Prior authorization and step therapy.
The bill amends various sections of the Health and Safety Code and the Insurance Code to require that the appeal processes for prior authorization or step therapy exceptions be reviewed by a clinical peer of the healthcare provider. This change aims to improve the fairness and thoroughness of denial appeals, ensuring that patient-specific medical needs are duly considered. Moreover, providers would be mandated to maintain records for various treatment requests for a minimum of ten years, fostering greater transparency and accountability in decision-making processes regarding drug approvals.
Assembly Bill 1880, introduced by Assembly Member Arambula, seeks to amend key provisions related to health coverage, specifically focusing on prior authorization and step therapy protocols within California. This legislation addresses the current requirements for health care service plans and health insurers that utilize these management processes, reiterating their obligations to expedite requests for therapy exceptions when sufficient clinical evidence is provided. The intention is to enhance patient care by ensuring quicker access to essential medications, especially in situations involving nonformulary drugs.
The sentiment surrounding AB 1880 reflects a positive reception from healthcare providers and patient advocacy groups who see the bill as a much-needed reform to streamline care delivery and protect patient interests. Supporters argue that the bill reinforces necessary safeguards against potentially arbitrary denials of treatment and helps ensure compliance with clinical standards. However, there are concerns from some stakeholders regarding administrative burdens and the operational feasibility of implementing such requirements across varying healthcare providers and insurance plans.
Notable points of contention include the implications for existing insurer protocols and the additional administrative requirements imposed by the bill. Critics are wary that increased regulations could lead to higher operational costs for insurers, potentially translating into increased premiums for consumers. Additionally, while the requirement for clinical peer reviews is aimed at protecting patient interests, some administrators argue it may lead to complexities in handling requests efficiently. Balancing timely access to medications with thorough review processes remains a critical challenge in the implementation of this legislation.