The bill is designed to have significant implications for state health laws by providing enhanced protections for patients receiving treatment for alcohol and opioid use disorders. It specifically restricts health insurance practices that could lead to denial of necessary medical services based on outdated protocols. By mandating that insurance companies must not require prospective or concurrent reviews for specific prescription medications—namely, those used in the treatment of opioid withdrawal symptoms—the legislation encourages a more supportive approach toward treating individuals facing substance use challenges.
Summary
House Bill 5255, titled the Benefit Determination and Utilization Review Act, is focused on the regulation of health care insurers concerning the approval processes for prescription medication, particularly with regard to substance use disorders. Specifically, the bill prohibits insurers from retrospectively denying coverage for health care services when prior approval has been obtained, unless it can be proven that the approval was based on fraudulent or materially inaccurate information. This aims to protect individuals from losing coverage for necessary treatments due to administrative oversights or misinterpretations.
Contention
While the bill is primarily aimed at improving patient access to treatment, there are potential points of contention surrounding the operational impact on insurers and the overall health care system. Insurers may argue that these restrictions could limit their ability to manage costs and ensure appropriate use of medical resources. Advocates, on the other hand, emphasize the critical need to prioritize patient care and reduce barriers to accessing effective treatment options for substance use disorders, arguing that the bill addresses an urgent public health crisis.
Health insurance; Ensuring Transparency in Prior Authorization Act; definitions; disclosure and review of prior authorization; adverse determinations; consultation; reviewing physicians; utilization review entity; exception; retrospective denial; length of prior authorization; continuity of care; standard for transmission of authorization; failure to comply; severability; effective date.