Oklahoma 2023 Regular Session

Oklahoma House Bill HB1736 Compare Versions

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Version 2 (New)

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1		-	An Act
2		-	ENROLLED HOUSE
3		-	BILL NO. 1736 By: Townley, Miller, Conley and
4		-	Davis of the House
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	29	+	SENATE FLOOR VERSION
	30	+	April 4, 2023
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	33	+	ENGROSSED HOUSE
	34	+	BILL NO. 1736 By: Townley, Miller, Conley,
	35	+	and Davis of the House
5	36
6	37		and
7	38
8	39		Stanley of the Senate
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14	45		An Act relating to step therapy protocol; defining
15	46		terms; requiring health benefit plans to implement a
16	47		new process; providing exceptions to step therapy
17	48		protocol; prescribing required processes; providing
18	49		for certain information or supporting documentation
19	50		not required for submission; providing standard for
20	51		determinations; requiring informatio n be readily
21	52		available on the health benefit pl an's website;
22	53		establishing disposition process fo r requests;
23	54		clarifying applicability of act; providing for
24	55		codification; and providing an effective date.
25	56
26	57
27	58
28		-	~~SUBJECT: Step therapy protocol~~
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29	60
30	61		BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
31		-
32	62		SECTION 1. NEW LAW A new section of law to be codifie d
33	63		in the Oklahoma Statutes as Section 7330 of Title 63, unless there
34	64		is created a duplication in numberin g, reads as follows:
35		-
36	65		A. "Health benefit plan" means a plan as defined pursuant to
37	66		Section 6060.4 of Title 3 6 of the Oklahoma Statutes, that provides
38	67		coverage for invasive or noninvasive mechanical ventilation to treat
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39	95		chronic respiratory failure consequent to chronic obstructive
40	96		pulmonary disease (CRF -COPD), requiring a step therapy protocol.
41		-
42	97		B. "Treatment step therap y protocol" means a treatment
43	98		utilization management protocol or program under which a g roup
44	99		health plan or health insurance issuer offerin g group health
45	100		insurance coverage of respiratory care treatmen ts requires a
46		-	participant or beneficiary to tr y an alternative, plan-preferred ~~ENR. H. B. NO. 1736 Page 2~~
	101	+	participant or beneficiary to tr y an alternative, plan-preferred
47	102		treatment and fail on this treatment before the plan or health
48	103		insurance issuer approves coverage for the non -preferred therapy
49		-	prescribed by the beneficiar y's medical provider.
50		-
	104	+	prescribed by the beneficiaries medical provider .
51	105		C. A health benefit plan shall:
52		-
53	106		1. Implement a clear and transparent process for a pa rticipant
54	107		or beneficiary, or the prescribing health ca re provider on behalf of
55	108		the participant or benefic iary, with CRF-COPD to request an
56	109		exception to such a step therapy protocol, pursuant to subsection B
57	110		of this section; and
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59	111		2. Where the participant or beneficiary or prescribing health
60	112		care provider's request for an exception to the treatment step
61	113		therapy protocols satisfies the criteria and requirements of
62	114		subsection D of this section, cover the requested treatment in
63	115		accordance with the terms established by the health plan or coverage
64	116		for patient cost-sharing rates or amounts at the time of the
65	117		participant's or beneficiary's enrollment in the health plan or
66	118		health insurance coverage.
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68	146		D. The circumstances requiring an e xception to a treatment step
69	147		therapy protocol, pursuant to a request und er subsection C of this
70	148		section, are any of the following:
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72	149		1. Any treatments otherwise required under the protocol have
73	150		not been shown to be as effective as other available options in the
74	151		treatment of the disease or condition or the participant or
75	152		beneficiary, when prescribed consistent with clinical indications,
76	153		clinical guidelines, or other peer-reviewed evidence;
77		-
78	154		2. Delay of proven effective treatment would lead to severe or
79	155		irreversible consequences, and the tre atment initially required
80		-	under the protocol is reasonably expected to be less effective
81		-	~~based~~ upon the documented physical or mental characteristics of the
	156	+	under the protocol is reasonably expected to be less effective based
	157	+	upon the documented physical or mental characteristics of the
82	158		participant or beneficiary and the known characteristics of such
83	159		treatment;
84		-
85	160		3. Any treatments otherwise required under the protocol are
86	161		contraindicated for the participant or beneficiary or have caused,
87	162		or are likely to cause, based on clinical, peer -reviewed evidence,
88	163		an adverse reaction or other physical harm to the p articipant or
89	164		beneficiary;
90		-	ENR. H. B. NO. 1736 Page 3
91	165		4. Any treatment otherwise required under the prot ocol has
92	166		prevented, will prevent, or is likely to prevent a participant or
93	167		beneficiary from achieving or maintaining reasona ble and safe
94	168		functional ability in performing occupati onal responsibilities or
95	169		activities of daily living; or
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97	197		5. The patient's disease state is classified as life
98	198		threatening.
99		-
100	199		E. The process required by subsection C of this section shall:
101		-
102	200		1. Provide the prescribing health care provider or beneficiary
103	201		or designated third-party advocate an opportunity to present such
104	202		provider's clinical rationale and relevant medical information for
