Prior Authorization Bill

AN ACT TO ENSURE PROTECTION OF PATIENTS IN MEDICAL REVIEW BY HEALTH INSURANCE CARRIERS AND TO IMPROVE PRIOR AUTHORIZATION PROCESSES

DRAFT 12/30/16

 

Sponsor:         Senator Geoffrey Gratwick, M.D.

Contact:         Andrew MacLean, Maine Medical Association, 622-3374, ext. 214 (O);

215-7462 (Cell); amaclean@mainemed.com

 

Be it enacted by the People of the State of Maine as follows:

 

            Sec. 1.  24-A M.R.S.A. §4301-A is amended as follows:

          Sec. 2.  24-A M.R.S.A. §4304 is amended as follows:

4Clinical peer.  "Clinical peer" means a physician or other licensed health care practitioner who holds a nonrestricted license in a state of the United States and is both board certified and in active medical practice in the same or similar specialty as typically manages the medical condition, procedure or treatment under review, or other physician or health care practitioner with demonstrable expertise necessary to review a case.

§4304. UTILIZATION REVIEW

 

The following requirements apply to health plans doing business in this State that require prior authorization by the plan of health care services or otherwise subject payment of health care services to review for clinical necessity, appropriateness, efficacy or efficiency. A carrier offering or renewing a health plan subject to this section that contracts with other entities to perform utilization review on the carrier's behalf is responsible for ensuring compliance with this section and chapter 34. [2007, c. 199, Pt. B, §12 (AMD).]

1Requirements for medical review or utilization review practices.  A carrier must appoint a medical director who is responsible for reviewing and approving the carrier's policies governing the clinical aspects of coverage determinations by any health plan that it offers or renews. A carrier's medical review or utilization review practices must be governed by the standard of medically necessary health care as defined in this chapterAll medical review decisions, including utilization review, case management, or other type of medical review, must be conducted by a clinical peer as defined in this chapter.

[ 2007, c. 199, Pt. B, §13 (AMD).]

2Prior authorization of nonemergency services.  Requests by a provider for prior authorization of a nonemergency service must be answered by a carrier within 2 business days. Both the provider and the enrollee on whose behalf the authorization was requested must be notified by the carrier of its determination. If the information submitted is insufficient to make a decision, the carrier shall notify the provider within 2 business days of the additional information necessary to render a decision. If the carrier determines that outside consultation is necessary, the carrier shall notify the provider and the enrollee for whom the service was requested within 2 business days. The carrier shall make a good faith estimate of when the final determination will be made and contact the enrollee and the provider as soon as practicable. Notification requirements under this subsection are satisfied by written notification postmarked within the time limit specified.

[ 1999, c. 742, §12 (AMD).]

No later than January 1, 2018, a carrier must accept and respond to prior authorization requests under the pharmacy benefit through a secure electronic transmission using the National Council for Prescription Drug Programs (NCPDP) SCRIPT Standard electronic prescribing (ePA) transactions.  No later than July 1, 2018, a carrier must accept and respond to prior authorization requests for medical services through a standard secure electronic transmission under the Health Insurance Portability & Accountability Act (HIPAA).  Facsimile, proprietary payer portals, and electronic forms shall not be considered electronic transmission.

3Background information; affirmative duty of provider.  A provider has an affirmative duty to submit to the carrier the background information necessary for the carrier to complete its review and render a decision within the time period required in subsection 2. If the provider needs additional time to submit that required information, the provider must inform the carrier in a timely manner. Nothing in this section requires a provider to submit confidential information without a signed consent from the enrollee.

[ 1995, c. 673, Pt. C, §1 (NEW); 1995, c. 673, Pt. C, §2 (AFF).]

4Revocation of prior authorization.  When prior approval for a service or other covered item is granted, a carrier may not retrospectively deny coverage or payment for the originally approved service unless fraudulent or materially incorrect information was provided at the time prior approval for the service was granted.  A carrier may not deny coverage of post-acute physician visits of patients who are hospitalized or in a skilled nursing, rehabilitation, or other long-term care facility when the post-acute admission of the patient has been prior authorized by the carrier.

[ 1995, c. 673, Pt. C, §1 (NEW); 1995, c. 673, Pt. C, §2 (AFF).]

5Emergency services.  When conducting utilization review or making a benefit determination for emergency services, a carrier shall provide benefits for emergency services consistent with the requirements of any applicable bureau rule.

[ 1999, c. 742, §13 (NEW).]

6Notice.  A notice issued by a carrier or its contracted utilization review entity in response to a request by or on behalf of an insured or enrollee for authorization of medical services that advises that the requested service has been determined to be medically necessary must also advise whether the service is covered under the policy or contract under which the insured or enrollee is covered. Nothing in this subsection requires a carrier to provide coverage for services performed when the insured or enrollee is no longer covered by the health plan.

Sec. 3.  24-A M.R.S.A. §4311 is amended as follows:

§4311. ACCESS TO PRESCRIPTION DRUGS

1Formulary.  If a health plan provides coverage for prescription drugs but the coverage limits such benefits to drugs included in a formulary, a carrier shall:

A. Ensure participation of participating physicians and pharmacists in the development of the formulary; and [1999, c. 742, §19 (NEW); 1999, c. 742, §21 (AFF).]

B. Provide exceptions to the formulary limitation when a nonformulary alternative is medically indicated, consistent with the utilization review standards in section 4304. [1999, c. 742, §19 (NEW);  1999, c. 742, §21 (AFF).]

[ 1999, c. 742, §19 (NEW); 1999, c. 742, §21 (AFF).]

     C.  Ensure participating clinicians with prescriptive authority and pharmacists have access to the health plans’ most current formulary in electronic form at all times.

2Coverage of approved drugs and medical devices.  A carrier that provides coverage for prescription drugs and medical devices may not deny coverage of a prescribed drug or medical device on the basis that the use of the drug or device is investigational if the intended use of the drug or device is included in the labeling authorized by the federal Food and Drug Administration or if the use of the drug or device is recognized in one of the standard reference compendia or in peer-reviewed medical literature.

[ 1999, c. 742, §19 (NEW); 1999, c. 742, §21 (AFF).]

3Construction.  This section may not be construed to require a carrier to provide coverage of prescription drugs or medical devices.

[ 1999, c. 742, §19 (NEW); 1999, c. 742, §21 (AFF).]

4Application.  The requirements of this section apply to all individual and group policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date.

Sec. 4.  The Superintendent of Insurance shall ensure that Bureau of Insurance Rule Chapter 850, Health Plan Accountability is amended as necessary to comply with these provisions.

 

SUMMARY

The bill proposes amendments to Maine’s Health Plan Improvement Act to ensure that a health care practitioner who on behalf of a health insurance carrier licensed in the State of Maine conducts any type of medical review of the treatment recommendations of a patient’s treating practitioner is qualified to conduct such medical review by appropriate training and experience in the treating practitioner’s medical specialty. 

The bill also requires a health insurance carrier to develop an electronic transmission system for prior authorization of prescription drug orders by January 1, 2018 and for medical services by July 1, 2018. 

The bill requires a health insurance carrier to make its most current prescription drug formulary available to health care practitioners in electronic form at all times.

Finally, the bill prohibits a health insurance carrier from denying post-acute physician visits with patients who are hospitalized or in a skilled, rehabilitation, or other long-term care facility when that post-acute admission of the patient has been prior authorized by the carrier.