HB 220 — Regards health insurance, Medicaid prior authorization

305 (4) On the date the health care practitioner renders the 306 prior approved health care service, drug, or device, all of the 307 following are true:

308 Sub.

220 Page 12 As ReportedPassed by the House Insurancecorporation. Committee (a) The patient is eligible under the health benefit plan.

305 (4) On the date the health care practitioner renders the 306 prior approved health care service, drug, or device, all of the 307 following are true:

308 (a) The patient is eligible under the health benefit plan.

332 (F)Sub. The superintendent of insurance may adopt rules in 333 accordance with Chapter 119.

of the Revised Code as necessary to 334 implement the provisions of this section.

335 (G) This section does not apply to any of the following 336 types of coverage:

a policy, contract, certificate, or agreement 337 Sub.

220 Page 13 As ReportedPassed by the House Insurance(F) CommitteeThe thatsuperintendent coversof onlyinsurance amay specifiedadopt accident,rules accident only, credit, 338 dental, disability income, long-term care, hospital indemnity, 339 supplemental coverage as described in section333 3923.37accordance ofwith theChapter 340119. Revised Code, specified disease, or vision care;

of the Revised Code as necessary to 334 implement the provisions of this section.

335 (G) This section does not apply to any of the following 336 types of coverage:

a policy, contract, certificate, or agreement 337 that covers only a specified accident, accident only, credit, 338 dental, disability income, long-term care, hospital indemnity, 339 supplemental coverage as described in section 3923.37 of the 340 Revised Code, specified disease, or vision care;

360 (2) "Clinical peer" means a health care practitioner in 361 the same or in a similar, specialty that typically manages the 362 medicalSub. condition, procedure, or treatment under review.

363 (3) "Covered person" means a person receiving coverage for 364 health services under a policy of sickness and accident 365 insurance or a public employee benefit plan.

366 Sub.

220 Page 14 As ReportedPassed by the House Insurancemedical Committeecondition, (4)procedure, "Emergencyor service"treatment hasunder thereview. same meaning as in section 367 1753.28 of the Revised Code.

363 (3) "Covered person" means a person receiving coverage for 364 health services under a policy of sickness and accident 365 insurance or a public employee benefit plan.

366 (4) "Emergency service" has the same meaning as in section 367 1753.28 of the Revised Code.

391 (a)Sub. Could seriously jeopardize the life, health, or safety 392 of the patient or others due to the patient's psychological 393 state;

394 (b) In the opinion of a practitioner with knowledge of the 395 Sub.

220 Page 15 As ReportedPassed by the House Insurance(a) CommitteeCould patient'sseriously medicaljeopardize or behavioral condition, would subject the 396life, patienthealth, toor adversesafety health392 consequencesof without the carepatient or 397others treatmentdue thatto is the subjectpatient's ofpsychological the393 request.state;

394 (b) In the opinion of a practitioner with knowledge of the 395 patient's medical or behavioral condition, would subject the 396 patient to adverse health consequences without the care or 397 treatment that is the subject of the request.

412 (b) For policies issued on or after January 1, 2018, the 413 insurer or plan, a pharmacy benefit manager responsible for 414 handling prior authorization requests, or other payer acting on 415 behalf of the insurer or plan shall accept and respond to prior 416 prescription benefit authorization requests through a secure 417 electronic transmission using NCPDP SCRIPT standard ePA 418 transactions, and for prior medical benefit authorization 419 requests through a secure electronic transmission using 420 standardsSub. established by the council for affordable quality 421 health care on operating rules for information exchange or its 422 successor.

423 (c) For purposes of division (B)(2) of this section, 424 Sub.

220 Page 16 As ReportedPassed by the House Insurancestandards Committeeestablished neitherby of the followingcouncil shallfor beaffordable consideredquality a421 securehealth electroniccare 425on transmission:operating rules for information exchange or its 422 successor.

423 (c) For purposes of division (B)(2) of this section, 424 neither of the following shall be considered a secure electronic 425 transmission:

447 (b) The response required under division (B)(4)(a) of this 448 section shall indicate whether the request is approved or 449 denied.Sub.

If the prior authorization is denied, the insurer or 450 plan shall provide the specific reason for the denial.

451 (c) If the prior authorization request is incomplete, the 452 insurer or plan shall indicate the specific additional 453 Sub.

220 Page 17 As ReportedPassed by the House Insurancedenied. Committee information that is required to process the request.