105	203		the group health plan or health insurance issuer to evaluate such
106	204		request for exception;
107		-
108	205		2. Clearly set forth all required info rmation and the specific
109	206		criteria that will be used to determine whether an exception is
110	207		warranted, which may require disclosure of the medical history or
111	208		other health records of the participant or beneficiary demonstrating
112	209		that the participant or benefici ary seeking an exception :
113		-
114	210		a. has tried other qualifying treatments without success,
115	211		or
116		-
117	212		b. has received the requested treatment for a clinically
118	213		appropriate amount of time t o establish stability, in
119	214		relation to the condition being treated and guidelines
120	215		given by the prescribing physician .
121		-
122	216		Other clinical information that may be relevant to conducting
123	217		the exception review may require disclosure.
124		-
125	218		3. Not require the submission of any information or supportin g
126	219		documentation beyond what is strictly necessary to d etermine whether
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127	247		any of the circumstances listed in subsection B of this section
128	248		exist.
129		-
130	249		F. The health benefit plan shall make information regarding the
131	250		process required under subsection C of this section readily
132	251		available on the Internet website of the gr oup health plan or health
133	252		insurance issuer. Such information shall include:
134		-	ENR. H. B. NO. 1736 Page 4
135	253		1. The requirements for requesting an exception to a treatment
136	254		step therapy protocol pursuant to this section; and
137		-
138	255		2. Any forms, supporting information, and contact information,
139	256		as appropriate.
140		-
141	257		G. The process required under paragraph 1 of subsection C of
142	258		this section shall provide for the disposition of requests received
143	259		under such paragraph in accordance with the following:
144		-
145	260		1. Subject to paragraph 2 of this subsection, not lat er than
146	261		seventy-two (72) hours after receiving an initial exception request,
147	262		the plan or issuer shall respond to the requesting prescriber with
148	263		either a determination of exception eligibility or a reque st for
149	264		additional required information , strictly necessary to make a
150	265		determination of whether the conditions specified in subsection D of
151	266		this section are met. The plan or issuer shall respon d to the
152	267		requesting provider with a determination of exception eligibility no
153	268		later than seventy-two (72) hours after receipt of the additional
154	269		required information; or
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156	297		2. In the case of a request under circu mstances in which the
157	298		applicable equipment step therapy protocol may seriously jeopardize
158	299		the life or health of the participant or beneficiary, the plan or
159	300		issuer shall conduct a review of the reque st and respond to the
160	301		requesting prescriber with either a determination or exception
161	302		eligibility or a request for additional required information
162	303		strictly necessary to make a determination of whether the conditions
163	304		specified in subsection D of this section are met, in accordance
164	305		with the following:
165		-
166	306		a. if the plan or issuer can make a determination of
167	307		exception eligibility without additional information,
168	308		such determination shall be made on an expedited basis
169	309		and no later than one (1) business day after receipt
170	310		of such request, or
171		-
172	311		b. if the plan or issuer require s additional information
173	312		before making a determin ation of exception
174	313		eligibility, the plan or issuer shall resp ond to the
175	314		requesting provider with a request for such
176	315		information within one (1) business day of the request
177	316		for a determination, and shall res pond with a
178	317		determination of exception eligibility as quickly as
179		-	the condition or disease requires and no later than ~~ENR. H. B. NO. 1736 Page 5~~
	318	+	the condition or disease requires and no later than
180	319		one (1) business day after receipt of the additional
181	320		required information.
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182	347
183	348		H. This act shall apply with respect to any licen sed provider
184	349		in the State of Oklahoma that provides coverage of a treatment
185	350		pursuant to a policy that meets the definitio n of treatment step
186	351		therapy protocol in subsection B of this section, regardless of
187	352		whether such policy is described by such group he alth plan or health
188	353		insurance coverage as a step therapy protocol.
189		-
190	354		SECTION 2. This act shall become effective November 1, 2023.
191		-	ENR. H. B. NO. 1736 Page 6
192		-	Passed the House of Representatives the 8th day of March, 2023.
193		-
194		-
195		-
196		-
197		-	Presiding Officer of the House
198		-	of Representatives
199		-
200		-
201		-
202		-	Passed the Senate the 18 day of April, 2023.
203		-
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206		-
207		-	Presiding Officer of the Senate
208		-
209		-
210		-	OFFICE OF THE GOVERNO R
211		-	Received by the Office of the Governor this ____________________
212		-	day of ___________________, 20_______, at _______ o'clock _______ M.
213		-	By: _________________________________
214		-	Approved by the Governor of the State of Oklahoma this _____ ____
215		-	day of ___________________, 20_______, at _______ o'clock _______ M.
216		-
217		-
218		-	_________________________________
219		-	Governor of the State of Oklahoma
220		-
221		-	OFFICE OF THE SECRETARY OF STATE
222		-	Received by the Office of the Secretary of State this __________
223		-	day of ___________________, 20___ ____, at _______ o'clock _______ M.
224		-	By: _________________________________
225		-
	355	+	COMMITTEE REPORT BY: COMMITTEE ON RETIREMENT AND INSURANCE
	356	+	April 4, 2023 - DO PASS