By Grace Vitaglione
Bryan Lewis, 59, discovered a lump on his neck about a year ago. After moving to North Carolina without employer health insurance, he enrolled in a plan through the Affordable Care Act marketplace.
Shortly after, he learned he had tongue cancer and began radiation and chemotherapy. The radiation treatments made it difficult for him to eat or drink, forcing him to rely on a feeding tube.
“It was tough,” Lewis remarked.
Throughout his treatment, his insurance company often denied coverage for vital procedures like CT and PET scans. His doctor had to advocate for these tests, emphasizing their importance for Lewis’s care.
“The system is definitely broken,” Lewis said.
This situation highlights a common issue called prior authorization. It’s a process where insurers require doctors and patients to follow specific steps before they will approve certain treatments, tests, or visits. For many, including Lewis, this can delay crucial care.
On January 28, some lawmakers in North Carolina met with the NC Medical Society to discuss reforming the prior authorization process. They aim to reduce the burden it places on healthcare providers.
However, just after this meeting, two bills were introduced in the North Carolina Senate and House. These bills could complicate efforts to reform prior authorization by making government mandates on insurance companies harder to implement.
The proposed legislation defines health benefit mandates as specific regulations that insurers must follow. It would classify controlling costs through methods like prior authorization as a mandate, making it harder to regulate.
Rep. Donny Lambeth (R-Winston-Salem), who co-sponsored the House version, believes House Bill 46 could work alongside prior authorization reforms to help lower healthcare costs overall. “We can partner with providers to find ways to cut costs,” he explained.
Who’s Affected?
If the bill passes, any future government mandates on health benefit plans effective after July 1, 2025, will also apply to the State Health Plan. This raises the stakes for new regulations.
Moreover, if a new health benefit mandate is approved, an existing one must be repealed. Current regulations include requirements for timely claim payments and providing insurance identification cards.
The impact of this legislation will be felt by individuals with insurance plans in North Carolina, including approximately 750,000 state employees and their families covered under the State Health Plan.
However, self-funded plans—typically offered by large employers—will not be affected by this bill. These plans operate under federal laws, meaning companies like IBM and Walmart manage their own insurance without much oversight from state regulations.
In North Carolina, nearly half of the population relies on employer-sponsored insurance. Over two-thirds of businesses with at least 50 employees offer self-funded plans.
On February 5, the Senate version of the bill to limit mandates passed through two committees easily, while the House version is still awaiting action.
Support for the Bill
A recent Forbes report showed that North Carolina has the highest healthcare costs in the U.S., despite only ranking the 30th healthiest state. This situation has raised concerns among lawmakers.
“This is unacceptable,” Senator Jim Burgin (R-Angier) said, addressing the committee on February 5.
Senate Bill 24 aims to curb further healthcare costs by making it harder to pass new requirements that may lead to higher premiums.
Several business representatives voiced their support, including Gregg Thompson from the National Federation of Independent Business. He emphasized that every new insurance mandate raises costs for employers.
The State Treasurer’s Office is also backing the bill. The State Health Plan faces a $500 million deficit this year. Treasurer Brad Briner noted that the legislation addresses factors contributing to healthcare inflation, particularly unfunded mandates.
Furthermore, the North Carolina Association of Health Plans, representing insurers, has supported the bill. Executive Director Peter Daniel expressed that historical mandates have made it difficult for insurers to manage costs.
Concerns from Providers
Despite the support, some groups worry about potential consequences for providers. Anthony Solari, a lobbyist for the North Carolina Association of Pharmacists, voiced concerns about how the bill could limit independent pharmacists’ ability to negotiate payments.
“Be cautious of unintended consequences,” he advised lawmakers.
New Republican Rep. Grant Campbell, a physician himself, echoed these concerns about future mandates leading to the removal of essential medical services, suggesting it could seem arbitrary.
“Adding a new coverage mandate shouldn’t mean an existing service is no longer valuable,” he said.
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Affordable Care Act,Duke University,NC Department of Insurance,NC General Assembly,NC Medical Society,North Carolina Association of Health Plans,Rep Donny Lambeth,Rep. Grant Campbell,Rep. Tim Reeder,Sen. Jim Burgin,State Treasurer Brad Briner
