Overview
During December 2022, Pennsylvania passed Act 146 of 2022, landmark legislation to reform the commonwealth’s prior authorization process and support patients’ timely access to care. Specifically, the law established clear and predictable processes while lessening costly administrative burdens for hospitals and health care providers.
HAP provided initial member education about changes during 2023, however, all provisions are effective as of January 1, 2024; so this refresher session will provide a general overview of Act 146 with emphasis on the key prior authorization process provisions in the bill:
- Defines terms for the prior authorization process for all commercial insurers, including the state’s Medicaid and Children’s Health Insurance Program (CHIP) managed care plans
- Affirms that emergency treatment is not subject to prior authorization
- Requires insurers publish a list of all services and drugs that require prior authorization, as well as the criteria used to approve or deny coverage
- Establishes defined timeframes for insurers to respond to prior authorization requests and for providers to submit additional information
- Requires written documentation with specific reasons for denial decisions and instructions for how patients can appeal
- Sets minimum requirements for FDA-approved opioid use disorder treatments that must be available without prior authorization
- Creates a process where patients and physicians can request exceptions from step-therapy (also called “fail first”) programs
- Outlines the sharing of electronic documents between the patient, physician, and insurer which continues to protect privacy of electronic medical records