Amendments for HB24-1149
House Journal, February 22
47 HB24-1149 be amended as follows, and as so amended, be referred to
48 the Committee on Appropriations with favorable
49 recommendation:
50
51 Amend printed bill, page 4, line 6, after "(2)(c)," insert "(3)(a)(I),", and
52 after "add" insert "(3)(c)(III), (3.5),".
53
54 Page 4, lines 6 and 7, strike "(4)(c), (4)(d), and (7)(g)" and substitute "and
55 (4)(c)".
1 Page 5, strike line 19 and substitute the following:
2 "(B.5) THE TOTAL NUMBER OF PRIOR".
3
4 Page 5, line 22 strike "AND".
5
6 Page 5, after line 22, insert:
7 "(C) THE reason for THE denial IN EACH OF THE CATEGORIES
8 SPECIFIED IN SUBSECTION (2)(c)(I)(A) OF THIS SECTION, WITH THE DENIAL
9 REASONS SORTED BY CATEGORIES DEFINED BY RULE; and".
10
11 Page 6, line 16, strike "REQUESTS ARE APPROVED".
12
13 Page 6, strike line 17.
14
15 Page 6, line 18, strike "AUTHORIZATION REQUIREMENT".
16
17 Page 6, line 19, after "NOR" insert "SUBSTANTIALLY", and strike
18 "SPENDING TO A DEGREE" and substitute "SPENDING.".
19
20 Page 6, strike line 20.
21
22 Page 6, line 21, strike "ORGANIZATION.".
23
24 Page 6, line 22, after "ATTEST" insert "TO THE COMMISSIONER".
25
26 Page 7, line 14, strike "TO IMPLEMENT" and substitute "TO:
27 (A) IMPLEMENT".
28
29 Page 7, line 18, strike "CARRIERS." and substitute "CARRIERS; AND
30 (B) DEFINE CATEGORIES OF PRIOR AUTHORIZATION REQUEST
31 DENIALS FOR PURPOSES OF SUBSECTION (2)(c)(I)(C) OF THIS SECTION.".
32
33 Page 7, line 20, strike "(c) (II) If" and substitute "(a) Except as provided
34 in subsection (3)(b) of this section, a prior authorization request is
35 deemed granted if a carrier or organization fails to:
36 (I) (A) Notify the provider and covered person, within five
37 business days after receipt of the request, that the request is approved,
38 denied, or incomplete and INDICATE: If DENIED, WHAT RELEVANT
39 ALTERNATIVE SERVICES OR TREATMENTS MAY BE A COVERED BENEFIT OR
40 ARE REQUIRED BEFORE APPROVAL OF THE DENIED SERVICE OR
41 TREATMENT; OR IF incomplete, indicate the specific additional
42 information, consistent with criteria posted pursuant to subsection (2)(a)
43 of this section, that is required to process the request; or
44 (B) Notify the provider and covered person, within five business
45 days after receiving the additional information required by the carrier or
46 organization pursuant to subsection (3)(a)(I)(A) of this section, that the
47 request is approved or denied AND, IF DENIED, INDICATE WHAT RELEVANT
48 ALTERNATIVE SERVICES OR TREATMENTS MAY BE A COVERED BENEFIT OR
49 ARE REQUIRED BEFORE APPROVAL OF THE DENIED SERVICE OR
50 TREATMENT; and
51 (c) (II) If".
52
53 Page 7, line 24, strike "must include" and substitute "must:
54 (A) Include".
