Washington State

House of Representatives

Office of Program Research

BILL

ANALYSIS

Health Care & Wellness Committee

ESSB 6157

This analysis was prepared by non-partisan legislative staff for the use of legislative members in their deliberations. This analysis is not a part of the legislation nor does it constitute a statement of legislative intent.

Brief Description: Regarding prior authorization.

Sponsors: Senate Committee on Health & Long Term Care (originally sponsored by Senators Short, Kuderer, Rivers, Cleveland, Palumbo, Nelson, Becker, Walsh, Warnick and Van De Wege).

Brief Summary of Engrossed Substitute Bill

  • Increases the number of treatment visits that a health plan must cover without prior authorization for chiropractic, physical therapy, occupational therapy, East Asian medicine, massage therapy, or speech and hearing therapy.

Hearing Date: 2/20/18

Staff: Jim Morishima (786-7191).

Background:

Health carriers may require prior authorization for certain health care procedures. Prior authorization is the requirement that a health care provider seek approval of a drug, procedure, or test before seeking reimbursement from an insurer. A health carrier may not retrospectively deny coverage for care that had prior authorization unless the prior authorization was based on a material misrepresentation by the provider.

A health carrier may not require prior authorization for an evaluation and management visit or an initial treatment visit with a contracting provider in a new episode of chiropractic, physical therapy, occupational therapy, East Asian medicine, massage therapy, or speech and hearing therapy. This prohibition does not affect the ability of a health plan to require a referral or prescription for these therapies. A "new episode of care" means treatment for a new or recurrent condition for which the enrollee has not been treated by the provider within the previous 90 days and is not currently undergoing any active treatment.

Summary of Bill:

The prohibition against requiring prior authorization for an evaluation and management visit for chiropractic, physical therapy, occupational therapy, East Asian medicine, massage therapy, or speech and hearing therapy applies only to an initial evaluation and management visit. The prohibition applies to up to six consecutive treatment visits that meet the standards of medical necessity and are subject to quantitative treatment limits of the health plan, instead of only to an initial treatment visit.

Appropriation: None.

Fiscal Note: Available.

Effective Date: The bill takes effect 90 days after adjournment of the session in which the bill is passed.