Florida 2023 Regular Session

Florida House Bill H1533 Compare Versions

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

Old	New	Differences
1	1
2	2
3	3	HB 1533 2023
4	4
5	5
6	6
7	7	CODING: Words stricken are deletions; words underlined are additions.
8	8	hb1533-00
9	9	Page 1 of 11
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
11	11
12	12
13	13
14	14	A bill to be entitled 1
15	15	An act relating to prior authorization for health care 2
16	16	services; amending s. 627.42392, F.S.; providing 3
17	17	definitions; deleting the definition of the term 4
18	18	"health insurer"; providing a process to accept 5
19	19	electronic requests for prior authorization for health 6
20	20	care services; providing requirements for the 7
21	21	electronic prior authorization process; providing 8
22	22	notification requirements for prior authorization 9
23	23	determinations; prohibiting requirements for prior 10
24	24	authorizations for certain health care services and 11
25	25	medications; prohibiting prior authorization 12
26	26	revocations, limitations, conditions, and restrictions 13
27	27	under a specified circumstance; providing requirements 14
28	28	for payments to health care providers; providing 15
29	29	length of prior authorization validity under certain 16
30	30	circumstances; prohibiting requirements for additional 17
31	31	prior authorizations under certain circumstances; 18
32	32	providing construction; prohibiting certain provisions 19
33	33	from being waived; providing an effective date. 20
34	34	21
35	35	Be It Enacted by the Legislature of the State of Florida: 22
36	36	23
37	37	Section 1. Section 627.42392, Florida Statutes, is amended 24
38	38	to read: 25
39	39
40	40	HB 1533 2023
41	41
42	42
43	43
44	44	CODING: Words stricken are deletions; words underlined are additions.
45	45	hb1533-00
46	46	Page 2 of 11
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
48	48
49	49
50	50
51	51	627.42392 Prior authorization. — 26
52	52	(1) As used in this section, the term : 27
53	53	(a) "Adverse determination" means a decision by a 28
54	54	utilization review entity that the health care services provided 29
55	55	or proposed to be provided to an insured are not medically 30
56	56	necessary or are experimental or investigational and that 31
57	57	benefit coverage is theref ore denied, reduced, or terminated. 32
58	58	For purposes of this section, the term does not include a 33
59	59	decision to deny, reduce, or terminate services that are not 34
60	60	covered for reasons other than their medical necessity or 35
61	61	experimental or investigational nature. 36
62	62	(b) "Electronic prior authorization process" does not 37
63	63	include a transmission through a facsimile machine. 38
64	64	(c) "Emergency health care service" has the same meaning 39
65	65	as the term "emergency services and care" as defined in s. 40
66	66	395.002(9). 41
67	67	(d) "Prior authoriz ation" means the process by which a 42
68	68	utilization review entity determines the medical necessity or 43
69	69	appropriateness of otherwise covered health care services before 44
70	70	the provision of such health care services. The term also 45
71	71	includes any health insurer's or ut ilization review entity's 46
72	72	requirement that an insured or health care provider notify the 47
73	73	health insurer or utilization review entity before providing a 48
74	74	health care service. 49
75	75	(e) "Urgent health care service" means a health care 50
76	76
77	77	HB 1533 2023
78	78
79	79
80	80
81	81	CODING: Words stricken are deletions; words underlined are additions.
82	82	hb1533-00
83	83	Page 3 of 11
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
85	85
86	86
87	87
88	88	service with respect to whic h the application of the time 51
89	89	periods for making a nonexpedited prior authorization, in the 52
90	90	opinion of a physician with knowledge of the patient's medical 53
91	91	condition, could: 54
92	92	1. Seriously jeopardize the life or health of the patient 55
93	93	or the ability of the p atient to regain maximum function; or 56
94	94	2. Subject the patient to severe pain that cannot be 57
95	95	adequately managed without the care, treatment, or prescription 58
96	96	drugs that are the subject of the prior authorization request. 59
97	97	(f) "Utilization review entity" "health insurer" means an 60
98	98	authorized insurer offering health insurance as defined in s. 61
99	99	624.603, a managed care plan as defined in s. 409.962(10), or a 62
100	100	health maintenance organization as defined in s. 641.19(12) , a 63
101	101	pharmacy benefit manager as defined in s. 6 24.490(1), or any 64
102	102	other individual or entity that provides, offers to provide, or 65
103	103	administers hospital, outpatient, medical, prescription drug, or 66
104	104	other health benefits to a person treated by a health care 67
105	105	provider in the state under a policy, plan, or con tract. 68
106	106	(2) Beginning January 1, 2024, a utilization review entity 69
107	107	must establish a secure, interactive online electronic prior 70
108	108	authorization process for accepting electronic prior 71
109	109	authorization requests. The process must allow a person seeking 72
110	110	prior authorization to upload documentation if such 73
111	111	documentation is required by the utilization review entity to 74
112	112	adjudicate the prior authorization request. 75
113	113
114	114	HB 1533 2023
115	115
116	116
117	117
118	118	CODING: Words stricken are deletions; words underlined are additions.
