformity in the submission of prior authorization forms, 173 effective January 1, 2015, a health insurer that delivers, 174 issues for delivery, renews, amends, or continues an individual 175 or group health insurance policy in this state, including a 176 policy issued to a small employer as defined in s. 627.6699, 177 shall use a single standardized form for obtaining prior 178 authorization for a medical procedure, course of treatment, or 179 prescription drug benefit. The form may not exceed two pages in 180 length, excluding any instructions or guiding documentation. 181 (a) The health insurer shall make the form available 182 electronically and online to practitioners. The prescribing 183 provider may submit the completed prior authorization form 184 electronically to the health insurer. 185 (b) If the health insurer contracts with a pharmacy 186 benefits manager to perform prior authorization services for a 187 medical procedure, course of treatment, or prescription drug 188 benefit, the pharmacy benefits manager must use and accept the 189 standardized prior authorization form. 190 (c) A completed prior authorization request submitted by a 191 health care provider using the standardized prior authorization 192 form is deemed approved upon receipt by the health insurer 193 unless the health insurer responds otherwise within 3 business 194 days. 195 (2) This section does not apply to a grandfathered health 196 plan as defined in s. 627.402. 197 Section 3. Section 627.42393, Florida Statutes, is created 198 to read: 199 627.42393 Medication protocol override.—If an individual or 200 group health insurance policy, including a policy issued by a 201 small employer as defined in s. 627.6699, restricts medications 202 for the treatment of a medical condition by a step-therapy or 203 fail-first protocol, the prescribing provider must have access 204 to a clear and convenient process to request an override of the 205 protocol from the health insurer. 206 (1) The health insurer shall authorize an override of the 207 protocol within 72 hours if the prescribing provider documents 208 that: 209 (a) Based on sound clinical evidence, the preferred 210 treatment required under the step-therapy or fail-first protocol 211 has been ineffective in the treatment of the insured’s disease 212 or medical condition; or 213 (b) Based on sound clinical evidence or medical and 214 scientific evidence, the preferred treatment required under the 215 step-therapy or fail-first protocol: 216 1. Is expected or is likely to be ineffective based on 217 known relevant physical or mental characteristics of the insured 218 and known characteristics of the drug regimen; or 219 2. Will cause or is likely to cause an adverse reaction or 220 other physical harm to the insured. 221 (2) If the prescribing provider allows the insured to enter 222 the step-therapy or fail-first protocol recommended by the 223 health insurer, the duration of the step-therapy or fail-first 224 protocol may not exceed the customary period for use of the 225 medication if the prescribing provider demonstrates such 226 treatment to be clinically ineffective. If the health insurer 227 can, through sound clinical evidence, demonstrate that the 228 originally prescribed medication is likely to require more than 229 the customary period for such medication to provide any relief 230 or amelioration to the insured, the step-therapy or fail-first 231 protocol may be extended for an additional period of time, but 232 no longer than the original customary period for the medication. 233 Notwithstanding this provision, a step-therapy or fail-first 234 protocol shall be terminated if the prescribing provider 235 determines that the insured is having an adverse reaction or is 236 suffering from other physical harm resulting from the use of the 237 medication. 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 the 250 regulations adopted pursuant to those acts, the health insurer 251 verified the eligibility of the insured at the time of treatment 252 and provided an authorization number, unless, at the time 253 eligibility was verified, the provider was notified that the 254 insured was 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) AnAnyinsurer issuing a policy of health insurance in 260 this state,whichinsuranceincludes coverage for the services 261 of a preferred provider shall,mustprovide each policyholder 262 and certificateholder with a current list of preferred 263 providers, shalland mustmake 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 in compliance with the federal 289 Patient Protection and Affordable Care Act, as amended by the 290 Health Care and Education Reconciliation Act of 2010, and the 291 regulations adopted pursuant to those acts, the health 292 maintenance organization verified the eligibility of the 293 subscriber at the time of treatment and provided an 294 authorization number, unless, at the time eligibility was 295 verified, the provider was notified that the subscriber was 296 delinquent in paying the premium. 297 Section 8. Section 641.393, Florida Statutes, is created to 298 read: 299 641.393 Prior authorization.—Notwithstanding any other law, 300 in order to establish uniformity in the submission of prior 301 authorization forms, effective January 1, 2015, a health 302 maintenance organization shall use a single standardized form 303 for obtaining prior authorization for prescription drug 304 benefits. The form may not exceed two pages in length, excluding 305 any instructions or guiding documentation. 306 (1) A health maintenance organization shall make the form 307 available electronically and online to practitioners. A health 308 care provider may electronically submit the completed form to 309 the health maintenance organization. 310 (2) If a health maintenance organization contracts with a 311 pharmacy benefits manager to perform prior authorization 312 services for prescription drug benefits, the pharmacy benefits 313 manager must use and accept the standardized prior authorization 314 form. 315 (3) A completed prior authorization request submitted by a 316 health care provider using the standardized prior authorization 317 form required under this section is deemed approved upon receipt 318 by the health maintenance organization unless the health 319 maintenance organization responds otherwise within 3 business 320 days. 321 (4) This section does not apply to grandfathered health 322 plans, as defined in s. 627.402. 323 Section 9. Section 641.394, Florida Statutes, is created to 324 read: 325 641.394 Medication protocol override.—If a health 326 maintenance organization contract restricts medications for the 327 treatment of a medical condition by a step-therapy or fail-first 328 protocol, the prescribing provider shall have access to a clear 329 and convenient process to request an override of the protocol 330 from the health maintenance organization. 331 (1) The health maintenance organization shall grant an 332 override within 72 hours if the prescribing provider documents 333 that: 334 (a) Based on sound clinical evidence, the preferred 335 treatment required under the step-therapy or fail-first protocol 336 has been ineffective in the treatment of the subscriber’s 337 disease or medical condition; or 338 (b) Based on sound clinical evidence or medical and 339 scientific evidence, the preferred treatment required under the 340 step-therapy or fail-first protocol: 341 1. Is expected or is likely to be ineffective based on 342 known relevant physical or mental characteristics of the 343 subscriber and known characteristics of the drug regimen; or 344 2. Will cause or is likely to cause an adverse reaction or 345 other physical harm to the subscriber. 346 (2) If the prescribing provider allows the subscriber to 347 enter the step-therapy or fail-first protocol recommended by the 348 health maintenance organization, the duration of the step 349 therapy or fail-first protocol may not exceed the customary 350 period for use of the medication if the prescribing provider 351 demonstrates such treatment to be clinically ineffective. If the 352 health maintenance organization can, through sound clinical 353 evidence, demonstrate that the originally prescribed medication 354 is likely to require more than the customary period to provide 355 any relief or amelioration to the subscriber, the step-therapy 356 or fail-first protocol may be extended for an additional period, 357 but no longer than the original customary period for use of the 358 medication. Notwithstanding this provision, a step-therapy or 359 fail-first protocol shall be terminated if the prescribing 360 provider determines that the subscriber is having an adverse 361 reaction or is suffering from other physical harm resulting from 362 the use of the medication. 363 (3) This section does not apply to grandfathered health 364 plans, as defined in s. 627.402. 365 Section 10. This act shall take effect July 1, 2014.