55
1 Page 7, line 27, strike "MEDICATIONS" and substitute "TREATMENTS".
2
3 Page 8, strike line 1 and substitute: "HEALTH BENEFIT PLAN; OR
4 (B) IN THE CASE OF THE DENIAL OF A PRIOR AUTHORIZATION
5 REQUEST FOR A PRESCRIPTION DRUG, SPECIFY WHICH PRESCRIPTION DRUGS
6 AND DOSAGES IN THE SAME CLASS AS THE PRESCRIPTION DRUG FOR WHICH
7 THE PRIOR AUTHORIZATION REQUEST WAS DENIED ARE COVERED
8 PRESCRIPTION DRUGS UNDER THE HEALTH BENEFIT PLAN.
9 (III) A CARRIER'S, ORGANIZATION'S, OR PHARMACY BENEFIT
10 MANAGER'S COMPLIANCE".
11
12 Page 8, after line 3 insert:
13
14 "(3.5) (a) STARTING JANUARY 1, 2026, A CARRIER OR
15 ORGANIZATION SHALL HAVE, MAINTAIN, AND USE A PRIOR AUTHORIZATION
16 APPLICATION PROGRAMMING INTERFACE THAT AUTOMATES THE PRIOR
17 AUTHORIZATION PROCESS TO ENABLE A PROVIDER TO:
18 (I) DETERMINE WHETHER PRIOR AUTHORIZATION IS REQUIRED FOR
19 A HEALTH-CARE SERVICE;
20 (II) IDENTIFY PRIOR AUTHORIZATION INFORMATION AND
21 DOCUMENTATION REQUIREMENTS; AND
22 (III) FACILITATE THE EXCHANGE OF PRIOR AUTHORIZATION
23 REQUESTS AND DETERMINATIONS FROM THE PROVIDER'S ELECTRONIC
24 HEALTH RECORDS OR PRACTICE MANAGEMENT SYSTEMS THROUGH SECURE
25 ELECTRONIC TRANSMISSION.
26 (b) A CARRIER'S OR ORGANIZATION'S APPLICATION PROGRAMMING
27 INTERFACE MUST MEET THE MOST RECENT STANDARDS AND
28 IMPLEMENTATION SPECIFICATIONS ADOPTED BY THE SECRETARY OF THE
29 UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES AS
30 SPECIFIED IN 45 CFR 170.215 (a).
31 (c) IF A PROVIDER SUBMITS A PRIOR AUTHORIZATION REQUEST
32 THROUGH THE CARRIER'S OR ORGANIZATION'S APPLICATION PROGRAMMING
33 INTERFACE, THE CARRIER OR ORGANIZATION SHALL ACCEPT AND RESPOND
34 TO THE REQUEST THROUGH THE INTERFACE.".
35
36 Page 10, strike lines 5 through 13 and substitute "RESOLUTION, BINDING
37 ARBITRATION AS SPECIFIED IN SUBSECTION (4)(b)(VI) OF THIS SECTION.
38 (VI) IF A PROVIDER REQUESTS BINDING ARBITRATION PURSUANT
39 TO THE PROCEDURES A CARRIER OR AN ORGANIZATION DEVELOPS UNDER
40 SUBSECTION (4)(b)(V)(B) OF THIS SECTION, THE FOLLOWING PROVISIONS
41 GOVERN THE ARBITRATION PROCEDURE:
42 (A) THE PROVIDER AND CARRIER OR ORGANIZATION SHALL
43 JOINTLY SELECT AN ARBITRATOR FROM THE LIST OF ARBITRATORS
44 APPROVED PURSUANT TO SECTION 10-16-704 (15)(b). NEITHER THE
45 PROVIDER NOR THE CARRIER OR ORGANIZATION IS REQUIRED TO NOTIFY
46 THE DIVISION OF THE ARBITRATION OR OF THE SELECTED ARBITRATOR.
47 (B) THE SELECTED ARBITRATOR SHALL DETERMINE THE
48 PROVIDER'S ELIGIBILITY TO PARTICIPATE IN THE CARRIER'S OR
49 ORGANIZATION'S PROGRAM BASED ON THE PROGRAM CRITERIA DEVELOPED
50 PURSUANT TO SUBSECTION (4)(b)(II) OF THIS SECTION;
51 (C) WITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR
52 ACCEPTS THE MATTER, THE PROVIDER AND THE CARRIER OR
53 ORGANIZATION SHALL SUBMIT TO THE ARBITRATOR WRITTEN MATERIALS
54 IN SUPPORT OF THEIR RESPECTIVE POSITIONS;
55
1 (D) THE ARBITRATOR MAY RENDER A DECISION BASED ON THE
2 WRITTEN MATERIALS SUBMITTED PURSUANT TO SUBSECTION (4)(b)(VI)(C)
3 OF THIS SECTION OR MAY SCHEDULE A HEARING, LASTING NOT LONGER
4 THAN ONE DAY, FOR THE PROVIDER AND CARRIER OR ORGANIZATION TO
5 PRESENT EVIDENCE;
6 (E) WITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR
7 RECEIVES THE WRITTEN MATERIALS OR, IF A HEARING IS CONDUCTED, THE
8 DATE OF THE HEARING, THE ARBITRATOR SHALL ISSUE A WRITTEN
9 DECISION STATING WHETHER THE PROVIDER IS ELIGIBLE FOR THE
10 PROGRAM; AND
11 (F) IF THE ARBITRATOR OVERTURNS THE CARRIER'S OR
12 ORGANIZATION'S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE
13 PROGRAM, THE CARRIER OR ORGANIZATION SHALL PAY THE ARBITRATOR'S
