Senate Study Bill 1164



                                    SENATE FILE       
                                    BY  (PROPOSED COMMITTEE ON
                                        HUMAN RESOURCES BILL
                                        BY CHAIRPERSON RAGAN)

                                         A BILL FOR

     1 An Act requiring the development and use of a standard form for
     2    prior authorization of prescription drug benefits.
     3 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
       TLSB 2161SC (2) 85
       av/nh

PAG LIN



  1  1    Section 1.  NEW SECTION.  505.26  Prior authorization for
  1  2 prescription drug benefits == standard form.
  1  3    1.  The commissioner shall develop, by rule, a standard prior
  1  4 authorization form for use by health carriers that require
  1  5 prior authorization for prescription drug benefits pursuant to
  1  6 a health benefit plan, by January 1, 2014.
  1  7    2.  Prior to development of the standard prior authorization
  1  8 form, the commissioner shall hold at least one public hearing
  1  9 to gather input in developing the standard form from interested
  1 10 parties.
  1 11    3.  The standard prior authorization form shall meet all of
  1 12 the following requirements:
  1 13    a.  Not exceed two pages in length.
  1 14    b.  Be available in an electronic format.
  1 15    c.  Be transmissible in an electronic format.
  1 16    4.  Health carriers shall use and accept the standard prior
  1 17 authorization form beginning on July 1, 2014.  Health care
  1 18 providers shall use and submit the standard prior authorization
  1 19 form, when prior authorization is required by a health benefit
  1 20 plan, beginning on July 1, 2014.
  1 21    5.  If a health carrier fails to use or accept the standard
  1 22 prior authorization form or to respond to a health care
  1 23 provider request for prior authorization of prescription drug
  1 24 benefits within forty=eight hours of the health care provider's
  1 25 submission of the form, the request for prior authorization
  1 26 shall be considered to be approved.
  1 27    6.  As used in this section:
  1 28    a.  "Facility" means an institution providing health care
  1 29 services or a health care setting, including but not limited
  1 30 to hospitals and other licensed inpatient centers, ambulatory
  1 31 surgical or treatment centers, skilled nursing centers,
  1 32 residential treatment centers, diagnostic, laboratory, and
  1 33 imaging centers, and rehabilitation and other therapeutic
  1 34 health settings.
  1 35    b.  "Health benefit plan" means a policy, contract,
  2  1 certificate, or agreement offered or issued by a health carrier
  2  2 to provide, deliver, arrange for, pay for, or reimburse any of
  2  3 the costs of health care services.
  2  4    c.  "Health care professional" means a physician or other
  2  5 health care practitioner licensed, accredited, registered, or
  2  6 certified to perform specified health care services consistent
  2  7 with state law.
  2  8    d.  "Health care provider" or "provider" means a health care
  2  9 professional or a facility.
  2 10    e.  "Health care services" means services for the diagnosis,
  2 11 prevention, treatment, cure, or relief of a health condition,
  2 12 illness, injury, or disease.
  2 13    f.  "Health carrier" means an entity subject to the
  2 14 insurance laws and regulations of this state, or subject
  2 15 to the jurisdiction of the commissioner, including an
  2 16 insurance company offering sickness and accident plans, a
  2 17 health maintenance organization, a nonprofit health service
  2 18 corporation, a plan established pursuant to chapter 509A
  2 19 for public employees, or any other entity providing a plan
  2 20 of health insurance, health care benefits, or health care
  2 21 services. "Health carrier" includes, for purposes of this
  2 22 section, an organized delivery system.
  2 23                           EXPLANATION
  2 24    This bill requires the development and use of a standard form
  2 25 to obtain prior authorization for prescription drug benefits
  2 26 under a health benefit plan.
  2 27    The bill requires the commissioner of insurance to develop,
  2 28 by rule, a standard form by January 1, 2014.  Before developing
  2 29 the form, the commissioner is required to hold at least one
  2 30 public hearing to obtain input from interested parties on the
  2 31 form.  The form must not exceed two pages in length and must be
  2 32 available and transmissible in an electronic format.
  2 33    Health carriers are required to use and accept the standard
  2 34 prior authorization form, and health care providers are
  2 35 required to use and submit the form, beginning on July 1, 2014.
  3  1 If a health carrier fails to use or accept the standard form
  3  2 or to respond to a health care provider's request for prior
  3  3 authorization of prescription drug benefits within 48 hours of
  3  4 the provider's submission of the form, the request shall be
  3  5 considered to be granted.
       LSB 2161SC (2) 85
       av/nh