SENATE BILL REPORT

SHB 2498

As Reported by Senate Committee On:

Health Care, February 25, 2016

Title: An act relating to prior authorization for dental services and supplies in medical assistance programs.

Brief Description: Concerning prior authorization for dental services and supplies in medical assistance programs.

Sponsors: House Committee on Health Care & Wellness (originally sponsored by Representatives Caldier, Cody, DeBolt, Manweller, Walsh, Johnson, Pike, Appleton, Jinkins, Kilduff and Gregerson).

Brief History: Passed House: 2/16/16, 97-0.

Committee Activity: Health Care: 2/25/16, 2/25/16 [DP].

Majority Report: Do pass.

Signed by Senators Becker, Chair; Dammeier, Vice Chair; Cleveland, Ranking Minority Member; Angel, Bailey, Brown, Conway, Frockt, Jayapal, Keiser, Parlette and Rivers.

Staff: Mich'l Needham (786-7442)

Background: Medical assistance is available to eligible low-income state residents and their families from the Health Care Authority (Authority), primarily through the Medicaid program. The majority of medical assistance clients are served under a managed care arrangement which provides a prepaid, comprehensive system of medical and health care delivery, including primary, specialty, and ancillary health services. Dental services for medical assistance clients, however, are provided through a fee-for-service arrangement in which the dentist directly bills the Authority. Certain dental services require that the dental provider obtain authorization prior to the service being performed. Prior authorization generally requires that the dental provider establish medical necessity for the service through sufficient, objective, clinical information.

Summary of Bill: The Authority must convene a work group or use an existing work group to make recommendations for improving the prior authorization system for dental providers in medical assistance programs. The objective of the work group is to develop a prior authorization system that protects patients against unnecessary treatments and procedures while encouraging more dentists to treat medical assistance clients and increase their access to dental care.

The work group consists of dental providers in private practice, dental providers in community health centers, oral health care advocates, and other relevant stakeholders. The work group must submit recommendations to the Director of the Authority and the health care committees of the Legislature by December 15, 2016. The recommendations must address:

• wait times for prior authorization approvals and options for reducing wait times;

• which dental services currently subject to prior authorization should remain under prior authorization and which should be removed from prior authorization requirements;

• ways to remove the cost burden of prior authorization on dental providers; and

• options for adjusting payments for services subject to prior authorization.

Appropriation: None.

Fiscal Note: Available.

Committee/Commission/Task Force Created: No.

Effective Date: Ninety days after adjournment of session in which bill is passed.

Staff Summary of Public Testimony: PRO: I am a dentist and I used to take Medicaid patients but the prior authorization requirements became too burdensome. The process needs to be simplified. The hygienists take Medicaid clients and experience a number of issues with prior authorization. This work group represents a good first step to gather data and improve the process. I had experience with the delays in care because of the Medicaid prior authorization process. My daughter's surgery was delayed for over eight weeks while waiting for prior authorization, for a surgery the surgeon was doing for free. Finally I sought help from my Senators and it was resolved but there are a lot of gaps and barriers in the system today.

Persons Testifying: PRO: Representative Caldier, Prime Sponsor; Melissa Johnson, Washington State Dental Hygienists Association; Lesley Bush.

Persons Signed In To Testify But Not Testifying: No one.