14 FEES AND COSTS, AND IF THE ARBITRATOR AFFIRMS THE CARRIER'S OR
15 ORGANIZATION'S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE
16 PROGRAM, THE PROVIDER SHALL PAY THE ARBITRATOR'S FEES AND
17 COSTS.".
18
19 Page 10, strike lines 14 through 19.
20
21 Reletter succeeding paragraph accordingly.
22
23 Page 11, line 26, strike "(4)(d)," and substitute "(4)(c),".
24
25 Page 12, strike lines 23 through 27.
26
27 Page 13, strike lines 1 through 4.
28
29 Page 13, line 5, after "amend" insert "(2)(a)(II)(A), (2)(c)(II)(A), (3)(a)
30 introductory portion, (3)(a)(I), (3)(a)(VI),".
31
32 Page 13, line 6, after "repeal" insert "(3)(a)(II) and".
33
34 Page 13, line 6, after "add" insert "(3.3),".
35
36 Page 13, line 7, strike "(6.5), and (8)(c)" and substitute "and (6.5)".
37
38 Page 13, strike line 9 and substitute "of commissioner - definitions -
39 repeal. (2) (a) Except as provided in subsection (2)(b) or (2)(c) of this
40 section, a prior authorization request is deemed granted if a carrier or
41 pharmacy benefit management firm fails to:
42 (II) For prior authorization requests submitted electronically:
43 (A) Notify the prescribing provider, within two business days after
44 receipt of the request, that the request is approved, denied, or incomplete,
45 and if incomplete, indicate the specific additional information, consistent
46 with criteria posted pursuant to subparagraph (II) of paragraph (a) of
47 subsection (3) SUBSECTION (3.5)(a) of this section, that is required to
48 process the request; or
49 (c) For nonurgent prior authorization requests related to a covered
50 person's HIV prescription drug coverage, the prior authorization request
51 is deemed granted if a carrier or pharmacy benefit management firm fails
52 to:
53 (II) For prior authorization requests submitted electronically:
54 (A) Notify the prescribing provider within one business day after
55 receipt of the request that the request is approved, denied, or incomplete,
1 and if incomplete, indicate the specific additional information, consistent
2 with criteria posted pursuant to subsection (3)(a)(II) SUBSECTION (3.5)(a)
3 of this section, that is required to process the request; or
4 (3) (a) On or before July 31, 2014, The commissioner shall
5 develop, by rule, a uniform prior authorization process that:
6 (I) Is made available electronically by the carrier or pharmacy
7 benefit management firm, but that does not require the prescribing
8 provider to submit a prior authorization request electronically, AND
9 SATISFIES THE REQUIREMENTS OF SUBSECTION (3.3) OF THIS SECTION;
10 (II) Requires each carrier and pharmacy benefit management firm
11 to make the following available and accessible in a centralized location
12 on its website:
13 (A) Its prior authorization requirements and restrictions, including
14 a list of drugs that require prior authorization;
15 (B) Written clinical criteria that are easily understandable to the
16 prescribing provider and that include the clinical criteria for
17 reauthorization of a previously approved drug after the prior authorization
18 period has expired; and
19 (C) The standard form for submitting requests;
20 (VI) Requires carriers and pharmacy benefit management firms,
21 when notifying a prescribing provider of its decision to deny a prior
22 authorization request, to include THE INFORMATION REQUIRED BY SECTION
23 10-16-112.5 (3)(c)(II) AND a notice that the covered person has a right to
24 appeal the adverse determination pursuant to sections 10-16-113 and
25 10-16-113.5.
26 (b) In developing the".