If the prior authorization is denied, the insurer or 450 plan shall provide the specific reason for the denial.

451 (c) If the prior authorization request is incomplete, the 452 insurer or plan shall indicate the specific additional 453 information that is required to process the request.

477 (c)Sub. An insurer or plan, in relation to prior approval 478 under division (B)(6)(a) of this section, may require a health 479 care practitioner to submit information to the insurer or plan 480 indicating that the patient's chronic condition has not changed.

481 Sub.

220 Page 18 As ReportedPassed by the House Insurance(c) CommitteeAn (i)insurer Theor requestplan, forin informationrelation byto theprior insurerapproval or478 planunder anddivision 482(B)(6)(a) theof responsethis bysection, themay require a health 479 care practitioner shallto besubmit ininformation anto 483the electronicinsurer format,or whichplan may480 beindicating bythat electronicthe mailpatient's orchronic othercondition 484has electronicnot communication.changed.

481 (i) The request for information by the insurer or plan and 482 the response by the health care practitioner shall be in an 483 electronic format, which may be by electronic mail or other 484 electronic communication.

506 (iii)Sub. Medications that require an initial trial period to 507 determine effectiveness and tolerability, beyond which a one- 508 year, or greater, prior authorization period will be given;

509 Sub.

220 Page 19 As ReportedPassed by the House Insurance(iii) Committee (iv) Medications wherethat thererequire isan medicalinitial ortrial scientificperiod 510to evidence507 asdetermine definedeffectiveness inand sectiontolerability, 3922.01beyond ofwhich thea Revisedone- Code508 thatyear, 511or dogreater, notprior supportauthorization aperiod twelve-monthwill priorbe approval;given;

509 (iv) Medications where there is medical or scientific 510 evidence as defined in section 3922.01 of the Revised Code that 511 do not support a twelve-month prior approval;

533 For purposes of division (B)(7) of this section, "rare 534 medicalSub. condition" means any disease or condition that affects 535 fewer than two hundred thousand individuals in the United 536 States.

537 Sub.

220 Page 20 As ReportedPassed by the House Insurancemedical Committeecondition" (8)means Nothingany indisease divisionor (B)(6)condition orthat (7)affects of535 thisfewer sectionthan 538two prohibitshundred thethousand substitution,individuals in accordance with section 4729.38 539 of the RevisedUnited Code,536 ofStates. any drug that has received a twelve- 540 month approval under division (B)(6)(a) of this section when 541 there is a release of either of the following:

537 (8) Nothing in division (B)(6) or (7) of this section 538 prohibits the substitution, in accordance with section 4729.38 539 of the Revised Code, of any drug that has received a twelve- 540 month approval under division (B)(6)(a) of this section when 541 there is a release of either of the following:

561 (b) Once the written request and all necessary information 562 isSub. received, the insurer or plan shall review the claim for 563 coverage and medical necessity.

The insurer or plan shall not 564 deny a claim for such a new service based solely on the fact 565 that a prior authorization approval was not received for the new 566 Sub.

220 Page 21 As ReportedPassed by the House Insuranceis Committeereceived, servicethe ininsurer question.or plan shall review the claim for 563 coverage and medical necessity.

The insurer or plan shall not 564 deny a claim for such a new service based solely on the fact 565 that a prior authorization approval was not received for the new 566 service in question.

590 (b) The insurer or plan shall make available on its web 591 siteSub. information about the policies, contracts, or agreements 592 offered by the insurer or plan that clearly identifies specific 593 services, drugs, or devices to which a prior authorization 594 requirement exists.

595 Sub.

220 Page 22 As ReportedPassed by the House Insurancesite Committeeinformation (12)about Forthe policiespolicies, issuedcontracts, on or afteragreements January592 1,offered 2018,by the 596 insurer or plan shallthat establishclearly aidentifies streamlinedspecific appeal593 processservices, 597drugs, relatingor devices to adversewhich a prior authorization determinations594 thatrequirement 598exists. shall include all of the following:

595 (12) For policies issued on or after January 1, 2018, the 596 insurer or plan shall establish a streamlined appeal process 597 relating to adverse prior authorization determinations that 598 shall include all of the following:

620 (C) For policies issued on or after January 1, 2017, 621 except in cases of fraudulent or materially incorrect 622 information, an insurer or plan shall not retroactively deny a 623 prior authorization for a health care service, drug, or device 624 Sub.

