Physician & Patient Groups Applaud Pennsylvania Legislation Prohibiting Unfair Insurance Coverage Changes for Medical Care

Updated on February 22, 2018

Rep. Donna Oberlander will Introduce Bill Amending PA Insurance Law to Protect Patients from Unfair Coverage Reductions During the Policy Year

Pennsylvanians for Fair Health Coverage, a coalition of patient and provider groups working to ensure that health plan benefits will be concrete over the course of each year, today applauded a Pennsylvania lawmaker for pursuing legislation that protects consumers with commercial health insurance from unfair coverage changes. Rep. Donna Oberlander (R- Armstrong, Clarion and Forest counties) released a cosponsorship memo revealing that she will soon introduce legislation amending the Pennsylvania Unfair Insurance Practices Act to prohibit commercial health plans and pharmacy benefit managers from making coverage changes during the policy year that deny or increase the cost of benefits that a patient is already receiving.

“Right now, insurers in Pennsylvania are free to raise out-of-pocket costs or deny medical care at any time, even when individuals and families are locked into their plans for the duration of the year,” said Rep. Oberlander. “It’s important that every insured Pennsylvanian, especially those battling serious health issues, receive the health benefits that were advertised to them when they signed up for a plan.”

Oberlander continued, “Insurers play a critical role in making health care accessible, so the goal of this legislation is to protect consumers in a way that doesn’t inhibit business. My legislation will only prohibit insurers from reducing coverage mid-policy year for patients who already depend on products, services, procedures, treatments and prescription drugs. The legislation will not impact an insurer’s decision to change coverage options for patients not already being treated, nor will it limit their ability to add new therapies and services or to remove unsafe treatments.”

The legislation is modeled after principle number five contained in the American Medical Association’s Prior Authorization and Utilization Management Reform Principles, which says: “A drug or medical service that is removed from a plan’s formulary or is subject to new coverage restrictions after the beneficiary enrollment period has ended should be covered without restrictions for the duration of the benefit year,” and notes:  “Unanticipated changes to a formulary or coverage restriction throughout the plan year can negatively impact patients’ access to needed medical care and unfairly reduce the value patients receive for their paid premiums.”

“Pennsylvania families can’t change plans throughout the year, so insurers shouldn’t be able to change the coverage they offer,” said Suzanna Masartis, executive director of the Community Liver Alliance, which leads Pennsylvanians for Fair Health Coverage. “Rep. Oberlander’s legislation will go a long way to protect insured Pennsylvanians who rely on medical care to keep their health stable.”

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