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What to Know: Pa. Lawmakers Pass Prior Authorization Reform

October 27, 2022

Pennsylvania lawmakers have passed critical legislation to reform the prior authorization process and support patients’ timely access to care.

The legislation, Senate Bill 225, sponsored by Senator Kristin Phillips-Hill (R-York), has now reached Governor Tom Wolf’s desk for his signature.

“HAP and Pennsylvania’s hospital community thank leaders and members of the General Assembly for prioritizing and supporting this important reform and Governor Tom Wolf for his anticipated signature,” HAP President and CEO Andy Carter said in a statement following the legislation’s passage late Wednesday. “Senate Bill 225 establishes clear and predictable processes that will reduce delays in medically necessary care for patients, while also lessening costly administrative burdens for hospitals and health care providers.”

Senate Bill 225 reforms the prior authorization process to expedite approval of patient care and reduce administrative burdens for hospitals, physicians, and other health care providers.

Among the key 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

“This reform was made possible by diverse stakeholders coming together to benefit all Pennsylvanians,” Carter said. “HAP thanks Senator Kristin Phillips-Hill for her leadership and the Coalition to Improve Prior Authorization and Step Therapy for Pennsylvanians, health systems, insurers, legislative staff, and others for their work to reach consensus on this plan.”

HAP continues to advocate for reforms at the state and federal levels to remove administrative barriers that delay patient access to care and services. For more information, contact Heather Tyler, HAP’s vice president, state legislative advocacy, or Jolene Calla, Esq., HAP’s vice president, health care finance and insurance.