220 Page 23 As ReportedPassed by the House Insurance(C) CommitteeFor policies issued on or after January 1, 2017, 621 except in cases of fraudulent or materially incorrect 622 information, an insurer or plan shall not retroactively deny a 623 prior authorization for a health care service, drug, or device 624 including, for policies delivered, issued for delivery, or 625 renewed on or after the effective date of this amendment, an 626 authorization for mental health or substance use disorder 627 treatment, when all of the following are met:

648 (a)Sub. The patient is eligible under the health benefit plan.

649 (b) The patient's condition or circumstances related to 650 the patient's care has not changed.

651 Sub.

220 Page 24 As ReportedPassed by the House Insurance(a) Committee (c) The healthpatient careis practitionereligible submitsunder an accurate claim 652 that matches the information submitted by the health carebenefit 653plan. practitioner in the approved prior authorization request.

649 (b) The patient's condition or circumstances related to 650 the patient's care has not changed.

651 (c) The health care practitioner submits an accurate claim 652 that matches the information submitted by the health care 653 practitioner in the approved prior authorization request.

a policy, contract, certificate, or agreement 677 that covers only a specified accident, accident only, credit, 678 dental, disability income, long-term care, hospital indemnity, 679 supplemental coverage as described in section 3923.37 of the 680 Sub.

220 Page 25 As ReportedPassed by the House Insurancethat Committeecovers only a specified accident, accident only, credit, 678 dental, disability income, long-term care, hospital indemnity, 679 supplemental coverage as described in section 3923.37 of the 680 Revised Code, specified disease, or vision care;

704 (4) "Prior authorization requirement" means any practice 705 implemented by a medical assistance program in which coverage of 706 a health care service, device, or drug is dependent upon a 707 medical assistance recipient or a health care provider, 708 receiving approval from the department of medicaid or its 709 Sub.

220 Page 26 As ReportedPassed by the House Insurancea Committeehealth care service, device, or drug is dependent upon a 707 medical assistance recipient or a health care provider, 708 receiving approval from the department of medicaid or its 709 designee, including a medicaid managed care organization, prior 710 to the service, device, or drug being performed, received, or 711 prescribed, as applicable.

735 (2)(a) On or before January 1, 2018, permit the department 736 or its designee to accept and respond to prior prescription 737 benefit authorization requests through a secure electronic 738 Sub.

220 Page 27 As ReportedPassed by the House Insurance(2)(a) CommitteeOn or before January 1, 2018, permit the department 736 or its designee to accept and respond to prior prescription 737 benefit authorization requests through a secure electronic 738 transmission.

761 (4)(a) On or before January 1, 2018, if the health care 762 provider submits the request for prior authorization 763 electronically as described in divisions (B)(1) and (2) of this 764 section, respond to all prior authorization requests within 765 forty-eight hours for urgent care services, or ten calendar days 766 for any prior authorization request that is not for an urgent 767 Sub.

220 Page 28 As ReportedPassed by the House Insurancesection, Committeerespond to all prior authorization requests within 765 forty-eight hours for urgent care services, or ten calendar days 766 for any prior authorization request that is not for an urgent 767 care service, of the time the request is received by the 768 department or its designee.

793 (i)Sub. Twelve months;

794 (ii) The last day of the medical assistance recipient's 795 eligibility for the medical assistance program.

796 Sub.

220 Page 29 As ReportedPassed by the House Insurance(i) CommitteeTwelve (b)months; The duration of all other prior authorization 797 approvals shall be dictated by the medical assistance program.

794 (ii) The last day of the medical assistance recipient's 795 eligibility for the medical assistance program.

796 (b) The duration of all other prior authorization 797 approvals shall be dictated by the medical assistance program.

820 (e) A twelve-month approval provided under division (B)(6) 821 (a)Sub. of this section does not apply to and is not required for 822 any of the following:

823 (i) Medications that are prescribed for a non-maintenance 824 condition;

825 Sub.

220 Page 30 As ReportedPassed by the House Insurance(a) Committeeof (ii)this Medicationssection thatdoes havenot aapply typicalto treatmentand ofis lessnot 826required thanfor one822 year;any of the following:

823 (i) Medications that are prescribed for a non-maintenance 824 condition;

825 (ii) Medications that have a typical treatment of less 826 than one year;

848 (a) The drug is prescribed or administered to treat a rare 849 medicalSub. condition and pursuant to medical or scientific evidence 850 as defined in section 3922.01 of the Revised Code.

