Passage of national legislation recognizing pharmacists as health care providers will be a long and challenging process. There are some states that are not waiting for Congress to act. The state of Washington successfully passed legislation ESSB 5557 that will increase patient access to medical care from pharmacists practicing within their scope of practice. This landmark law is the first of its kind in the nation to require health insurance carriers to include pharmacists as network providers.
ESSB 5557 requires health insurance carriers to recognize pharmacists in the same way as other providers. The law states that for health plans issued or renewed on or after January 1, 2017, benefits shall not be denied for any health care service performed by a pharmacist if:
- The service performed was within the lawful scope of such person’s license;
- The plan would have provided benefits if the service had been performed by a physician, an advanced registered nurse practitioner or a physician’s assistant;
- The pharmacist is included in the plan’s network of participating providers;
- The health plan must include an adequate number of pharmacists in its network of participating medical providers.
For health benefit plans issued or renewed on or after January 1, 2016, but before January 1, 2017:
- Health plans that delegate credentialing agreements to contracted health care facilities must accept credentialing for pharmacists employed or contracted by those facilities.
- Health plans must reimburse facilities for covered services provided by network pharmacists within the pharmacists’ scope of practice per negotiations with the facility.
The law requires the insurance commissioner to designate a lead organization to establish and facilitate an advisory committee to implement the provisions of this law.
The lead organization, defined as a private sector organization or organizations designated by the insurance commissioner, and the advisory committee shall develop best practice recommendations on standards for credentialing, privileging, billing, and payment processes to ensure pharmacists are adequately included and appropriately utilized in participating provider networks of health plans. The advisory committee, in developing these standards, shall also discuss topics as they relate to implementation including current credentialing requirements for health care providers, existing processes of similarly situated health care providers, pharmacist training, care coordination, and the role of pharmacist prescriptive authority agreements.
The advisory committee will have at least 13 members. The 3 members representing pharmacy will be from an organization representing pharmacists, a community pharmacy with pharmacists providing medical services, and a school or college of pharmacy.
The remainder of the committee members will include the secretary of health, 5 members representing health insurers and PBMs, 3 members representing hospitals and clinics and one representing physicians. The insurance commissioner may appoint additional representatives.
I’m sure that the Washington State Pharmacy Association will be kept busy in the coming months carefully monitoring the activities and progress of this advisory committee, advocating for the profession of pharmacy and demonstrating the value of pharmacists as part of the health care team. To see a copy of the Washington law, click here http://lawfilesext.leg.wa.gov/biennium/2015-16/Pdf/Bills/Session%20Laws/Senate/5557-S.SL.pdf