HARTFORD, CT – Today, Senate Democrats led passage of legislation that will eliminate certain delays and inefficiencies to care. Senate Bill 6: “An Act Concerning Utilization Review and Health Care Contracts, Health Insurance Coverage for Newborns and Step Therapy,” advanced out of the state Senate and heads to the state House of Representatives for further debate and action.
“This bill takes important steps forward to improve the interactions of health care and insurance in this state,” said State Senator MD Rahman (D-Manchester), who voted in support of the bill. “It heavily reduces red tape in the process of receiving care and ensures that patients and families will be able to better access the care they need. I’m proud to vote in support and look forward to it being taken up in the House.”
SB 6 implements several changes to make more efficient the currently cumbersome and lengthy administrative process of prior authorization, which frequently delays care for patients and unnecessarily occupies health care workers seeking to obtain required approval from insurance companies to fill prescriptions and/or treat patients. The legislation also broadens prohibitions on step therapy, a cost-cutting practice by insurers which also delays care. As patients gradually progress through less costly medications, and as they fail, they are then provided access to the medication the patient originally required.
Regarding newborns, Senate Bill 6 will lengthen the deadline for parents of newborns to enroll the child in their insurance to 91 days. Currently, parents must do so 61 days after the baby is born, a deadline which can pass parents by as they acclimate to parenthood and, in some instances, comes before the baby leaves the hospital to go home with their family. Per the bill, SB 6 will do the following:
To address the unnecessary pain and suffering of patients, and the frustration of medical professionals, S.B. 6 makes the following changes to prior authorization: “One-and-Done” – Section 2 prevents insurers from requiring prior authorization for a prescription that addresses cancer, autoimmune diseases, and multiple sclerosis, if the insurer already approved the prescription for a patient in the past. With chronic illnesses, a provider and patient should not have to seek approval every month, 6 months or otherwise; shorter Timelines – Connecticut requires insurers to approve or disapprove a request for health care coverage within fifteen-day deadline, which can be extended by another fifteen days under circumstances beyond the insurer’s control. Section 3 changes it to a 7-day deadline, with a possible 5 day extension. A survey by the American Medical Association identified the deadlines for 35 states, and most of those states had deadlines of 5 days or less, and a good mix of 13 red and blue states have a deadline of 72 hours. If the health condition of the patient is urgent, current law provides a 72 hour deadline, and the bill would shorten the time frame to 24 hours, a deadline that at least 14 states already require.
Sections 5 and 6 would protect families from missing important enrollment deadlines after a baby is born. Insurers must provide coverage to newborns, but that can be denied if the parent, who is the member, does not notify the insurer within 61 days of birth. The total denial of coverage is a heavy-handed way to force compliance with a mostly arbitrary deadline. In our FY 2021, the average length of stay for babies in the NICU greater than 30 days, was 77 days and in FY 2022 it was 63 days. These parents have exponential stress on top of the regular challenges of a newborn that can keep them occupied from completing insurance forms in a timely manner. This bill would extend to 91 days the time parents have to enroll their newborn onto their insurance.
Like prior authorization, insurers use step-therapy as a cost-cutting mechanism, which unfortunately leads to the same consequences of pain and suffering for patients and frustration and burnout for health care providers. When a doctor prescribes a drug, the insurer will use the process of step-therapy to deny coverage of the doctor preferred drug until the patient tests cheaper alternatives, each which must fail to help the patient before the insurer agrees to cover the costs of the drug preferred to be used by the patient’s doctor. The General Assembly has pushed back, first with the passage of PA 14-118 that capped step-therapy to 60 days, and then with PA 17-228 that prohibits step-therapy for stage IV metastatic cancer. But there are far too many scenarios where 60 days forces unnecessary suffering of the patient. In January, the Washington Post ran an article highlighting the suffering of a three-year-old boy who was forced in and out of the emergency room with debilitating arthritis, fevers, and rash because the insurer required step-therapy.
Sections 7 and 8 would change the 60-day cap on step therapy to 30 days, which is the current cap for Medicaid/HUSKY. In addition, for a three year period from January 1, 2024 to January 1, 2027, the bill will exempt from step therapy the treatment of schizophrenia, major depressive disorder and bipolar disorder.
Currently in Connecticut, for emergency medical care, insurers cannot require prior authorization.
In a 2021 survey of physicians conducted by the American Medical Association (AMA): 93% of respondents reported that prior authorization requirements created delays in accessing necessary care; 82% of physicians reported that prior authorization can lead to patients abandoning a recommended course of treatment; 34% of respondents reported that prior authorization requirements have led to a serious adverse medical event for a patient with nearly one quarter reporting that prior authorization delays have led to a patient’s hospitalization
In a 2022 survey of physicians conducted by the Connecticut State Medical Society of its membership: 70% of respondents said they spent at least 9 hours per week dealing with health insurer prior authorizations; 11% spent at least 26 hours and 19% spent more than 35 hours per week; 42% of respondents indicated that prior authorizations requests are ultimately approved more than 90% of the time and 30% of respondents indicated that prior authorization requests are ultimately approved between 70 and 90% of the time; 63% of respondents submitted at least 11 prior authorization requests per week; 14% submit at least 31 requests per week and 19% greater than 40 prior authorization requests per week on average.
Currently in Connecticut, for emergency medical care, insurers cannot require prior authorization. In a 2021 survey of physicians conducted by the American Medical Association (AMA): 93% of respondents reported that prior authorization requirements created delays in accessing necessary care; 82% of physicians reported that prior authorization can lead to patients abandoning a recommended course of treatment; 34% of respondents reported that prior authorization requirements have led to a serious adverse medical event for a patient with nearly one quarter reporting that prior authorization delays have led to a patient’s hospitalization In a 2022 survey of physicians conducted by the Connecticut State Medical Society of its membership: 70% of respondents said they spent at least 9 hours per week dealing with health insurer prior authorizations; 11% spent at least 26 hours and 19% spent more than 35 hours per week; 42% of respondents indicated that prior authorizations requests are ultimately approved more than 90% of the time and 30% of respondents indicated that prior authorization requests are ultimately approved between 70 and 90% of the time; 63% of respondents submitted at least 11 prior authorization requests per week; 14% submit at least 31 requests per week and 19% greater than 40 prior authorization requests per week on average
Public Act 14-118 capped step-therapy to 60 days; Public Act 17-228 prohibits step-therapy for stage IV metastatic cancer