September 26, 2020
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HB 591

A bill to be entitled
2An act relating to health insurance; amending s. 409.912,
3F.S.; requiring certain entities to include all
4antiretroviral agents on their formularies; prohibiting
5such entities from using access-limiting procedures to
6restrict antiretroviral agents prescribed to treat a
7person with HIV; creating ss. 627.6404, 627.6572, and
8641.31093, F.S.; requiring all antiretroviral agents to be
9included on health plan formularies; prohibiting access-
10limiting procedures used to restrict antiretroviral agents
11prescribed to treat a person with HIV; amending s.
12627.6515, F.S.; including reference to such requirements
13on policies issued by out-of-state groups; providing an
14effective date.
16Be It Enacted by the Legislature of the State of Florida:
18     Section 1.  Subsection (54) is added to section 409.912,
19Florida Statutes, to read:
20     409.912  Cost-effective purchasing of health care.-The
21agency shall purchase goods and services for Medicaid recipients
22in the most cost-effective manner consistent with the delivery
23of quality medical care. To ensure that medical services are
24effectively utilized, the agency may, in any case, require a
25confirmation or second physician's opinion of the correct
26diagnosis for purposes of authorizing future services under the
27Medicaid program. This section does not restrict access to
28emergency services or poststabilization care services as defined
29in 42 C.F.R. part 438.114. Such confirmation or second opinion
30shall be rendered in a manner approved by the agency. The agency
31shall maximize the use of prepaid per capita and prepaid
32aggregate fixed-sum basis services when appropriate and other
33alternative service delivery and reimbursement methodologies,
34including competitive bidding pursuant to s. 287.057, designed
35to facilitate the cost-effective purchase of a case-managed
36continuum of care. The agency shall also require providers to
37minimize the exposure of recipients to the need for acute
38inpatient, custodial, and other institutional care and the
39inappropriate or unnecessary use of high-cost services. The
40agency shall contract with a vendor to monitor and evaluate the
41clinical practice patterns of providers in order to identify
42trends that are outside the normal practice patterns of a
43provider's professional peers or the national guidelines of a
44provider's professional association. The vendor must be able to
45provide information and counseling to a provider whose practice
46patterns are outside the norms, in consultation with the agency,
47to improve patient care and reduce inappropriate utilization.
48The agency may mandate prior authorization, drug therapy
49management, or disease management participation for certain
50populations of Medicaid beneficiaries, certain drug classes, or
51particular drugs to prevent fraud, abuse, overuse, and possible
52dangerous drug interactions. The Pharmaceutical and Therapeutics
53Committee shall make recommendations to the agency on drugs for
54which prior authorization is required. The agency shall inform
55the Pharmaceutical and Therapeutics Committee of its decisions
56regarding drugs subject to prior authorization. The agency is
57authorized to limit the entities it contracts with or enrolls as
58Medicaid providers by developing a provider network through
59provider credentialing. The agency may competitively bid single-
60source-provider contracts if procurement of goods or services
61results in demonstrated cost savings to the state without
62limiting access to care. The agency may limit its network based
63on the assessment of beneficiary access to care, provider
64availability, provider quality standards, time and distance
65standards for access to care, the cultural competence of the
66provider network, demographic characteristics of Medicaid
67beneficiaries, practice and provider-to-beneficiary standards,
68appointment wait times, beneficiary use of services, provider
69turnover, provider profiling, provider licensure history,
70previous program integrity investigations and findings, peer
71review, provider Medicaid policy and billing compliance records,
72clinical and medical record audits, and other factors. Providers
73shall not be entitled to enrollment in the Medicaid provider
74network. The agency shall determine instances in which allowing
75Medicaid beneficiaries to purchase durable medical equipment and
76other goods is less expensive to the Medicaid program than long-
77term rental of the equipment or goods. The agency may establish
78rules to facilitate purchases in lieu of long-term rentals in
79order to protect against fraud and abuse in the Medicaid program
80as defined in s. 409.913. The agency may seek federal waivers
81necessary to administer these policies.
82     (54)  Any entity that provides Medicaid services on a
83prepaid or fixed-sum basis shall include all antiretroviral
84agents on its formulary and may not restrict antiretroviral
85agents prescribed to treat a person with HIV through a
86requirement for prior authorization, step therapy, or other
87limitation that limits access to any antiretroviral agent.
88     Section 2.  Section 627.6404, Florida Statutes, is created
89to read:
90     627.6404  HIV treatment.-Antiretroviral agents prescribed
91to treat a person with HIV must be included on a health plan
92formulary and may not be restricted through a requirement for
93prior authorization, step therapy, or other limitation that
94limits access to any antiretroviral agent.
