arthritis advocacy state health laws

State of Your Health

How New Laws May Impact You

Arthritis Foundation Advocates have played a pivotal role in more than 85 state legislative victories across the country since 2014. But what do those victories mean for patients and their access to care?

The Arthritis Foundation has got you covered as your go-to resource to learn more about the benefits of these new and improved changes in law. We are here to help ensure that your new protections are implemented fully and that patients in your state know their new rights. This includes providing resources that explain the issue, the new law and what it means to patients. While we’ll focus our initial 2018 efforts on 10 states with laws pertaining to step therapy, prior authorization and out-of-pocket costs, our work will not stop there. We’ll also provide resources about new laws in additional states. If you would like to be alerted to our continued progress with this project, please be sure to sign up as an Advocate.   

If you are experiencing a barrier to care, you should contact your insurance commissioner, who can help address your situation. Visit this link to find instructions on how to appeal, request an external review or file a complaint with your insurance commissioner. Use the map on that website to find the appropriate process for your state and contact information for the Department of Insurance. 

Not sure if a law pertains to you?

Below are explanations of the different types of insurance plans. Also below, you’ll find the ten state laws we’re highlighting and an explanation of which insurance plans are covered or not covered within the new laws. We have developed an interactive toolkit to help answer your specific insurance-related questions.   

Commercial and Employer Plans

Commercial and Employer Plans: 

  • If you are in the workforce, you have the option to use the major medical insurance plan provided by your employer. This plan is managed by a private insurer for your employer or is self-funded (i.e., the employer is the insurer).   
  • You can contact your employer’s HR department to find out more. 
Health Exchange Market Plans

Health Exchange Market Plans: 

These plans are federally regulated as governed by the Affordable Care Act. However, they are administered by a private insurer (e.g., Blue Cross Blue Shield). These plans are for individuals who: 

  • are self-employed 
  • work for a company that offers no or limited health coverage 
  • are unemployed 
  • have historically purchased individual coverage directly from a private insurer  
  • To find out more about these plans, visit healthcare.gov.  
Government-Funded Health Plans

Government-Funded Health Plans: 

The federal government funds a wide range of medical services through its own programs, and in partnership with states as well as private insurers. This includes Medicare and Medicaid.   

  • What is Medicare?  Medicare is the government’s health coverage for people age 65 or older, and younger people with disabilities or certain health conditions. Today, Medicare provides health insurance for 54 million Americans, a number that is expected to grow in the coming years. 
  • What is Medicaid?  Medicaid is a jointly-funded, federal-state health insurance program for low-income and needy people. It covers children, the aged, blind, and/or disabled and other people who are eligible to receive federally-assisted income maintenance payments. 

New State Laws

Colorado | Illinois | Indiana | Iowa | Missouri | New York | Ohio | Texas | Washington, D.C. | West Virginia 

Click on the state above to jump to more information!

Colorado | Step Therapy

What is step therapy?  

Step therapy is a practice used by insurers that requires people with arthritis to try lower-cost medications before permitting more expensive treatments, even when the doctor wants to prescribe them. In other words, more expensive and effective drugs can only be prescribed if the cheaper ones prove ineffective.  

How does this new law address step therapy in Colorado? 

In 2017, Colorado passed legislation to address step therapy and the law went into effect in late 2017.  This new law increases the ability of the patient’s health care provider, not insurance company, to make important decisions about a patient’s treatment.  The insurer will not be allowed to require patients to go through step therapy if they already completed step therapy for the same drug, either with their current or former insurance provider, and the drug was discontinued due to lack of efficacy or effectiveness, diminished effect or adverse event.   

Which patients will benefit from this new law?  This law is not applicable to patients who have Medicare, Medicaid or ERISA-protected, self-insured plans.  To learn if you are covered, contact your insurer and provide your policy number.   

What should I do if I experience this barrier to care in Colorado? 

If you are experiencing a barrier to care, you should contact your insurance commissioner, who can help address your situation. You can easily find instructions on how to appeal, request an external review, or file a complaint to your Insurance Commissioner, here. Use the map on the website to find the appropriate process for your state and the contact information for the Department of Insurance.

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Illinois | Step Therapy

What is step therapy?  