119	119	hb1533-00
120	120	Page 4 of 11
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
122	122
123	123
124	124
125	125	(3)(2) Notwithstanding any other provision of law, 76
126	126	effective January 1, 2017, or 6 six (6) months after the 77
127	127	effective date of the rule adopting the prior authorization 78
128	128	form, whichever is later, a utilization review entity that a 79
129	129	health insurer, or a pharmacy benefits manager on behalf of the 80
130	130	health insurer, which does not provide an electronic prior 81
131	131	authorization process for use by its contracted providers , shall 82
132	132	only use only the prior authorization form that has been 83
133	133	approved by the Financial Services Commission for granting a 84
134	134	prior authorization for a medical procedure, course of 85
135	135	treatment, or prescription d rug benefit. Such form may not 86
136	136	exceed two pages in length, excluding any instructions or 87
137	137	guiding documentation, and must include all clinical 88
138	138	documentation necessary for the utilization review entity health 89
139	139	insurer to make a decision. At a minimum, the for m must include: 90
140	140	(1) sufficient patient information to identify the member, date 91
141	141	of birth, full name, and Health Plan ID number; (2) provider 92
142	142	name, address and phone number; (3) the medical procedure, 93
143	143	course of treatment, or prescription drug benefit being 94
144	144	requested, including the medical reason therefor, and all 95
145	145	services tried and failed; (4) any laboratory documentation 96
146	146	required; and (5) an attestation that all information provided 97
147	147	is true and accurate. 98
148	148	(4)(3) The Financial Services Commission in consultation 99
149	149	with the Agency for Health Care Administration shall adopt by 100
150	150
151	151	HB 1533 2023
152	152
153	153
154	154
155	155	CODING: Words stricken are deletions; words underlined are additions.
156	156	hb1533-00
157	157	Page 5 of 11
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
159	159
160	160
161	161
162	162	rule guidelines for all prior authorization forms which ensure 101
163	163	the general uniformity of such forms. 102
164	164	(5)(4) Electronic prior authorization a pprovals do not 103
165	165	preclude benefit verification or medical review by the insurer 104
166	166	under either the medical or pharmacy benefits. 105
167	167	(6) A utilization review entity's prior authorization 106
168	168	process may not require information that is not needed to make a 107
169	169	determination or facilitate a determination of medical necessity 108
170	170	of the requested medical procedure, course of treatment, or 109
171	171	prescription drug benefit. 110
172	172	(7) A utilization review entity shall disclose all of its 111
173	173	prior authorization requirements and restrictions, in cluding any 112
174	174	written clinical criteria, on its website in a manner that is 113
175	175	readily accessible to the public. This information shall be 114
176	176	explained in detail and in clear and unambiguous language. 115
177	177	(8) A utilization review entity may not implement any new 116
178	178	requirements or restrictions or make changes to existing 117
179	179	requirements or restrictions on obtaining prior authorization 118
180	180	unless: 119
181	181	(a) The changes have been available on a publicly 120
182	182	accessible website for at least 60 days before being 121
183	183	implemented. 122
184	184	(b) Insureds and health care providers who are affected by 123
185	185	the new requirements and restrictions or changes to the 124
186	186	requirements and restrictions are provided with a written notice 125
187	187
188	188	HB 1533 2023
189	189
190	190
191	191
192	192	CODING: Words stricken are deletions; words underlined are additions.
