Revision: Dec. 18, 2015, midnight
\t \t\tHB 1608-FN - AS INTRODUCED
2016 SESSION
\t16-2349
\t01/10
HOUSE BILL\t1608-FN
AN ACT\trelative to uniform prior authorization forms.
SPONSORS:\tRep. Fothergill, Coos 1; Rep. Sherman, Rock. 24; Rep. Hunt, Ches. 11; Sen. Bradley, Dist 3; Sen. Woodburn, Dist 1
COMMITTEE:\tCommerce and Consumer Affairs
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ANALYSIS
\tThis bill requires all insurers and third party administrators to use and accept only the uniform prior authorization forms developed by the commissioner of insurance pursuant to rules adopted pursuant to RSA 541-A.
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Explanation:\tMatter added to current law appears in bold italics.
\t\tMatter removed from current law appears [in brackets and struckthrough.]
\t\tMatter which is either (a) all new or (b) repealed and reenacted appears in regular type.
\t16-2349
\t01/10
STATE OF NEW HAMPSHIRE
In the Year of Our Lord Two Thousand Sixteen
AN ACT\trelative to uniform prior authorization forms.
Be it Enacted by the Senate and House of Representatives in General Court convened:
\t1 Uniform Prior Authorization Forms; Individual New Section; Uniform Prior Authorization Forms. Amend RSA 400-A by inserting after section 15-d the following new section:
\t400-A:15-e Uniform Prior Authorization Forms.
\t\tI. All health insurers, health maintenance organizations, health services corporations, hospital services corporations, medical services corporations, preferred provider programs and third party administrators shall when requiring prior authorization for a health care service or benefit, use and accept only the prior authorization form designated for the specific types of services and benefits developed under paragraph III.
\t\tII. If a payer or any entity acting for a payer listed in paragraph I under contract fails to use or accept the required prior authorization form, or fails to respond within 2 business days after receiving a completed prior authorization request from a provider, pursuant to the submission of the prior authorization form developed as described in paragraph III, the prior authorization request shall be deemed to have been granted.
\t\tIII. The commissioner shall develop in accordance with rules adopted under RSA 541-A, and implement uniform prior authorization forms for different health care services and benefits. The forms shall cover such health care services and benefits including, but not limited to, provider office visits, prescription drug benefits, imaging and other diagnostic testing, laboratory testing, and any other health care services. The commissioner shall develop forms for different kinds of services as he or she deems necessary or appropriate; provided that, all payers and any entities acting for a payer under contract shall use the uniform form designated by the commissioner for the specific type of service. Six months after the full set of forms has been developed, every provider shall use the appropriate uniform prior authorization form to request prior authorization for coverage of the health care service or benefit and every payer or any entity acting for a payer under contract shall accept the form as sufficient to request prior authorization for the health care service or benefit. Nothing in this section shall prohibit a payer or any entity acting for a payer under contract from using a prior authorization methodology that utilizes an Internet webpage, Internet webpage portal, or similar electronic, Internet, and web-based system in lieu of a paper form; provided, that it is consistent with the paper form, developed pursuant to this paragraph.
\t\tIV. The prior authorization forms developed under paragraph III shall:
\t\t\t(a) Not exceed 2 pages;
\t\t\t(b) Be made electronically available; and
\t\t\t(c) Be capable of being electronically accepted by the payer after being completed.
\t\tV. The commissioner, in developing the forms, shall:
\t\t\t(a) Seek input from interested stakeholders and shall seek to use forms that have been mutually agreed upon by payers and providers;
\t\t\t(b) Ensure that the forms are consistent with existing prior authorization forms established by the federal Centers for Medicare and Medicaid Services; and
\t\t\t(c) Consider other national standards pertaining to electronic prior authorization.
\t\tVI. Nothing in this section shall limit a health plan from requiring prior authorization for services.
\t\tVII. This section shall also apply to RSA 420-J and to the Medicaid managed care program under RSA 126-A:5, XIX.
\t2 Effective Date. This act shall take effect 60 days after its passage.
\t\t\t\t\t\t\t\t\t\t\t16-2349
\t\t\t\t\t\t\t\t\t\t\t12/11/15
HB 1608-FN- FISCAL NOTE
AN ACT\trelative to uniform prior authorization forms.
FISCAL IMPACT:
The Departments of Health and Human Services and Administrative Services state this bill, as introduced, will have an indeterminable impact on state expenditures and revenue in FY 2017 and each year thereafter. There will be no impact on county and local revenue or expenditures.
METHODOLOGY:
The Department of Health and Human Services states the provisions of this bill would apply to the Medicaid program including managed care and fee-for service (FFS) payments. The Centers for Medicare and Medicaid Services (CMS) requires the State to implement a program to safeguard against unnecessary or inappropriate use of Medicaid services, but leaves the specifics of utilization management up to states. States are permitted to require prior authorization (PA), establish clinical criteria, and create the medical necessity requirements. The Department is required to control utilization and permitted to create service limits and PA requirements. These limits and requirements are included in the contracts between the State and the Managed Care Organizations (MCOs). The Department is currently working with MCOs to develop a single PA form for both managed care and FFS. The Department indicates the proposed bill allows automatic approval of the PA if it is not responded to within two business days, but the bill does not require providers to submit clinical documentation. Without clinical documentation the MCOs and the Department cannot assess the medical necessity of the requested services and the Department would be hindered in its ability to safeguard against unnecessary utilization as required by law. The Department indicates the current MCO contracts allow five business days to review prior authorization requests and assess medical necessity. The requirement for the Insurance Department to develop forms consistent with existing forms established by CMS will not benefit the Medicaid program since the existing CMS forms only apply to Medicare, and not Medicaid. The Department assumes the bill will increase Medicaid administrative costs as a two-day review of prior authorization requests will require the MCOs to hire additional staff. The Department assumes the shorter time period could result in more initial denials for PA requests which would increase the number of appeals, there review and the associated costs. Finally, the Department indicates a short review of PA requests could result in Medicaid service delivery without proper review and potential unnecessary utilization in violation of federal law. If a CMS audit that determined unnecessary or inappropriate services were provided and approved by the Medicaid program, CMS could withhold or recover federal funds and the State would need to recoup those payments made to the providers.
The Department of Administrative Services states this bill would have an indeterminable impact on state expenditures. The Department does not expect the uniform prior authorization form to result in a change in the administrative fees paid by the state, but the Department indicates it has no way of knowing for certain.
The Insurance Department states this bill requires health insurance issuers and administrators to use a uniform prior authorization form which shall be promulgated through rule making by the Commissioner. The Department states, while carriers may incur some additional administrative expense to adopt the new form, the Department does not expect such costs to impact premiums or the premium tax revenue to the State general fund. The Department does not expect to incur any additional costs due to the responsibilities the bill imposes on the Commissioner.