Step therapy is a practice used by insurers that requires people with arthritis to try lower-cost medications before permitting more expensive treatments, even when the doctor wants to prescribe them. In other words, more expensive and effective drugs can only be prescribed if the cheaper ones prove ineffective. 

How does this new law address step therapy in Illinois? 

In 2016, Illinois passed legislation to address step therapy and the law went into effect in early 2018.  This new law increases the ability of the patient’s health care provider, not insurance company, to make important decisions about a patient’s treatment.  If an insurer denies a request (within 72 hours or 24 for expedited), they must provide a reason.  Medical exceptions shall be approved if required drug is contraindicated, patient has tried and failed under current or previous or the patient is stable on prescription drug selected by his or her health care provider.  

Which patients will benefit from this new law? 

This law is not applicable to patients who have Medicare, Medicaid or ERISA-protected, self-insured plans.  To learn if you are covered, contact your insurer and provide your policy number.   

What should I do if I experience this barrier to care in Illinois? 

If you are experiencing a barrier to care, you should contact your insurance commissioner, who can help address your situation. You can easily find instructions on how to appeal, request an external review, or file a complaint to your Insurance Commissioner, here. Use the map on the website to find the appropriate process for your state and the contact information for the Department of Insurance. 

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Indiana | Prior Authorization

What is prior authorization?  

Many insurers require prior approval before giving you the OK to get an expensive drug.  This process can be long and cumbersome, and often creates a significant administrative burden for both patients and providers.  Further, it can keep patients from accessing the drugs they need to remain healthy.  

How does this new law address prior authorization in Indiana? 

In 2017, Indiana passed legislation to address prior authorization and that law went into effect in early 2018.  Requires certain health plans to accept and respond to electronic prior authorization requests according to a particular electronic transaction standard.  This bill leverages technology to improve pharmacist efficiency in community and health system pharmacy settings, thus reducing pharmacist time and employee expense in securing prior authorizations from physicians. 

Which patients will benefit from this new law?  To learn if you are covered, contact your insurer and provide your policy number.   

What should I do if I experience this barrier to care in Indiana? 

If you are experiencing a barrier to care, you should contact your insurance commissioner, who can help address your situation. You can easily find instructions on how to appeal, request an external review, or file a complaint to your Insurance Commissioner, here. Use the map on the website to find the appropriate process for your state and the contact information for the Department of Insurance. Back to top >>

Iowa | Step Therapy

What is step therapy?  

Step therapy is a practice used by insurers that requires people with arthritis to try lower-cost medications before permitting more expensive treatments, even when the doctor wants to prescribe them. In other words, more expensive and effective drugs can only be prescribed if the cheaper ones prove ineffective. 

How does this new law address step therapy in Iowa? 

In 2017, Iowa passed legislation to address step therapy and the law went into effect in early 2018.  This new law increases the ability of the patient’s health care provider, not insurance company, to make important decisions about a patient’s treatment.  If an insurer denies a request (within 5 days or 72 hours in an emergency), they must provide a reason.  Medical exceptions shall be approved if required prescription drug is contraindicated, is expected to be ineffective based on known clinical characteristics of the patient, patients documented experience with the prescription drug regimen; if patient is experiencing positive therapeutic outcome on another prescription drug selected by their HCP under current or previous health plan.

Which patients will benefit from this new law? 

Patients with individual or fully insured group health insurance coverage will benefit from these new protections against burdensome step therapy protocols.  The new law does not apply to Medicare, Medicaid fee-for service or "self-insured" plans, which are exempted by the federal Employee Retirement Income Security Act of 1974 (ERISA).  To learn if you are covered, contact your insurer and provide your policy number.   

What should I do if I experience this barrier to care in Iowa? 

If you are experiencing a barrier to care, you should contact your insurance commissioner, who can help address your situation. You can easily find instructions on how to appeal, request an external review, or file a complaint to your Insurance Commissioner, here. Use the map on the website to find the appropriate process for your state and the contact information for the Department of Insurance. 

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Missouri | Step Therapy

What is step therapy?  

Step therapy is a practice used by insurers that requires people with arthritis to try lower-cost medications before permitting more expensive treatments, even when the doctor wants to prescribe them. In other words, more expensive and effective drugs can only be prescribed if the cheaper ones prove ineffective. 

How does this new law address step therapy in Missouri? 

