Pennsylvania lawmakers have been working diligently to pass a bill that would expand coverage of medical procedures for chronically ill patients. While the bill mainly applies to
private insurers, it would do the following for individuals in Pennsylvania:
- Remove prior authorization for emergency care
- Standardize timelines for insurers to approve or deny a request for treatment
- Guarantee that doctors can request that plans cover medications without a patient first trying a cheaper drug
Ultimately, the bill would allow medical providers more time on caring for patients as opposed to fighting with insurance companies. The patients will receive more clarity and flexibility when deciding on their treatment options.
The current proposal passed the Republican-controlled state Senate in June. The bill is now waiting for the state House to vote, then the state Senate must approve the changes before taking additional measures.
Diving Deeper Into The Bill
The proposal aims to change two fundamental aspects of American health care which include:
- Prior authorization
- Step therapy
Prior authorization is a process used by insurance companies to determine if a prescribed product or service will be covered.
Step therapy means trying less expensive options prior to “stepping up” to drugs that cost more. Both ensure that medically sound and cost-effective medications are prescribed appropriately. However, the bill would not completely eliminate either practice. Instead, it would require insurers to offer exemptions for both along with creating a standardized process for doctors to apply for approval or request an exemption.
To accomplish this, the bill would:
- Establish standardized electronic forms for the application
- Set a statutory deadline for responding to requests
- Require insurers to provide written notification explaining the denial
- Allow the state Insurance Department to review the decision
In addition, this bill would allow physicians to dispute an insurer’s decision directly with a doctor employed by the insurer rather than an individual who may not have a medical degree. The goal of the bill is to create a new and more effective process for prior authorization of medical services which will keep everything consistent and transparent.
What Now?
While individuals in Pennsylvania wait for a further notice regarding this proposal, it’s important to understand alternative solutions. This proposal still must pass through multiple stages for it to become a law. Partner with GMS to ensure your employees are covered under any circumstance. When you partner with GMS, it’s possible to reduce your health insurance costs while still providing top-tier coverage. GMS changes the approach to increase affordable options by giving small businesses the buying power of a large corporation.
Contact us today to learn more.