851 (b) Medications that are controlled substances not 852 included in division (B)(6)(e)(v) of this section.

853 Sub.

220 Page 31 As ReportedPassed by the House Insurancemedical Committeecondition Forand purposespursuant ofto division (B)(7) of this section, "rare 854 medical condition" means any disease or conditionscientific thatevidence affects850 855as fewerdefined thanin two-hundredsection thousand3922.01 individualsof in the UnitedRevised 856Code. States.

851 (b) Medications that are controlled substances not 852 included in division (B)(6)(e)(v) of this section.

853 For purposes of division (B)(7) of this section, "rare 854 medical condition" means any disease or condition that affects 855 fewer than two-hundred thousand individuals in the United 856 States.

877 (ii)Sub. The new service was not known to be needed at the 878 time the original prior authorized service was performed.

879 (iii) The need for the new service was revealed at the 880 time the original authorized service was performed.

881 Sub.

220 Page 32 As ReportedPassed by the House Insurance(ii) CommitteeThe (b)new Onceservice thewas writtennot requestknown andto allbe necessaryneeded informationat 882 is received, the department878 ortime its designee shall review the 883original claimprior forauthorized coverageservice andwas medicalperformed. necessity.

879 (iii) The need for the new service was revealed at the 880 time the original authorized service was performed.

881 (b) Once the written request and all necessary information 882 is received, the department or its designee shall review the 883 claim for coverage and medical necessity.

902 (11)(a) On or before January 1, 2017, make available to 903 all participating health care providers on its web site or 904 provider portal a listing of its prior authorization 905 requirements, including specific information or documentation 906 thatSub. a provider must submit in order for the prior authorization 907 request to be considered complete.

908 (b) Make available on its web site information about the 909 medical assistance programs offered in this state that clearly 910 Sub.

220 Page 33 As ReportedPassed by the House Insurancethat Committeea identifiesprovider specificmust services,submit drugs,in ororder devicesfor tothe whichprior aauthorization prior907 911request authorizationto requirementbe exists.considered complete.

908 (b) Make available on its web site information about the 909 medical assistance programs offered in this state that clearly 910 identifies specific services, drugs, or devices to which a prior 911 authorization requirement exists.

933 (C) Beginning January 1, 2017, except in cases of 934 fraudulentSub. or materially incorrect information, the department 935 or its designee shall not retroactively deny a prior 936 authorization for a health care service, drug, or device, 937 including an authorization for mental health or substance use 938 disorder treatment, when all of the following are met:

939 Sub.

220 Page 34 As ReportedPassed by the House Insurancefraudulent Committeeor (1)materially Theincorrect healthinformation, carethe providerdepartment submits935 aor priorits authorizationdesignee 940shall requestnot toretroactively thedeny departmenta orprior its936 designeeauthorization for a health care 941 service, drug, or device.device, 937 including an authorization for mental health or substance use 938 disorder treatment, when all of the following are met:

939 (1) The health care provider submits a prior authorization 940 request to the department or its designee for a health care 941 service, drug, or device.

962 (b)Sub. The recipient's condition or circumstances related to 963 the recipient's care has not changed.

964 (c) The health care provider submits an accurate claim 965 that matches the information submitted by the health care 966 provider in the approved prior authorization request.

967 Sub.

220 Page 35 As ReportedPassed by the House Insurance(b) CommitteeThe (5)recipient's Ifcondition the health care provider submits a claim that 968 includes an unintentional error and the error results in a claim 969 that does not match the information originally submitted by the 970 health care provider in the approved prior authorization 971 request, upon receiving a denial of services from the department 972 or itscircumstances designee,related the health care provider may resubmit the claim 973 pursuant to division963 (C) of this section with the informationrecipient's 974care thathas matchesnot thechanged. information included in the approved prior 975 authorization.

964 (c) The health care provider submits an accurate claim 965 that matches the information submitted by the health care 966 provider in the approved prior authorization request.

967 (5) If the health care provider submits a claim that 968 includes an unintentional error and the error results in a claim 969 that does not match the information originally submitted by the 970 health care provider in the approved prior authorization 971 request, upon receiving a denial of services from the department 972 or its designee, the health care provider may resubmit the claim 973 pursuant to division (C) of this section with the information 974 that matches the information included in the approved prior 975 authorization.