In 2016, Missouri passed legislation to address step therapy and the law went into effect in early 2018.  This new law increases the ability of the patient’s health care provider, not insurance company, to make important decisions about a patient’s treatment.  More specifically this law requires state regulated health plans to provide physicians and patients with access to a clear and timely process for requesting an exception to a step therapy protocol.  A health plan must also grant an immediate override of the step therapy protocol if the patient has already tried the “fail first” prescription drug under current or previous health plan. 

Which patients will benefit from this new law? 

Patients who have state regulated health plans.  Self-insured health plans, where benefits are paid directly from employer and the health plan acts as just a claims administrator, are subject to ERISA and generally are not subject to state insurance laws.  To learn if you are covered, contact your insurer and provide your policy number.   

What should I do if I experience this barrier to care in Missouri? 

If you are experiencing a barrier to care, you should contact your insurance commissioner, who can help address your situation. You can easily find instructions on how to appeal, request an external review, or file a complaint to your Insurance Commissioner, here. Use the map on the website to find the appropriate process for your state and the contact information for the Department of Insurance. Back to top >>

New York | Step Therapy

What is step therapy?  

Step therapy is a practice used by insurers that requires people with arthritis to try lower-cost medications before permitting more expensive treatments, even when the doctor wants to prescribe them. In other words, more expensive and effective drugs can only be prescribed if the cheaper ones prove ineffective. 

How does this new law address step therapy in New York? 

In 2016, New York passed legislation to address step therapy and the law went into effect in early 2018.  This new law increases the ability of the patient’s health care provider, not insurance company, to make important decisions about a patient’s treatment.  The law includes two basic patient protections that will improve the safety and efficacy of step therapy protocols.  First, it requires that clinical review criteria, used by an insurer to establish fail first protocols, is based on science and evidence-based clinical practice guidelines and not exclusively driven by cost.  Second, the bill requires a clear and expedient process (timelines of 72 hours or 24 for an emergency) that can be used by physicians and other prescribers to request an override of a fail first protocol.  There will be immediate coverage for a prescription drug if decision that step therapy should be overridden.  

Which patients will benefit from this new law? 

The new law applies to state-regulated commercial health insurance plans, HMO plans, Medicaid Managed Care plans and Child Health Plus plans.  The new law does not apply to Medicare, Medicaid fee for service or “self-insured” plans, which are exempted by the federal Employee Retirement Income Security Act of 1974 (ERISA).  To learn if you are covered, contact your insurer and provide your policy number.   

What should I do if I experience this barrier to care in New York? 

If you are experiencing a barrier to care, you should contact your insurance commissioner, who can help address your situation. You can easily find instructions on how to appeal, request an external review, or file a complaint to your Insurance Commissioner, here. Use the map on the website to find the appropriate process for your state and the contact information for the Department of Insurance. Back to top >>

Ohio | Prior Authorization

What is prior authorization?  

Many insurers require prior approval before giving you the OK to get an expensive drug.  This process can be long and cumbersome, and often creates a significant administrative burden for both patients and providers.  Further, it can keep patients from accessing the drugs they need to remain healthy.  

How does this new law address prior authorization in Ohio? 

In 2016, Ohio passed legislation to address prior authorization and the law went into effect in late 2017.   

For Providers:  Insurer must make its prior authorization rules available on website – including specific information or documentation provider must submit; insurer must provide 30-day notice 

For patients:  Insurer must make information about policies that clearly identify specific services, drugs or devices for which PA requirement exists available on website.  Additionally, there are now faster turnaround times for prior authorization requests (urgent within 48 hours; non-urgent within 10 calendar days).  Lastly, insurers must provide specific reason to patient if prescription is denied.    

Which patients will benefit from this new law? 

The new law will apply broadly to health insuring corporations, sickness and accident insurers as well as the Medicaid managed care plan.  To learn if you are covered, contact your insurer and provide your policy number.   

What should I do if I experience this barrier to care in Ohio? 

If you are experiencing a barrier to care, you should contact your insurance commissioner, who can help address your situation. You can easily find instructions on how to appeal, request an external review, or file a complaint to your Insurance Commissioner, here. Use the map on the website to find the appropriate process for your state and the contact information for the Department of Insurance. Back to top >>

Texas | Step Therapy

What is step therapy?  

