Florida 2022 Regular Session

Florida House Bill H0633 Compare Versions

Only one version of the bill is available at this time.

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3	3	HB 633 2022
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10	10	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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14	14	A bill to be entitled 1
15	15	An act relating to insurance coverages for drugs and 2
16	16	medical procedures and treatments; amending s. 3
17	17	627.4239, F.S.; defining the terms "associated 4
18	18	condition" and "health care provider"; prohibiting 5
19	19	health maintenance organizations from excluding 6
20	20	coverage for certain cancer treatment drugs; 7
21	21	prohibiting health insurers and health maintenance 8
22	22	organizations from requiring, before providing 9
23	23	prescription drug coverage for the treatment of stage 10
24	24	4 metastatic cancer and associated conditions, that 11
25	25	treatment have failed with a different drug; providing 12
26	26	applicability; prohibiting insurers and health 13
27	27	maintenance organizations from excluding coverage for 14
28	28	certain drugs on certain grounds; prohibiting insurers 15
29	29	and health maintenance organizations from requiring 16
30	30	home infusion for certain cancer treatment drugs or 17
31	31	that certain cancer treatment drugs be sent to certain 18
32	32	entities for home infusion unless a certain condition 19
33	33	is met; revising construction; amending s. 627.42392, 20
34	34	F.S.; revising the definition of the term "health 21
35	35	insurer"; defining the term "urgent care situation"; 22
36	36	specifying a requirement for the prior authorization 23
37	37	form approved by the Financial Services Commission; 24
38	38	authorizing the commission to adopt certain rules; 25
39	39
40	40	HB 633 2022
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45	45	hb0633-00
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47	47	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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49	49
50	50
51	51	specifying requirements for, and restrictions on , 26
52	52	health insurers and pharmacy benefits managers 27
53	53	relating to prior authorization information, 28
54	54	requirements, restrictions, and changes; providing 29
55	55	applicability; specifying timeframes in which prior 30
56	56	authorization requests must be authorized or denied 31
57	57	and the patient and the patient's provider must be 32
58	58	notified; providing an effective date. 33
59	59	34
60	60	Be It Enacted by the Legislature of the State of Florida: 35
61	61	36
62	62	Section 1. Section 627.4239, Florida Statutes, is amended 37
63	63	to read: 38
64	64	627.4239 Coverage for use of drugs in treatment of 39
65	65	cancer.— 40
66	66	(1) DEFINITIONS.—As used in this section, the term: 41
67	67	(a) "Associated condition" means a symptom or side effect 42
68	68	that: 43
69	69	1. Is associated with a particular cancer at a particular 44
70	70	stage or with the treatment of that cancer; and 45
71	71	2. In the judgment of a health care provider, will further 46
72	72	jeopardize the health of a patient if left untreated. As used in 47
73	73	this subparagraph, the term "health care provider" means a 48
74	74	physician licensed under chapter 458, chapter 459, or chapter 49
75	75	461; a physician assistant licensed under chapter 458 or chapter 50
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77	77	HB 633 2022
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82	82	hb0633-00
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84	84	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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88	88	459; an advanced practice registered nurse licensed under 51
89	89	chapter 464; or a dentist licensed under chapter 466. 52
90	90	(b) "Medical literature" means scientific studies 53
91	91	published in a United States peer -reviewed national professional 54
92	92	journal. 55
93	93	(c)(b) "Standard reference compendium" means authoritative 56
94	94	compendia identified by the Secretary of the United States 57
95	95	Department of Health and Human Services and recognized by the 58
96	96	federal Centers for Medicare and Medic aid Services. 59
97	97	(2) COVERAGE FOR TREATMENT OF CANCER. — 60
98	98	(a) An insurer or a health maintenance organization may 61
99	99	not exclude coverage in any individual or group health insurance 62
100	100	policy or health maintenance contract issued, amended, 63
101	101	delivered, or renewed i n this state which covers the treatment 64
