Gov. JB Pritzker says his health care insurance reform aims to lift a roadblock patients can run into when getting approval for treatment.
The legislation targets insurance company practices that are used to deny claims or use lower-cost treatment, such as step therapy.
That’s a practice where insurance companies will require patients to prove that a lower-cost drug doesn’t work for them before approving a higher-cost drug — even if the doctor prescribed the higher-cost drug first.
“There's no question that medical professionals are better suited to make recommendations about treatment than insurance company employees,” Pritzker said during a visit Monday to Peoria. “So with this bill, we're requiring insurance companies to use the same treatment to determine medical necessity that doctors do. That way, patients get what they need.”
The measure also would ban prior authorization for people seeking psychiatric treatment, and would require internal audits from insurance companies to ensure their list of providers is updated.
Democratic Rep. Anna Moeller of Elgin, the bill's sponsor in the Illinois House, said lawmakers heard stories from doctors who couldn’t treat patients seeking psychiatric help because of prior authorization.
“We know that when someone is facing a mental health crisis time is of the essence,” she said. “And the doctor and in our hearing, testifying that once someone leaves, you don't know the chances of them coming back, the chances of something of them harming themselves or harming someone else.”
The legislation also bans short-term insurance policies. Moeller shared the story of someone who purchased one of these policies and was later denied care after he was diagnosed with multiple sclerosis.
“He filed a claim with his insurance company in order to get treatment, only to be told that his MS was a prior pre-existing condition,” she said. “He hadn't been diagnosed before, but because he had had it before he was diagnosed, they denied coverage.”
Republican Rep. Bill Hauter of Morton, also a physician at OSF St. Francis Medical Center, said this issue goes beyond politics.
“We see this every day,” he said. “We see the issues every day, we see pre-authorization abuse, inadequate networks, step therapy, denials of care, and we have to deal with the insurance tactics to delay or deny care to patients and delay and deny payments to providers.”
But some are raising concerns the plan could raise costs for taxpayers.
The measure passed in the Illinois House last Thursday on a bipartisan vote and now goes to the Illinois Senate for consideration. The General Assembly returns to session next week.
