BOSTON – State Representative Donald H. Wong (R- Saugus) recently voted to support legislation that will give patients more of a say in pursuing a specific course of medical treatment recommended by their doctor rather than by their insurance company.
House Bill 4929, An Act relative to step therapy and patient safety, was engrossed by the House of Representatives on a vote of 153-0 on June 29.
Representative Wong said House Bill 4929 will protect consumers from an insurance practice known as step therapy, or “fail first”, which mandates that a patient must first try one or more preferred treatments dictated by an insurance company before they can be covered for a specific treatment recommended by a clinician. Although the bill does not ban step therapy, it calls for greater transparency by providing patients with the ability to request an exemption and the right to a speedy appeals process.
The House bill outlines four specific circumstances under which a patient appeal can be triggered, including instances where:
- the required treatment will harm the patient;
- the required treatment is expected to be ineffective;
- the patient previously tried the required treatment, or a similar treatment, and it proved to be ineffective or harmed the patient; or
- the patient is stable on a current treatment and switching treatments will harm the patient
According to Representative Wong, House Bill 4929 requires MassHealth and commercial insurers to provide “continuity of coverage” to patients so they can continue to receive their clinician-preferred method of treatment while their request for a step therapy exemption is reviewed. The bill also requires that a step therapy exemption request be approved or denied within three business days but mandates a decision within one business day if a delay would cause harm to the patient. It also provides for an appeals process if a patient’s request for an exemption is denied.
Under House Bill 4929, commercial carriers will be required to file an annual report with the state’s Division of Insurance detailing data related to step therapy exemption requests and related coverage determinations. The bill also calls for the creation of a step therapy protocols commission that will study and assess the implementation of step therapy reforms recommended in House Bill 4929, and will file a report by October 1 in every even-numbered year with the Secretary of Health and Human Services and the House and Senate chairs of the Joint Committee on Health Care Financing.
Representative Wong noted that 30 other states already have some form of step therapy protocols in place to protect patients, including Connecticut, Maine and New York.
House Bill 4929 now moves to the Senate for its consideration.