102	102	of cancer for any drug prescribed for the treatment of cancer on 65
103	103	the ground that the drug is not approved by the United States 66
104	104	Food and Drug Administration for a particular indication, if 67
105	105	that drug is recognized for treatment of that indication in a 68
106	106	standard reference compendium or recommended in the medical 69
107	107	literature. 70
108	108	(b) Coverage for a drug required by this section also 71
109	109	includes the medically necessary services associated with the 72
110	110	administration of the drug. 73
111	111	(3) COVERAGE FOR TREATMENT OF STAGE 4 METASTATIC CANCER 74
112	112	AND ASSOCIATED CONDITIONS. — 75
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121	121	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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125	125	(a) An insurer or a health maintenance organization may 76
126	126	not require in any individual or group health insurance policy 77
127	127	or health maintenance contract issued, amended, deliv ered, or 78
128	128	renewed in this state which covers the treatment of stage 4 79
129	129	metastatic cancer and its associated conditions that, before a 80
130	130	drug prescribed for the treatment is covered, the insured or 81
131	131	subscriber fail or have previously failed to respond 82
132	132	successfully to a different drug. 83
133	133	(b) Paragraph (a) applies to a drug that is recognized for 84
134	134	the treatment of stage 4 metastatic cancer or its associated 85
135	135	conditions, as applicable, in a standard reference compendium or 86
136	136	that is recommended in the medical literature. The insurer or 87
137	137	health maintenance organization may not exclude coverage for 88
138	138	such drug on the ground that the drug is not approved by the 89
139	139	United States Food and Drug Administration for stage 4 90
140	140	metastatic cancer or its associated conditions, as a pplicable. 91
141	141	(4) COVERAGE FOR SERVICES ASSOCIATED WITH DRUG 92
142	142	ADMINISTRATION.—Coverage for a drug required by this section 93
143	143	also includes the medically necessary services associated with 94
144	144	the administration of the drug. 95
145	145	(5) PROHIBITION ON MANDATORY HOME INFU SION.—An insurer or 96
146	146	a health maintenance organization may not require that a cancer 97
147	147	medication be administered using home infusion, and may not 98
148	148	require that such medication be sent directly to a third party 99
149	149	or to the patient for home infusion, unless the p atient's 100
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158	158	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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161	161
162	162	treating oncologist determines that home infusion of the cancer 101
163	163	medication will not jeopardize the health of the patient. 102
164	164	(6) APPLICABILITY AND SCOPE. —This section may not be 103
165	165	construed to: 104
166	166	(a) Alter any other law with regard to provisions limi ting 105
167	167	coverage for drugs that are not approved by the United States 106
168	168	Food and Drug Administration , except for drugs for the treatment 107
169	169	of stage 4 metastatic cancer or its associated conditions . 108
170	170	(b) Require coverage for any drug , except for a drug for 109
171	171	the treatment of stage 4 metastatic cancer or its associated 110
172	172	conditions, if the United States Food and Drug Administration 111
173	173	has determined that the use of the drug is contraindicated. 112
174	174	(c) Require coverage for a drug that is not otherwise 113
175	175	approved for any indica tion by the United States Food and Drug 114
176	176	Administration, except for a drug for the treatment of stage 4 115
177	177	metastatic cancer or its associated conditions . 116
178	178	(d) Affect the determination as to whether particular 117
179	179	levels, dosages, or usage of a medication associa ted with bone 118
180	180	marrow transplant procedures are covered under an individual or 119
181	181	group health insurance policy or health maintenance organization 120
182	182	contract. 121
183	183	(e) Apply to specified disease or supplemental policies. 122
184	184	(f)(4) Nothing in this section is intended , Expressly or 123
185	185	by implication, to create, impair, alter, limit, modify, 124
186	186	enlarge, abrogate, prohibit, or withdraw any authority to 125
187	187
188	188	HB 633 2022
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192	192	CODING: Words stricken are deletions; words underlined are additions.
