Washington, DC -- Today, the Committee on Health, chaired by Councilmember Christina Henderson, approved 10 measures including the Prior Authorization Reform Amendment Act of 2023, the Health Professional Licensing Board Residency Requirement Amendment Act of 2023, the Ambulatory Surgical Facility Amendment Act of 2023, and 7 nominations for health advisory boards.
The full Council is expected to vote on the measures at its October 3 meeting. After the legislative session resumed September 15, Councilmember Henderson had aimed to put the trio of bills and the roster of nominees to a vote before the end of her first year as Committee chair.
The Prior Authorization Reform Amendment Act of 2023 in particular will improve access to health care by establishing a suite of guidelines and protections to ensure District residents enrolled in health benefit plans can access medications and medically appropriate care without undue burden or delay.
Health insurers have adopted a practice in recent years of requiring an enrollee and their provider to submit medical record information and request prior approval for a medication, medical procedure, or other form of medical care before it can be provided and paid for by the insurer. While this began as a practice for experimental drugs and procedures, this has now become common practice often with lengthy delays.
“The stories doctors shared during a May hearing about the suffering patients had endured due to prior authorization were heart wrenching,” Councilmember Henderson stated. “Effectively, this gives an insurer the ability to overrule the treatment prescribed by a patient’s medical provider without ever seeing the patient. Making matters worse, insurers often do not make prior authorization requirements clear or accessible to patients or their providers. Often, patients learn about prior authorization for the first time at the pharmacy counter and are told the insurance plan has not approved their treatment,” Henderson continued. “Further, without any limits on the time the insurers can take to make their decision, patients are often left to wait weeks to receive the care they desperately need.”
The Committee incorporated feedback of patients, health care providers, and insurance providers to arrive at a set of reforms that will preserve the aspects of prior authorization that ensure appropriate, evidence-based care is delivered while limiting the burden on patients and their providers and speeding up the process. The legislation creates the following new guidelines:
· Sets strict time limits so that prior authorizations for urgent health services must be decided within 24 hours, and for most other care must be decided within 3 business days if information is submitted through the insurer’s electronic portal, or 5 business days if information is submitted by phone, mail, or fax.
· Requires transparency of prior authorization requirements and of data regarding the insurer’s use of prior authorizations and rates of denials.
· Sets qualifications to ensure physicians reviewing prior authorization requests and appeals have appropriate training and experience with the treatments they are reviewing.
· Prohibits prior authorization requirements based solely on cost and sets continuity of care requirements for enrollees who switch health insurance plans.
“Collectively, this suite of reforms will be a significant step forward in making certain health insurers are not using prior authorization as a means of preventing use of needed health care services solely because of the cost of those services,” Henderson said. “Residents will have more information about the requirements, and insurers will have to respond to requests for care on an expedited timeline,” she added.
The Prior Authorization Reform Amendment Act of 2023 was co-introduced by Councilmembers Brooke Pinto, Christina Henderson, Charles Allen, Anita Bonds, Robert C. White, Jr., Trayon White, Sr., Janeese Lewis George, and Vincent C. Gray, and co-sponsored by Councilmember Zachary Parker. The bill was originally introduced in the last Council Period by Councilmember Mary Cheh.
In addition to the Prior Authorization Reform Amendment Act of 2023, the Committee recommended approval of three nominees to the Board of Physical Therapy, one nominee to the Board of Occupational Therapy, and three nominees to the Board of Medicine.
The Health Professional Licensing Board Residency Requirement Amendment Act of 2023 will allow for up to half of the licensed provider positions on health boards to be filled by health professionals who live outside of the District but who have demonstrated commitment to the District through years of service treating District residents.
The Ambulatory Surgical Facility Amendment Act of 2023 will allow DC Health to finally issue regulations for ambulatory surgical facilities after 38 years of delay.