27
28 Page 13, after line 12 insert:
29 "(3.3) STARTING JANUARY 1, 2026, IF A PROVIDER SUBMITS A
30 PRIOR AUTHORIZATION REQUEST TO A CARRIER OR PBM THROUGH A
31 SECURE ELECTRONIC TRANSMISSION SYSTEM THE CARRIER OR PBM USES
32 THAT COMPLIES WITH THE MOST RECENT VERSION OF THE NATIONAL
33 COUNCIL FOR PRESCRIPTION DRUG PROGRAMS SCRIPT STANDARD, OR ITS
34 SUCCESSOR STANDARD, AND 21 CFR 1311, THE CARRIER OR PBM SHALL
35 ACCEPT AND RESPOND TO THE REQUEST THOUGH THE SECURE ELECTRONIC
36 TRANSMISSION SYSTEM.".
37
38 Page 13, after line 18 insert:
39 "(I) THE CARRIER'S PRIOR AUTHORIZATION REQUIREMENTS AND
40 RESTRICTIONS, INCLUDING A LIST OF DRUGS THAT REQUIRE PRIOR
41 AUTHORIZATION;
42 (II) WRITTEN CLINICAL CRITERIA THAT ARE EASILY
43 UNDERSTANDABLE TO THE PRESCRIBING PROVIDER AND THAT INCLUDE THE
44 CLINICAL CRITERIA FOR REAUTHORIZATION OF A PREVIOUSLY APPROVED
45 DRUG AFTER THE PRIOR AUTHORIZATION PERIOD HAS EXPIRED;
46 (III) THE STANDARD FORM FOR SUBMITTING PRIOR AUTHORIZATION
47 REQUESTS;".
48
49 Renumber succeeding subparagraphs accordingly.
50
51 Page 15, line 10, strike "(5)(b), (5)(c)," and substitute "(5)(b)".
52
53 Page 15, line 18, after "PLAN" insert "MORE THAN ONCE EVERY THREE
54 YEARS".
55
1 Page 15, after line 22 insert:
2 "(II) THIS SUBSECTION (5)(b) DOES NOT APPLY IF:
