2020 has been a year that has brought a number of unforeseen challenges. Throughout these difficult times, Advocates continually raised their voices in support of legislation that makes a difference for people with arthritis. COVID-19 has shined a light on issues within our healthcare system that disrupt care.
On a state level, the pandemic required many state legislative sessions to end early, meet very rarely, or adapt to virtual sessions. For the states that continued to meet this year, many legislative bodies condensed their work to COVID-19 legislation and budget issues. Accordingly, the Arthritis Foundation, our coalition partners, and our legislative partners put a pause on many of the bills we supported, with an eye to work on them in 2021 or a future session.
Although we’ve had to pause a lot of our state work in 2020, there were still many victories worth celebrating! Below are some of the key victories that will make a difference for arthritis patients!
South Dakota Step Therapy (Senate Bill 155)
On March 24th, Governor Kristi Noem signed Senate Bill 155 into law! This important bill will put guardrails in place for step therapy. Step therapy, sometimes known as “fail first,” is a practice used by many insurers that requires patients to try lower-cost therapies before being approved for the treatment that their doctor prescribed – even when doctors are certain that the cheaper option will not be effective. Senate Bill 155 ensures that there are standard exceptions to step therapy in situations where it does not make sense for the patient to try the medication required by the insurer. Also, this law will reduce delays for patients by requiring the insurer to respond to an exception request within 5 business days or 72 hours, in urgent circumstances. This bill requires insurers to have step therapy protocols in place that are evidence-based, as well as peer-reviewed clinical practice guidelines rather than purely based upon costs.
This bill was championed by Senator Kris Langer and Representative Mike Diedrich and had 47 co-sponsors throughout the state legislature. And we are so pleased that this bill did not have a single “no” vote cast against it during its path to becoming law!
Louisiana Step Therapy (House Bill 263)
On June 11th, House Bill 263 was signed into law by Governor John Bel Edwards! This new law strengthens the previous step therapy law that was passed in 2013. The language for this bill is similar to the South Dakota law and other “model” versions from other states. The protections created by HB 263 will ensure that there are standard exceptions to step therapy in situations where it does not make sense for the patient to try the medication being required by the insurer. Also, this new law will reduce delays for patients by requiring the insurer to respond to an exception request with 72 hours or 24 hours in urgent circumstances. As with the South Dakota bill, law requires insurers to have step therapy protocols in place that are based upon evidence-based and peer-reviewed clinical practice guidelines, rather than purely based upon costs.
Representative Michael Paul Huval sponsored HB 263, which did not receive a single “no” vote from members of the legislature.
North Carolina Step Therapy (Senate Bill 361)
The final step therapy reform bill signed into law in 2020 (so far) was in North Carolina! On July 1st, after years of great effort from the patient and provider community in the state, Governor Roy Cooper signed step therapy reform into law. This reform was included in a larger package of issues all contained in Senate Bill 361. This law will ensure that insurers quickly respond to step therapy exceptions from the patient and their physician. The new law also ensures that an insurer will use a standard set of exceptions to step therapy. This set of exceptions is in place to avoid using step therapy in cases where the patient would likely fail on the medication they are being required to take by the insurer. An example of this would be in a case where the patient has already tried and failed the medication that is being required by the insurer when they were on a different health insurance plan.
This effort was primarily led by Senator Joyce Krawiec, Representative Dan Bishop, and Senator Ralph Hise (R) with 10 other co-sponsors. Their leadership alongside the patient and provider community saw the S.B. 361 receive overwhelming bi-partisan success in each of the committees and chambers that the bill entered.
Georgia Accumulators (Senate Bill 313/House Bill 946)
Accumulator adjustment programs prevent any co-payment assistance for high cost specialty drugs from counting towards a patient’s deductible or maximum out-of-pocket expenses. Many pharmaceutical manufacturers offer co-pay cards that help cover the patient portion of drug costs. Traditionally, pharmacy benefit managers have allowed these co-pay card payments to count toward the deductible required by a patient’s health insurance plan. With an accumulator adjustment program, patients are still allowed to apply the co-pay card benefits to pay for their medications up to the full limit of the cards, but when that limit is met, the patient is required to pay their full deductible before cost-sharing protections kick in. Patients are often unaware they are enrolled in one of these programs until they go to the pharmacy counter and realize they must pay the full cost of their medication, which can lead them to abandon or delay their prescription. These programs can be called different names, are often marketed as a positive benefit, and are often disclosed many pages into plan materials, leading to a lack of awareness about them to patients.
To combat this, the Arthritis Foundation is a leader in enacting legislation that will ensure that copayment assistance counts towards a patient’s cost sharing, such as their deductible! That is exactly what Senate Bill 313 and House Bill 946, signed by Governor Brian Kemp on August 5th, will do.
In addition to the successful identified above, we saw the following victories:
- CO Reinsurance (SB 20-215) – This will fund the state’s reinsurance program, which offsets the costs insurers would otherwise pay for covering patients with high medical costs. Accordingly, this action will stabilize the market throughout the state.
- WA Prior Authorization (Senate Bill 6404) – This will ensure reporting of key data on prior authorization requests in the state from insurers to the Office of Insurance Commissioner.
- MN Prior Authorization (SF 3204) – This will ensure utilization reviews, such as those for prior authorization, are made within 5 business days (and even less in urgent circumstances). In addition, this law will ensure that determinations are made by using evidence-based, clinical criteria by doctors of the same or similar specialty as the treating doctor.
- GA Surprise Billing (Senate Bill 359) – This will help with surprise billing issue by taking the patient out from the middle of disputes between insures and out-of-network health care providers.
- IN Surprise Billing (House Bill 1004) – This will provide protections for patients from surprise bills by ensuring that health care provider provide a good faith estimate to patients for the price of nonemergency health care services. This will also ensure protections for patients from out of network charges by ensuring proper notification prior to the service being provided to the patient.
As we gear up for state legislative sessions in 2021, take 10 minutes to share your arthritis story in our story bank tool. Your story helps us better understand the arthritis challenges and access issues you face, so we can focus our work moving forward. Share your story at bit.ly/ArthritisStoryBank today!