Current Text for SB196
By Senator Dial
Rd 1 07-FEB-12
|SYNOPSIS:||This bill would create the Ensuring Appropriate Access to Medicines for Premature Infants Act to require the state Medicaid Agency to develop and implement policies and procedures to streamline the process for access to covered outpatient drugs for premature infants and to develop standards and common practices applicable to Medicaid programs that ensure timely and appropriate access to care for premature infants.|
TO BE ENTITLED
To require the state Medicaid Agency to develop and implement policies and procedures to streamline the process for access to covered outpatient drugs for premature infants and to ensure timely and appropriate access to care for premature infants.
BE IT ENACTED BY THE LEGISLATURE OF ALABAMA:
Section 1. This act shall be known as and may be cited as the Ensuring Appropriate Access to Medicines for Premature Infants Act.
Section 2. The Legislature makes the following findings of fact:
(1) Premature populations incur disproportionate costs to state Medicaid programs.
(2) This state currently has one of the highest rates of infant mortality in the country, and the state desires to improve this rate.
(3) This state currently has one of the highest rates of premature births in the country.
(4) After release from the hospital, an infant born under 37 weeks of gestation often needs certain prescription drugs and services to survive a premature birth.
(5) Infants born at less than 37 weeks gestation have immature lungs and are at risk of severe morbity and mortality throughout the first year of life.
(6) It is difficult for physicians, patients, and parents of premature populations to understand, track, and monitor the various drug prior authorization policies for the state Medicaid Agency and the various Medicaid managed care plans.
(7) Access to a drug therapy as prescribed by a physician may determine the outcome of whether or not a premature patient may be hospitalized.
(8) Hospital readmissions are in the national spotlight as policy makers at the highest levels recognize that costly readmissions, which are sometimes preventable, drive spending in health care programs. Furthermore, payment reform advocates are focusing on preventable hospital readmissions and quality to help control health care spending.
(9) Section 1927 of the Social Security Act, 42 U.S.C. § 1396r-8, requires state Medicaid agencies to provide a response by telephone or other telecommunication device within 24 hours of a request for prior authorization of a covered outpatient drug.
Section 3. For the purposes of this act, the following terms shall have the following meanings:
(1) MEDICAID PROGRAM or PROGRAM. The medical assistance program as established in Title XIX of the Social Security Act and as administered in this state by the Alabama Medicaid Agency.
(2) PREMATURE INFANTS. Infants less than one year of age who were born at less than 37 weeks gestational age.
Section 4. (a) By July 1, 2012, the Medicaid Agency shall develop and implement policies and procedures to streamline the prior authorization process and ensure timely and appropriate access to covered outpatient drugs for premature infants covered by the Medicaid Program as provided by this act.
(b) In implementing this act, the Medicaid Agency shall do all of the following:
(1) Develop and implement a process for ensuring fast-track review and decisions of prior authorization requests. The Medicaid Agency shall respond to prior authorization requests with a decision no later than 24 hours from receipt. The response shall include a decision to approve or deny the prior authorization request, and if denied, the rationale for the decision and information about the appeals process. The following requirements shall be satisfied:
a. For covered outpatient drugs that are utilized on a seasonal or periodic basis, prior approval requests shall be completed within a 24-hour basis rather than withheld until prior to time of care.
b. Prior to denying a request, every effort shall be made to contact the provider to clarify questions that would result in the approval of the request.
c. Upon receipt of a prior authorization request, the Medicaid Agency shall transmit a "notice of receipt" of the prior authorization request to the provider. All prior authorization requests shall be time and date stamped upon receipt in order to monitor compliance with the 24-hour requirement.
d. Prior authorization requests that are not adjudicated within 24 hours from receipt of the request shall be deemed approved as submitted.
(2) Ensure prior authorizations can be submitted by the patient's treating physician or designee electronically, via facsimile, or via telephone.
(3) Ensure transparency by posting all prior authorization requirements, forms, supporting materials, rationale, and appeals processes by therapeutic area or individual drug on the Medicaid Agency's publicly available website so that it is easy to access for physicians, parents, and caregivers.
(4) Develop standards for the Medicaid Agency to implement an effective appeals process that allows for all of the following:
a. Physicians, patients, or caregivers to appeal a decision by presenting evidence or testimony that the denied medical intervention is necessary for the patient's health.
b. Allow patients to receive continued coverage pending the outcome of the appeals process.
c. Allow patients or caregivers access to review their patient files.
d. Provide for timely reviews and decision of appeals.
e. Include the consumer protections set forth in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners.
(5) Ensure that all medicines that are prescribed to premature infants shall be given, at a minimum, in the dosage and duration as directed by the product's Prescribing Information provided by the Food and Drug Administration.
(6) Monitor and track health outcomes, such as hospital readmissions, emergency visits, and outpatient visits, for premature infants who are denied a covered prescription drug. The data shall be collected annually from all Medicaid programs and analyzed to identify any prior authorization policies that may be detrimentally impacting patient health or access to care. The Medicaid Agency shall annually report both data and findings to the Legislature.
(7) Develop standards and common practices applicable to all programs that ensure timely and appropriate access to care for premature infants.
(c) All policies, procedures, and requirements developed by the Medicaid Agency as required in subsection (b) are binding for all programs that serve Medicaid patients in this state.
Section 5. This act shall become effective immediately following its passage and approval by the Governor, or its otherwise becoming law.