3 (A) THERE IS EVIDENCE THAT THE AUTHORIZATION WAS OBTAINED
4 FROM THE CARRIER OR PBM BASED ON FRAUD OR MISREPRESENTATION;
5 (B) FINAL ACTION BY THE FDA OR OTHER REGULATORY AGENCIES,
6 OR THE MANUFACTURER, REMOVES THE CHRONIC MAINTENANCE DRUG
7 FROM THE MARKET, LIMITS ITS USE IN A MANNER THAT AFFECTS THE
8 AUTHORIZATION, OR COMMUNICATES A PATIENT SAFETY ISSUE THAT
9 WOULD AFFECT THE AUTHORIZATION ALONE OR IN COMBINATION WITH
10 OTHER AUTHORIZATIONS; OR
11 (C) A GENERIC EQUIVALENT OR DRUG THAT IS BIOSIMILAR, AS
12 DEFINED IN 42 U.S.C. SEC. 262 (i)(2), TO THE PRESCRIBED CHRONIC
13 MAINTENANCE DRUG IS ADDED TO THE CARRIER'S OR PBM'S DRUG
14 FORMULARY.
15 (III) NOTHING IN THIS SUBSECTION (5)(b) REQUIRES A CARRIER OR
16 PBM TO PAY FOR A BENEFIT:
17 (A) THAT IS NOT A COVERED BENEFIT UNDER THE HEALTH BENEFIT
18 PLAN; OR
19 (B) IF THE PATIENT IS NO LONGER A COVERED PERSON UNDER THE
20 HEALTH BENEFIT PLAN ON THE DATE THE CHRONIC MAINTENANCE DRUG
21 WAS PRESCRIBED, DISPENSED, ADMINISTERED, OR DELIVERED.".
22
23 Renumber succeeding subparagraph accordingly.
24
25 Page 15, strike lines 25 through 27.
26
27 Page 16, strike lines 1 through 3.
28
29 Page 17, line 14, strike "(A)" and substitute "(I)".
30
31 Page 17, line 17, strike "(B)" and substitute "(II)".
32
33 Page 17, strike lines 18 through 25 and substitute "RESOLUTION, BINDING
34 ARBITRATION AS SPECIFIED IN SUBSECTION (5.5)(e) OF THIS SECTION.
35 (e) IF A PROVIDER REQUESTS BINDING ARBITRATION PURSUANT TO
36 THE PROCEDURES A CARRIER OR A PBM DEVELOPS UNDER SUBSECTION
37 (5.5)(d)(II) OF THIS SECTION, THE FOLLOWING PROVISIONS GOVERN THE
38 ARBITRATION PROCEDURE:
39 (I) THE PROVIDER AND CARRIER OR PBM SHALL JOINTLY SELECT
40 AN ARBITRATOR FROM THE LIST OF ARBITRATORS APPROVED PURSUANT TO
41 SECTION 10-16-704 (15)(b). NEITHER THE PROVIDER NOR THE CARRIER OR
42 PBM IS REQUIRED TO NOTIFY THE DIVISION OF THE ARBITRATION OR OF
43 THE SELECTED ARBITRATOR.
44 (II) THE SELECTED ARBITRATOR SHALL DETERMINE THE
45 PROVIDER'S ELIGIBILITY TO PARTICIPATE IN THE CARRIER'S OR PBM'S
46 PROGRAM BASED ON THE PROGRAM CRITERIA DEVELOPED PURSUANT TO
47 SUBSECTION (5.5)(a) OF THIS SECTION;
48 (III) WITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR
49 ACCEPTS THE MATTER, THE PROVIDER AND THE CARRIER OR PBM SHALL
50 SUBMIT TO THE ARBITRATOR WRITTEN MATERIALS IN SUPPORT OF THEIR
51 RESPECTIVE POSITIONS;
52 (IV) THE ARBITRATOR MAY RENDER A DECISION BASED ON THE
53 WRITTEN MATERIALS SUBMITTED PURSUANT TO SUBSECTION (5.5)(e)(III)
54 OF THIS SECTION OR MAY SCHEDULE A HEARING, LASTING NOT LONGER
1 THAN ONE DAY, FOR THE PROVIDER AND CARRIER OR PBM TO PRESENT
2 EVIDENCE;
3 (V) WITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR
4 RECEIVES THE WRITTEN MATERIALS OR, IF A HEARING IS CONDUCTED, THE
5 DATE OF THE HEARING, THE ARBITRATOR SHALL ISSUE A WRITTEN
6 DECISION STATING WHETHER THE PROVIDER IS ELIGIBLE FOR THE
7 PROGRAM; AND
8 (VI) IF THE ARBITRATOR OVERTURNS THE CARRIER'S OR PBM'S
9 FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE PROGRAM, THE
10 CARRIER OR PBM SHALL PAY THE ARBITRATOR'S FEES AND COSTS, AND IF
11 THE ARBITRATOR AFFIRMS THE CARRIER'S OR PBM'S FAILURE OR REFUSAL
12 TO INCLUDE THE PROVIDER IN THE PROGRAM, THE PROVIDER SHALL PAY
13 THE ARBITRATOR'S FEES AND COSTS.".
14
15 Page 18, strike lines 15 through 24.
16
17
House Journal, March 1
1 HB24-1149 be amended as follows, and as so amended, be referred to
2 the Committee of the Whole with favorable
3 recommendation:
4
5 Amend printed bill, page 18, before line 25 insert:
6
7 "SECTION 4. Appropriation. (1) For the 2024-25 state fiscal
8 year, $36,514 is appropriated to the department of regulatory agencies for
9 use by the division of insurance. This appropriation is from the division
10 of insurance cash fund created in section 10-1-103 (3)(a)(I), C.R.S. To
11 implement this act, the division may use this appropriation as follows:
12 (a) $29,332 for personal services, which amount is based on an
13 assumption that the division will require an additional 0.4 FTE; and
14 (b) $7,182 for operating expenses.".
15
16 Renumber succeeding section accordingly.
17
18 Page 1, line 102, strike "PLANS." and substitute "PLANS, AND, IN
19 CONNECTION THEREWITH, MAKING AN APPROPRIATION.".
20
21
House Journal, March 8
20 Amendment No. 1, Appropriations Report, dated March 1, 2024, and
21 placed in member's bill file; Report also printed in House Journal,
22 March 1, 2024.
23
24 Amendment No. 2, Health & Human Services Report, dated February 21,
25 2024, and placed in member's bill file; Report also printed in House
26 Journal, February 22, 2024.
27
28 Amendment No. 3, by Representative Bird:
29
30 Amend the Health and Human Services Committee Report, dated
31 February 21, 2024, page 6, line 29, strike "OR".
32
33 Page 6, strike line 33 and substitute "FORMULARY; OR
34 (D) THE WHOLESALE ACQUISITION COST OF THE CHRONIC
35 MAINTENANCE DRUG EXCEEDS A DOLLAR AMOUNT AS ESTABLISHED BY
36 THE COMMISSIONER BY RULE, WHICH AMOUNT MUST BE NO LESS THAN
37 THIRTY THOUSAND DOLLARS FOR A TWELVE-MONTH SUPPLY OR FOR A
38 COURSE OF TREATMENT THAT IS LESS THAN TWELVE MONTHS IN
39 DURATION.".
40
41 Strike "2026," and substitute "2027," on: Page 3, line 2; and Page 5, line
42 40.
43
44 As amended, ordered engrossed and placed on the Calendar for Third
45 Reading and Final Passage.
46