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195	195	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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199	199	provide reimbursement for drugs used in the treatment of any 126
200	200	other disease or condition. 127
201	201	Section 2. Section 627.42392, Flo rida Statutes, is amended 128
202	202	to read: 129
203	203	(1) As used in this section, the term : 130
204	204	(a) "Health insurer" means an authorized insurer offering 131
205	205	an individual or group health insurance policy that provides 132
206	206	major medical or similar comprehensive coverage health insurance 133
207	207	as defined in s. 624.603 , a managed care plan as defined in s. 134
208	208	409.962(10), or a health maintenance organization as defined in 135
209	209	s. 641.19(12). 136
210	210	(b) "Urgent care situation" means an injury or a condition 137
211	211	of an insured which, if medical care and treatm ent are not 138
212	212	provided earlier than the time the medical profession generally 139
213	213	considers reasonable for a nonurgent situation, in the opinion 140
214	214	of the insured's treating physician, physician assistant, or 141
215	215	advanced practice registered nurse, would: 142
216	216	1. Seriously jeopardize the insured's life, health, or 143
217	217	ability to regain maximum function; or 144
218	218	2. Subject the insured to severe pain that cannot be 145
219	219	adequately managed. 146
220	220	(2) Notwithstanding any other provision of law, effective 147
221	221	January 1, 2023 January 1, 2017, or 6 six (6) months after the 148
222	222	effective date of the rule adopting the prior authorization 149
223	223	form, whichever is later, a health insurer, or a pharmacy 150
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232	232	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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236	236	benefits manager on behalf of the health insurer, which does not 151
237	237	provide an electronic prior authorization proces s for use by its 152
238	238	contracted providers, shall only use only the prior 153
239	239	authorization form that has been approved by the Financial 154
240	240	Services Commission for granting a prior authorization for a 155
241	241	medical procedure, course of treatment, or prescription drug 156
242	242	benefit. Such form may not exceed two pages in length, excluding 157
243	243	any instructions or guiding documentation, and must include all 158
244	244	clinical documentation necessary for the health insurer to make 159
245	245	a decision. At a minimum, the form must include all of the 160
246	246	following: 161
247	247	(a)(1) Sufficient patient information to identify the 162
248	248	member, including his or her date of birth, full name, and 163
249	249	Health Plan ID number .; 164
250	250	(b)(2) The provider's provider name, address, and phone 165
251	251	number.; 166
252	252	(c)(3) The medical procedure, course of treatment, or 167
253	253	prescription drug benefit being requested, including the medical 168
254	254	reason therefor, and all services tried and failed .; 169
255	255	(d)(4) Any required laboratory documentation . required; 170
256	256	and 171
257	257	(e)(5) An attestation that all information provided is 172
258	258	true and accurate. 173
259	259	174
260	260	The form, whether in electronic or paper format, must require 175
261	261
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269	269	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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273	273	only that information necessary for the determination of the 176
274	274	medical necessity of, or coverage for, the requested medical 177
275	275	procedure, course of t reatment, or prescription drug benefit. 178
276	276	The commission may adopt rules prescribing such necessary 179
277	277	information. 180
278	278	(3) The Financial Services Commission in consultation with 181
279	279	the Agency for Health Care Administration shall adopt by rule 182
280	280	guidelines for all pri or authorization forms which ensure the 183
281	281	general uniformity of such forms. 184
282	282	(4) Electronic prior authorization approvals do not 185
283	283	preclude benefit verification or medical review by the insurer 186
284	284	under either the medical or pharmacy benefits. 187
285	285	Prior authorization.— 188
286	286	(5) A health insurer, or a pharmacy benefits manager on 189
287	287	behalf of the health insurer, shall, upon request, provide the 190
288	288	following information in electronic or paper format and publish 191
289	289	it on a publicly accessible website: 192
290	290	(a) Detailed descriptions, i n clear, easily understandable 193
291	291	language, of the requirements for, and restrictions on, 194
292	292	obtaining prior authorization for coverage of a medical 195
293	293	procedure, course of treatment, or prescription drug. Clinical 196
294	294	criteria must be described in language that a heal th care 197
295	295	provider can easily understand. 198
296	296	(b) Prior authorization forms. 199
297	297	(6) A health insurer, or a pharmacy benefits manager on 200
298	298
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306	306	F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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310	310	behalf of the health insurer, may not implement any new 201
311	311	requirements or restrictions or make changes to existing 202
312	312	requirements or restrictions on obtaining prior authorization 203
313	313	unless: 204
314	314	(a) The changes have been available on a publicly 205
315	315	accessible website for at least 60 days before they are 206
316	316	implemented; and 207
317	317	(b) Insureds and health care providers affected by the new 208
318	318	requirements and restrictions or changes to the requirements and 209
319	319	restrictions are provided with a written notice of the changes 210
320	320	at least 60 days before they are implemented. Such notice may be 211
321	321	delivered electronically or by other means as agreed to by the 212
322	322	insured or the health care provider. 213
323	323	214
324	324	This subsection does not apply to the expansion of health care 215
325	325	services coverage. 216
326	326	(7) A health insurer, or a pharmacy benefits manager on 217
327	327	behalf of the health insurer, shall authorize or deny a prior 218
328	328	authorization request and no tify the patient and the patient's 219
329	329	treating health care provider of the decision within: 220
330	330	(a) Seventy-two hours after receiving a completed prior 221
331	331	authorization form for nonurgent care situations. 222
332	332	(b) Twenty-four hours after receiving a completed prior 223
333	333	authorization form for urgent care situations. 224
334	334	Section 3. This act shall take effect January 1, 2023. 225