Illinois: HUGE! Healthcare Protection Act passes; step therapy & prior authorization banned, premium alignment, network audits & more!

I've been following this bill for awhile now but never got around to writing about it until after it passed through both chambers of the Illinois legislature. That's a shame, because it's a pretty Big F*cking Deal for Illinois residents.

Via WAND Illinois:

 The Illinois House passed the Healthcare Protection Act Saturday to help curb predatory insurance practices and protect consumers.

Gov. JB Pritzker's monumental plan could make Illinois the first state to ban prior authorization for in-patient adult and children's mental healthcare. The legislation also bans step therapy, or the fail first method, where insurers force people to receive less effective treatment before moving to options initially recommended by doctors.

...The measure requires prior approval from the Department of Insurance before large group insurance plans can increase rates and states premiums must align with the actual cost of providing care as well.

"Premiums must align with the actual cost of providing care," otherwise known as...Premium Alignment, which over a half-dozen states have implemented via either legislation or administrative orders including both blue states like New Mexico and red states like Texas.

Premium Alignment is something I've been pushing heavily for my own state legislators here in Michigan as well:

A coalition of patient advocates is urging HHS to address high out-of-pocket costs by demanding that insurers selling marketplace coverage strictly adhere to the Affordable Care Act’s rate-setting requirements. Insurers have strayed from the mandate in recent years by underpricing silver-tier plans and overpricing the more-generous gold-level products, the advocates say, highlighting an issue that experts have been raising for years and that some states are already addressing at the local level.

But health experts also say that HHS must fix misalignments in the risk adjustment program - and that exchanges must have strong consumer decision support tools -for a policy fix to be sustainable.

By clarifying and enforcing the ACA’s single risk pool requirement, HHS could significantly reduce consumers’ cost-sharing burdens while also discouraging gaming, the advocates say.

As I estimated in an earlier analysis, Illinois implementing Premium Alignment at even a moderate level (say, equal to Pennsylvania) should result in up to 75,000 residents seeing a dramatic reduction in their deductibles & other out-of-pocket expenses by boosting them from Bronze or Silver-level coverage to Gold or better coverage.

...The measure could also crack down on ghost networks by forcing insurance companies to follow strict network adequacy and transparency standards. The proposal states that insurers would need to complete internal audits every 90 days to ensure their directories reflect the healthcare available to patients in those networks.

Excellent and long overdue. If you're going to have network adequacy requirements you have to actually enforce those requirements.