193	193	hb1533-00
194	194	Page 6 of 11
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
196	196
197	197
198	198
199	199	of the changes at least 60 days before being implemented. Such 126
200	200	notice must be delivered electronically or by other means as 127
201	201	agreed to by the insured or the health care provider. 128
202	202	(9) A utilization review entity shall make statistics 129
203	203	available regarding prior authorization approvals and denials on 130
204	204	its website in a manner that is readily acces sible to the 131
205	205	public. The statistics must include categories for: 132
206	206	(a) Physician specialty. 133
207	207	(b) Medication or diagnostic test or procedure. 134
208	208	(c) Indication offered. 135
209	209	(d) Reason for denial. 136
210	210	(e) Appeal. 137
211	211	(f) Approval or denial on appeal. 138
212	212	(g) The time between submission and the response. 139
213	213	140
214	214	This subsection does not apply to the expansion of health care 141
215	215	services coverage. 142
216	216	(10) A utilization review entity must ensure that all 143
217	217	adverse determinations are made by a physician licensed under 144
218	218	chapter 458 or chapter 459 who: 145
219	219	(a) Possesses a current, valid, and unrestricted license 146
220	220	to practice medicine in the state. 147
221	221	(b) Is of the same specialty as the physician who 148
222	222	typically manages the medical condition or disease or provides 149
223	223	the health care service involv ed in the request. 150
224	224
225	225	HB 1533 2023
226	226
227	227
228	228
229	229	CODING: Words stricken are deletions; words underlined are additions.
230	230	hb1533-00
231	231	Page 7 of 11
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
233	233
234	234
235	235
236	236	(c) Has experience treating patients with the medical 151
237	237	condition or disease for which the health care service is being 152
238	238	requested. 153
239	239	(11) Notice of an adverse determination shall be provided 154
240	240	by electronic mail to the insured and the heal th care provider 155
241	241	that initiated the prior authorization. Notice required under 156
242	242	this subsection must include: 157
243	243	(a) The name, title, e -mail address, and telephone number 158
244	244	of the physician responsible for making the adverse 159
245	245	determination. 160
246	246	(b) The written clinical criteria, if any, and any 161
247	247	internal rule, guideline, or protocol on which the utilization 162
248	248	review entity relied when making the adverse determination and 163
249	249	how those provisions apply to the insured's specific medical 164
250	250	circumstance. 165
251	251	(c) Information for the insured and the insured's health 166
252	252	care provider which describes the procedure through which the 167
253	253	insured or health care provider may request a copy of any report 168
254	254	developed by personnel performing the review that led to the 169
255	255	adverse determination. 170
256	256	(d) Information that explains to the insured and the 171
257	257	insured's healthcare provider how to appeal the adverse 172
258	258	determination. 173
259	259	(12) If a utilization review entity requires prior 174
260	260	authorization of a nonurgent health care service, the 175
261	261
262	262	HB 1533 2023
263	263
264	264
265	265
266	266	CODING: Words stricken are deletions; words underlined are additions.
267	267	hb1533-00
268	268	Page 8 of 11
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
270	270
271	271
272	272
273	273	utilization review entity shall make an authorization or adverse 176
274	274	determination and notify the insured and the insured's health 177
275	275	care provider of the decision within 2 business days after 178
276	276	obtaining all necessary information to make the authorization or 179
277	277	adverse determination. As used in th is subsection, the term 180
278	278	"necessary information" includes the results of any face -to-face 181
279	279	clinical evaluation or second opinion that may be required. 182
280	280	(13) A utilization review entity shall render an expedited 183
281	281	authorization or adverse determination concern ing an urgent 184
282	282	health care service and notify the insured and the insured's 185
283	283	health care provider of that expedited prior authorization or 186
284	284	adverse determination no later than 1 business day after 187
285	285	receiving all information needed to complete the review of the 188
286	286	requested urgent healthcare service. 189
287	287	(14) A utilization review entity may not require prior 190
288	288	authorization for prehospital transportation or for provision of 191
289	289	an emergency health care service. 192
290	290	(15) A utilization review entity may not require prior 193
291	291	authorization for the provision of medications for opioid use 194
292	292	disorder. As used in this subsection, the term "medications for 195
293	293	opioid use disorder" means the use of United States Food and 196
294	294	Drug Administration approved medications, commonly in 197
295	295	combination with counseling and behavioral therapies, to provide 198
296	296	a comprehensive approach to the treatment of opioid use 199
297	297	disorder. Food and Drug Administration approved medications used 200
298	298
299	299	HB 1533 2023
300	300
301	301
302	302
303	303	CODING: Words stricken are deletions; words underlined are additions.
