As cancer care professionals who experience the challenges of providing quality cancer care first-hand, VAHO members are well positioned to educate decision-makers on how coverage and reimbursement issues affect community oncology. State and federal legislation can have a significant impact on the financial viability of local cancer programs, which is why it's so important that our members make their voices heard.
In an effort to provide resources needed to effectively advocate on the issues that are important to them, our redesigned advocacy webpage features activity from the Centers for Medicare & Medicaid Services (CMS), national healthcare coverage through the Association of Community Cancer Centers (ACCC), local news articles and webinars, and more.
We want to hear from you! If there is a specific piece of legislation you want to know more about, an important resource we're missing, or if you want to get more involved, please contact us!
SB 1607 Health Insurance; Carrier Business Practices, Authorization of Health Care Services
Approved March 21, 2019
Provides that if a carrier has previously authorized an invasive or surgical health care service as medically necessary and during the procedure the health care provider discovers clinical evidence prompting the provider to perform a less or more extensive or complicated procedure than was previously authorized, then the carrier shall pay the claim, provided that it is appropriately coded consistent with the procedure actually performed, the additional procedures were not investigative in nature, and the additional procedure was compliant with a carrier's post-service claims process. The measure requires any provider contract between a carrier and a participating health care provider to contain certain specific provisions addressing how carriers interact with prior authorization requests. The measure requires that no prior authorization is required for at least one drug prescribed for substance abuse medication-assisted treatment, provided that (i) the drug is a covered benefit, (ii) the prescription does not exceed the FDA labeled dosages, and (iii) the drug is prescribed consistent with the regulations of the Board of Medicine. The measure clarifies that the 24-hour period during which a carrier is required to communicate to a prescriber if an urgent prior authorization request submitted telephonically or in an alternate method directed by the carrier has been approved, denied, or requires supplementation includes weekend hours. The measure provides that a carrier shall not be required to pay a claim if the carrier has previously authorized health care service and if, during the post-service claims process, it is determined that the claim was submitted fraudulently.
HB 2515 Health Plans; Calculation of Enrollee's Contribution
Approved March 21, 2019
Requires any carrier issuing a health plan in the Commonwealth to count any payments made by another person on the enrollee's behalf, as well as payments made by the enrollee, when calculating the enrollee's overall contribution to any out-of-pocket maximum or any cost-sharing requirement under the carrier's health plan. This bill is identical to SB 1596.
HB 2126 Accident and Sickness Insurance; Step Therapy Protocols
Approved March 12, 2019
Requires carriers issuing health benefit plans that develop step therapy protocols for a health benefit plan to ensure that those step therapy protocols are (i) developed and endorsed by a multidisciplinary panel of experts that manages conflicts of interest among the members; (ii) based on peer-reviewed research and medical practice; and (iii) continually updated based on a review of new evidence, research, and newly developed treatments. The measure requires that when coverage of a prescription drug for the treatment of a medical condition is restricted for use by a carrier or utilization review organization through the use of a step therapy protocol, the patient and prescribing provider have access to a clear, readily accessible, and convenient process to request a step therapy exception. The measure establishes conditions under which a request for a step therapy exception shall be granted and authorizes a patient to appeal a step therapy exception request denial. The provisions of the measure shall apply to any health benefit plan delivered, issued for delivery, or renewed on or after January 1, 2020.
Access ACCC’s CY 2019 PFS Proposed Rule Summary and ACCC’s CY 2019 OPPS Proposed Rule Summary
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