Protecting Patients from Treatment Delays Due to Prior Authorization
Prior authorization is a health plan utilization and cost-control process that requires health care providers to obtain approval from the plan before a service is delivered to confirm the patient qualifies for coverage of the service. Prior authorization requirements often apply to cancer treatments, such as surgery, medication, imaging, and other oncology services. Claim processing procedures and delays, as well as claim denials involved with these requirements, can create significant barriers to care, leading to significant treatment delays or even abandonment of treatment. According to an American Medical Association physician survey in 2021, 93% of physicians reported that prior authorization delays access to necessary care, and 91% reported that prior authorization had a negative impact on patient clinical outcomes, leading to treatment abandonment and even hospitalization. Policy changes are needed to reduce the burden of prior authorization on patients and providers and ensure timely access to needed care.
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Protecting Consumers from Non-ACA Compliant Health Plans
The Affordable Care Act established extensive consumer protections that apply to most health plans offered in the U.S., such as required coverage for pre-existing conditions without charging a higher cost, and ending yearly and lifetime limits on coverage of essential health benefits. Some insurers, however, have continued to offer plans that do not comply with these important protections and place consumers at great risk, especially those with pre-existing conditions such as cancer. These plans are often marketed to consumers through deceptive practices and exclude coverage for key benefits, leaving patients at risk of devastating consequences like coverage gaps and high out-of-pocket medical expenses. Several states have issued laws or regulations to protect consumers from these non-ACA-compliant health plans, but more needs to be done to curb these harmful practices.
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- GAO Report Sheds Additional Light on Misleading and Deceptive Marketing Practices Among Non-Compliant Health Plans
- Private Health Coverage: Results of Covert Testing for Selected Offerings
- State Regulation of Coverage Options Outside of the Affordable Care Act: Limiting the Risk to the Individual Market
Federal Lymphedema Treatment Act (S.1315/H.R.3630)
The Lymphedema Treatment Act (S.1315/H.R.3630) is a federal bill that would provide Medicare coverage of medically necessary, doctor-prescribed compression supplies that are an essential component of lymphedema treatment. Lymphedema affects millions of Americans each year, and many of these individuals are Medicare beneficiaries who currently lack coverage for these critical supplies. This bill would close that gap and ensure lymphedema patients have access to the treatment they need.
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