95     Section 3.  Subsection (2) of section 627.6515, Florida
96Statutes, is amended to read:
97     627.6515  Out-of-state groups.-
98     (2)  Except as otherwise provided in this part, this part
99does not apply to a group health insurance policy issued or
100delivered outside this state under which a resident of this
101state is provided coverage if:
102     (a)  The policy is issued to an employee group the
103composition of which is substantially as described in s.
104627.653; a labor union group or association group the
105composition of which is substantially as described in s.
106627.654; an additional group the composition of which is
107substantially as described in s. 627.656; a group insured under
108a blanket health policy when the composition of the group is
109substantially in compliance with s. 627.659; a group insured
110under a franchise health policy when the composition of the
111group is substantially in compliance with s. 627.663; an
112association group to cover persons associated in any other
113common group, which common group is formed primarily for
114purposes other than providing insurance; a group that is
115established primarily for the purpose of providing group
116insurance, provided the benefits are reasonable in relation to
117the premiums charged thereunder and the issuance of the group
118policy has resulted, or will result, in economies of
119administration; or a group of insurance agents of an insurer,
120which insurer is the policyholder.;
121     (b)  Certificates evidencing coverage under the policy are
122issued to residents of this state and contain in contrasting
123color and not less than 10-point type the following statement:
124"The benefits of the policy providing your coverage are governed
125primarily by the law of a state other than Florida".; and
126     (c)  The policy provides the benefits specified in ss.
127627.419, 627.6572, 627.6574, 627.6575, 627.6579, 627.6612,
128627.66121, 627.66122, 627.6613, 627.667, 627.6675, 627.6691, and
130     (d)  Applications for certificates of coverage offered to
131residents of this state must contain, in contrasting color and
132not less than 12-point type, the following statement on the same
133page as the applicant's signature:
135"This policy is primarily governed by the laws of ...insert
136state where the master policy if filed.... As a result, all of
137the rating laws applicable to policies filed in this state do
138not apply to this coverage, which may result in increases in
139your premium at renewal that would not be permissible under a
140Florida-approved policy. Any purchase of individual health
141insurance should be considered carefully, as future medical
142conditions may make it impossible to qualify for another
143individual health policy. For information concerning individual
144health coverage under a Florida-approved policy, consult your
145agent or the Florida Department of Financial Services."
147This paragraph applies only to group certificates providing
148health insurance coverage which require individualized
149underwriting to determine coverage eligibility for an individual
150or premium rates to be charged to an individual except for the
152     1.  Policies issued to provide coverage to groups of
153persons all of whom are in the same or functionally related
154licensed professions, and providing coverage only to such
155licensed professionals, their employees, or their dependents;
156     2.  Policies providing coverage to small employers as
157defined by s. 627.6699. Such policies shall be subject to, and
158governed by, the provisions of s. 627.6699;
159     3.  Policies issued to a bona fide association, as defined
160by s. 627.6571(5), provided that there is a person or board
161acting as a fiduciary for the benefit of the members, and such
162association is not owned, controlled by, or otherwise associated
163with the insurance company; or
164     4.  Any accidental death, accidental death and
165dismemberment, accident-only, vision-only, dental-only, hospital
166indemnity-only, hospital accident-only, cancer, specified
167disease, Medicare supplement, products that supplement Medicare,
168long-term care, or disability income insurance, or similar
169supplemental plans provided under a separate policy,
170certificate, or contract of insurance, which cannot duplicate
171coverage under an underlying health plan, coinsurance, or
172deductibles or coverage issued as a supplement to workers'
173compensation or similar insurance, or automobile medical-payment
175     Section 4.  Section 627.6572, Florida Statutes, is created
176to read:
177     627.6572  HIV treatment.-Antiretroviral agents prescribed
178to treat a person with HIV must be included on a health plan
179formulary and may not be restricted through a requirement for
180prior authorization, step therapy, or other limitation that
181limits access to any antiretroviral agent.
182     Section 5.  Section 641.31093, Florida Statutes, is created
183to read:
184     641.31093  HIV treatment.-Antiretroviral agents prescribed
185to treat a person with HIV must be included on a health plan
186formulary and may not be restricted through a requirement for
187prior authorization, step therapy, or other limitation that
188limits access to any antiretroviral agent.
189     Section 6.  This act shall take effect July 1, 2010.

CODING: Words stricken are deletions; words underlined are additions.
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