Latest PA Step Therapy Prior Auth Press Conference Recording - February 9, 2021

Legislative Info

6 things to know about the New Prior Authorization Law in Pennsylvania!
 

• Expands reforms to prior authorizations to all insurers including Medicaid and CHIP plans.
•  Clearly defines “closely related services” which now do not require prior authorization. Closely related services include any service a “prudent health care provider reasonably expected to perform in conjunction with or in lieu of an originally authorized service in response to minor differences in patient characteristics or needs for diagnostic information not readily identifiable before performing the authorized service.”
•  The time Frames for decisions changed from time of ‘complete request’ and is now from the time of submitting a request:
  
  • Urgent health care services: as soon as possible, but no more than 72 hours. If request is made 24 hours prior to reduction or termination of existing treatment, within 24 hours.
    
  • Non-urgent medical services: not more than 15 days from submission.
    
  • Prescription drugs –
    
    • Urgent requests not more than 24 hours.
    • Standard requests, two business days not to exceed 72 hours in total.
• If at any time after requesting prior authorization, the health care provider determines the enrollee's medical condition requires emergency services, then the emergency services may be provided without prior authorization.
•  Adds specialty specificity! The law requires prior authorization may only be denied after review by or consultation with a licensed medical professional in the same or similar specialty. Physicians submitting the prior authorization request can delegate a proxy who is a licensed professional, such as another physician, resident, physician’s assistant, or nurse practitioner, to complete the peer-to-peer review.
•  Upon submission and review by an insurer, if a request prior authorization is missing clinical information necessary to complete a review, the insurer must notify the provider that information is missing as soon as reviewed, and the insurer must provide enough specificity to the submitting provider to enable identification of the necessary information required to complete review. The insurer may extend the provider up to 45 additional days beyond the time limits if necessary to obtain the missing information.
•  Significantly expands the definition of what constitutes “medical or scientific evidence” and clinical standards to support approvals.
•  In addition, the law addresses adequacy of networks and timely payment:
•  Assures treating health care network sufficiency through the requirement that insurers, MCOs and contractors assure availability and accessibility of adequate health care providers in a timely manner.
•  Creates a requirement that insurers adopt procedures for an enrollee with a life-threatening, degenerative, or disabling disease or condition can receive a standing referral to a specialist.
•  Requires that all insurers and MA/CHIP managed care plans pay all clean claims within 45 days of receipt of the claim.

 

Thank you for all your efforts on having this bill cross the finish line and become Act 146!                                                                                                                                   

For more information click here


Prior Authorization Reform- HB 225 and SB 225 - 2/9/21
​State Rep. Steven Mentzer and Sen. Kristin Phillips-Hill recently circulated co-sponsorship memos to all members of the House and Senate about a prior authorization bill they plan to reintroduce this session. Urge your State Representative and State Senator to co-sponsor this important legislation. 

​HB 225 and SB 225 proposal would:

• Ensure physicians and other prescribers have access to more efficient electronic prior authorization systems
  
  
• Require that fail first protocols are based on clinical guidelines developed by independent experts
  
  
• Establish a basic framework for when it is medically appropriate to exempt patients from fail first, as well as an exceptions process that is transparent and accessible to patients and health care professionals
  
  
• Provide deadlines for insurers to render decisions on prior authorization requests

Prior authorization delays in Pennsylvania hurt patients and physicians. Urge your legislators to #FixPriorAuth by co-sponsoring HB 225 and SB 225. If you have any personal stories on how prior authorization has negatively impacted your patients, we encourage you to add them to your message. If your State Representative is Rep. Mentzer or State Senator is Kristin Phillips-Hill thank them for their efforts to reform prior authorization in Pennsylvania.

Support Prior Authorization Reform

Download A Patient Story Handout

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Pennsylvania's Indoor Tanning Regulation

PA Senator Pat Browne with eight cosponsors recently introduced PA Senate Bill 909 which would prohibit the use of indoor tanning facilities for those under the age of 18. This will replace the legislation from May 6, 2014,  Act 41 of 2014 which prohibits use of tanning facilities by minors under the age of 17, and requires parental consent for 17-year-olds.

