SENATE BILL REPORT

SB 5887

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 Summary of Bill

Prohibits a health carrier from requiring certain treatment visits to meet medical necessity standards, so long as the patient's primary care provider or chiropractor determines the visit is medically necessary.

Background: Prior authorization is a requirement that a health care provider obtain approval from a patient's insurance plan to prescribe a specific medication or treatment. Health carriers may impose different prior authorization standards and criteria for a covered service among tiers of contracting providers.

In 2018, the Legislature prohibited health carriers from requiring prior authorization for initial evaluation and management visits, and up to six consecutive treatment visits in a new episode of care of chiropractic, physical therapy, occupational therapy, east Asian medicine, massage therapy, and speech and hearing therapies that meet the standards of medical necessity and are subject to quantitative treatment limits of the health plan.

Summary of Bill: A health carrier may not require prior authorization, or require a treatment visit to meet the standards of medical necessity, for initial evaluation and management visits and up to six consecutive treatment visits for new episodes of care of chiropractic, physical therapy, occupational therapy, east Asian medicine, massage, or speech and hearing therapies. A determination by the patient's primary care provider or chiropractor that a treatment visit is medically necessary is sufficient for accessing the initial six visits.

Staff Summary of Public Testimony: PRO: This bill should not be necessary to clarify legislation that was enacted in 2018. The practice of prior authorization is referred to as medical necessity review and other terms. These semantics are delaying access to care. Benefit managers are retroactively denying payment after patients get to use their six visits. The intent is to ensure patients have access to their visits, and that intent is being violated by the current language in statute.

CON: There is concern that this bill would equate chiropractors with primary care physicians, and there is an interest in removing that specific language. Last year's legislation was a balanced compromise that allowed access to services that is not afforded for any other non-primary care services. This bill would guarantee that carriers have no ability to do managed care for visits, without any oversight. This would impinge on care quality and raise costs.

OTHER: There is a concern around the phrase "or other primary care physicians" in the bill, and would like the phrase to be deleted from the bill.

Persons Testifying: PRO: Senator Shelly Short, Prime Sponsor; Lori Grassi, Washington State Chiropractic Association; Melissa Johnson, Physical Therapy Association of Washington. CON: Katie Kolan, Washington State Medical Association; Meg Jones, Association of Washington Healthcare Plans. OTHER: Patricia Seib, Washington Academy of Family Physicians.