304	304	hb1533-00
305	305	Page 9 of 11
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
307	307
308	308
309	309
310	310	to treat opioid addiction inc lude, but are not limited to, 201
311	311	methadone, buprenorphine, alone or in combination with naloxone, 202
312	312	and extended-release injectable naltrexone. Types of behavioral 203
313	313	therapies include, but are not limited to, individual therapy, 204
314	314	group counseling, family behavior therapy, motivational 205
315	315	incentives, and other modalities. 206
316	316	(16) A utilization review entity may not revoke, limit, 207
317	317	condition, or restrict a prior authorization if care is provided 208
318	318	within 45 business days after the date the health care provider 209
319	319	received the prior authorization. A utilization review entity 210
320	320	must pay the health care provider at the contracted payment rate 211
321	321	for a health care service provided by the health care provider 212
322	322	per prior authorization unless: 213
323	323	(a) The health care provider knowingly and ma terially 214
324	324	misrepresented the health care service in the prior 215
325	325	authorization request with the specific intent to deceive and 216
326	326	obtain an unlawful payment from the utilization review entity; 217
327	327	(b) The health care service was no longer a covered 218
328	328	benefit on the day it was provided, and the utilization review 219
329	329	entity notified the health care provider in writing of this fact 220
330	330	before the health care service was provided; 221
331	331	(c) The health care provider was no longer contracted with 222
332	332	the insured's health insurance plan on the date the care was 223
333	333	provided, and the utilization review entity notified the health 224
334	334	care provider in writing of this fact before the health care 225
335	335
336	336	HB 1533 2023
337	337
338	338
339	339
340	340	CODING: Words stricken are deletions; words underlined are additions.
341	341	hb1533-00
342	342	Page 10 of 11
343	343	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
344	344
345	345
346	346
347	347	service was provided; 226
348	348	(d) The health care provider failed to meet the 227
349	349	utilization review entity's timely f iling requirements; 228
350	350	(e) The authorized service was never performed; or 229
351	351	(f) The patient was no longer eligible for health care 230
352	352	coverage on the day the care was provided, and the utilization 231
353	353	review entity notified the health care provider in writing of 232
354	354	this fact before the health care service was provided. 233
355	355	(17) If a utilization review entity required a prior 234
356	356	authorization for a health care service for the treatment of a 235
357	357	chronic or long-term care condition, the prior authorization 236
358	358	remains valid for the l ength of the treatment and the 237
359	359	utilization review entity may not require the insured to obtain 238
360	360	a prior authorization again for the health care service. 239
361	361	(18) A utilization review entity may not impose an 240
362	362	additional prior authorization requirement with re spect to a 241
363	363	surgical or otherwise invasive procedure, or any item provided 242
364	364	as part of the surgical or invasive procedure, if the procedure 243
365	365	or item is provided during the perioperative period of another 244
366	366	procedure for which prior authorization was granted by the 245
367	367	health insurer. 246
368	368	(19) If there is a change in coverage or approval criteria 247
369	369	for a previously authorized health care service, the change in 248
370	370	coverage or approval criteria may not affect an insured who 249
371	371	received prior authorization before the effective da te of the 250
372	372
373	373	HB 1533 2023
374	374
375	375
376	376
377	377	CODING: Words stricken are deletions; words underlined are additions.
378	378	hb1533-00
379	379	Page 11 of 11
380	380	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
381	381
382	382
383	383
384	384	change for the remainder of the insured's policy, plan, or 251
385	385	contract year. 252
386	386	(20) A utilization review entity shall continue to honor a 253
387	387	prior authorization that it has granted to an insurer when the 254
388	388	insurer changes products under the same health i nsurer. 255
389	389	(21) A failure by a utilization review entity to comply 256
390	390	with the deadlines and other requirements of this section will 257
391	391	result in a health care service subject to review to be 258
392	392	automatically deemed authorized by the utilization review 259
393	393	entity. 260
394	394	(22) The provisions of this section may not be waived by 261
395	395	any policy, plan, or contract. Any policy, plan, or contractual 262
396	396	arrangements or any actions taken in conflict with this section 263
397	397	or that purport to waive any requirements of this section are 264
398	398	void. 265
399	399	Section 2. This act shall take effect July 1, 2023. 266