It also requires:
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• tanning facilities to post warning signs on the premises , and keep records for three years;
• customers to sign a written warning statement prior to tanning;
• tanning devices meet federal and state standards;
• and employees of tanning facilities to have training in both the use of the devices and recognition of customer skin types.

According to the Skin Cancer Foundation, every year nearly 2.3 million American teenagers visit tanning salons. In addition, a study published in the International Journal of Cancer in May 2011 determined that for young people diagnosed with melanoma between the ages of 18 and 29 years old, 76 percent were attributable to indoor tanning bed use. 

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Access to Sun Protection in Schools- HB 1228
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On October 17, 2018, House Bill 1228, which aims to increase access to sun protection in schools, received final passage in the Senate with a vote of 49-0. The bill was signed into law by the governor on October 24, 2018.  

This legislation ensures the following: 

1. Allows students to possess and apply their own approved non-aerosolized sunscreen
2. Eliminates burdensome requirement of a doctor’s note and a visit to the school nurse to apply an FDA approved sunscreen.
3. Allows for the outdoor use by students of sun-protective clothing, including, but not limited to hats.

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View Complete Bill Information. ​

The PAD would like to thank Representative Hal English for sponsoring this legislation. 

RESOURCES

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Organizations that Support Indoor Tanning Legislation

• American Academy of Dermatology Association
• AIM At Melanoma
• Alabama Dermatology Society
• American Academy of Family Physicians
• American Academy of Ophthalmology
• American Academy of Otolaryngology—Head and Neck Surgery
• American Academy of Pediatrics
• American Academy of Physician Assistants
• American Academy of Orthopaedic Surgeons
• American Cancer Society Cancer Action Network
• American College of Emergency Physicians
• American College of Surgeons
• American Congress of Obstetricians and Gynecologists
• American Society for Dermatologic Surgery Association
• American Society for Mohs Surgery
• American Society for Radiation Oncology 
• American Society of Clinical Oncology
• Arizona Dermatology and Dermatologic Surgery Society
• California Society of Dermatology and Dermatologic Surgery
• Center for a Healthy Maryland
• Children's Melanoma Prevention Foundation
• Colette Coyne Melanoma Awareness Campaign
• Colorado Dermatologic Society​

• Connecticut Dermatology and Dermatologic Surgery Society
• Dermatology Nurses' Association
• Enright Melanoma Foundation
• Entertainment Industries Council
• Florida Society of Dermatology and Dermatologic Surgery
• Georgia Society of Dermatology and Dermatologic Surgery
• Greater Baltimore Dental Hygienists’ Association
• Hawaii Dermatological Association
• Idaho Dermatologic Society
• Indiana Academy of Dermatology
• Iowa Dermatological Society
• Kansas Society of Dermatology and Dermatologic Surgery
• Louisiana Dermatological Society
• Kentucky Dermatological Association
• Maryland Dermatologic Society
• Massachusetts Academy of Dermatology
• Melanoma Foundation of New England
• Melanoma Research Alliance
• Melanoma Research Foundation
• Michigan Dermatological Society
• Minnesota Dermatological Society
• Mississippi Dermatological Society
• Missouri Dermatological Society​
• New Hampshire Society of Dermatology

• New York State Society of Dermatology and Dermatologic Surgery
• North Carolina Dermatology Association
• North Carolina Medical Society
• ​Ohio Dermatological Association
• Oklahoma State Dermatology and Dermatologic Surgery Society
• Oregon Dermatology Society
• Pennsylvania Academy of Dermatology and Dermatologic Surgery
• Prevent Cancer Foundation
• Rhode Island Dermatological Society
• Society for Investigative Dermatology
• Society for Pediatric Dermatology
• Society for Public Health Education
• Sun Safety for Kids
• Tennessee Dermatology Association
• Texas Dermatological Society
• The Skin Cancer Foundation
• Vermont Dermatological Society
• Washington D.C. Dermatological Society
• Washington State Dermatology Association
• West Virginia Dermatological Society 
• Wisconsin Dermatological Society
• Wyoming Academy of Dermatology