Step therapy is a practice used by insurers that requires people with arthritis to try lower-cost medications before permitting more expensive treatments, even when the doctor wants to prescribe them. In other words, more expensive and effective drugs can only be prescribed if the cheaper ones prove ineffective.  

How does this new law address step therapy in Texas? 

In 2017, Texas passed legislation to address step therapy and the law went into effect in early 2018.  This new law increases the ability of the patient’s health care provider, not insurance company, to make important decisions about a patient’s treatment.  The bill includes essential patient protections to improve the safety and efficiency of step therapy protocols.  This includes a requirement that insurers must consider using science and evidence-based clinical practice guidelines to develop step therapy protocols, rather than relying exclusively on cost data.  The bill also requires a clear and expedient process that can be used by treating physicians to request an override of a step therapy protocol.  Prohibits insurers from requiring patients to fail on a prescribed medication more than once, even if patient switches to a different health insurance company.   

Which patients will benefit from this new law?  To learn if you are covered, contact your insurer and provide your policy number.   

What should I do if I experience this barrier to care in Texas? 

If you are experiencing a barrier to care, you should contact your insurance commissioner, who can help address your situation. You can easily find instructions on how to appeal, request an external review, or file a complaint to your Insurance Commissioner, here. Use the map on the website to find the appropriate process for your state and the contact information for the Department of Insurance. Back to top >>

Washington, D.C. | Out Of Pocket Costs

What are out of pocket costs?  

Insurers often place expensive drugs like biologics on specialty tiers, requiring you to pay a percentage of the cost (sometimes as much as 50 percent) rather than a fixed-dollar copay.  This can cause a patient to reach their annual out-of-pocket spending cap in the first few months of the plan year, a significant financial burden for many patients. 

How does this new law address step therapy in Washington DC? 

In 2017, Washington DC passed legislation to address out of pocket cap costs and the law went into effect in 2018.  This new law caps specialty drug copayment or co-insurance out-of-pocket costs to no more than $150 for up to a 30-day supply, or $300 for a 90-day supply  

Which patients will benefit from this new law? 

This law will decrease out of pocket cost to patient and gives patient right to request a non-preferred drug to be covered under the same cost sharing applicable to preferred drugs if physician determines that preferred drug would not be as effective or would have adverse effects or both.  To learn if you are covered, contact your insurer and provide your policy number.   

What should I do if I experience this barrier to care in Washington DC? 

If you are experiencing a barrier to care, you should contact your insurance commissioner, who can help address your situation. You can easily find instructions on how to appeal, request an external review, or file a complaint to your Insurance Commissioner, here. Use the map on the website to find the appropriate process for your state and the contact information for the Department of Insurance. 

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West Virginia | Step Therapy

What is step therapy?  

Step therapy is a practice used by insurers that requires people with arthritis to try lower-cost medications before permitting more expensive treatments, even when the doctor wants to prescribe them. In other words, more expensive and effective drugs can only be prescribed if the cheaper ones prove ineffective. 

How does this new law address step therapy in West Virginia? 

In 2017, West Virginia passed legislation to address step therapy and the law went into effect in early 2018.  This new law increases the ability of the patient’s health care provider, not insurance company, to make important decisions about a patient’s treatment.  The law establishes a clear channel for patients and practitioners to request an override when an insurance provider levies such mandate.  The override process must be easily accessible on the health plan insurer’s website.   

Medical exceptions include:   

  • required prescription is contraindicated 
  • required prescription is expected to be ineffective based on patient  
  • patient has tried and failed the prescription 
  • prescription is not in best interest of patient 
  • patient is stable on prescription  

Which patients will benefit from this new law?  The new law will apply to patients who receive benefits from entities required to be licensed under this chapter that contracts, or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services under a health benefit plan, including accident and sickness insurers, nonprofit hospital service corporations, medical service corporations and dental service organizations, prepaid limited health service organizations, health maintenance organizations, preferred provider organizations, provider sponsored network, and any pharmacy benefit manager that administers a fully-funded or self-funded plan.  To learn if you are covered, contact your insurer and provide your policy number.   

What should I do if I experience this barrier to care in West Virginia? 

If you are experiencing a barrier to care, you should contact your insurance commissioner, who can help address your situation. You can easily find instructions on how to appeal, request an external review, or file a complaint to your Insurance Commissioner, here. Use the map on the website to find the appropriate process for your state and the contact information for the Department of Insurance. 

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