Amendment 1754 to House Bill 18 P.N. 0463, Regular Session 2017-2018

H0018B0463A01754 SFR:JSL 06/09/17 #90 A01754

AMENDMENTS TO HOUSE BILL NO. 18

Sponsor: REPRESENTATIVE MACKENZIE

Printer's No. 463

Amend Bill, page 1, lines 13 through 16, by striking out all

of said lines and inserting

Section 1. Section 306(f.1)(6)(ii) of the act of June 2,

1915 (P.L.736, No.338), known as the Workers' Compensation Act,

is amended, paragraph (3)(vi) is amended by adding a subclause

and paragraph (6) is amended by adding a subparagraph to read:

Amend Bill, page 2, line 8, by striking out "provision" and

inserting

subclause

Amend Bill, page 2, lines 10 and 11, by striking out "at

least thirty (30) days but not more than "

Amend Bill, page 2, line 11, by inserting after "days."

During the public comment period, the department shall

conduct at least one public hearing on the selection of a drug

formulary.

Amend Bill, page 2, line 12, by inserting after "period"

and public hearings

Amend Bill, page 2, line 16, by striking out "its selection

of a" and inserting

the

Amend Bill, page 2, line 16, by inserting after "formulary"

selected

Amend Bill, page 2, line 18, by striking out "thirty (30)"

and inserting

one hundred eighty (180)

Amend Bill, page 2, by inserting between lines 19 and 20

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(III) In selecting a nationally recognized, evidence-based

prescription drug formulary for adoption, the department shall

consider the following factors:

(a) Whether the formulary focuses on medical treatment

specific to workers' compensation.

(b) Whether the basis for the formulary is readily apparent

and publicly available.

management of opioid medications.

(d) Whether the formulary appropriately limits both duration

and dosage of prescriptions.

(e) The cost of implementation of the formulary.

(IV) The department shall annually review updates issued by

the formulary publisher to the selected formulary and by

November 1 each year shall solicit public comments regarding the

updates proposed for adoption by publishing notice of the

proposed updates and a public comment period in the Pennsylvania

Bulletin. The public comment period for updates to the adopted

formulary shall be at least twenty (20) days, but not more than

than thirty (30) days. Within thirty (30) days after the close

of the public comment period, the department shall publish

notice of the adopted updates in the Pennsylvania Bulletin. The

published updates shall take effect thirty (30) days after the

publication required by this subprovision.

Amend Bill, page 2, line 20, by striking out "(III)" and

inserting

(V)

Amend Bill, page 2, line 24, by striking out "(IV)" and

inserting

(VI)

Amend Bill, page 2, line 24, by inserting after "The "

prescription of drugs that is consistent with or recommended

by the prescription drug formulary shall be considered

reasonable and necessary for the purposes of paragraph (6).

Except in cases of medical necessity under subprovision (VII),

the

Amend Bill, page 2, by inserting between lines 27 and 28

(VII) The prescription of drugs that is not consistent with

or recommended by the prescription drug formulary may only be

considered reasonable and necessary for the purposes of

paragraph (6) if the treating health care provider has submitted

documentation of medical necessity, including evidence-based

analysis of the reason for the exception, to the insurer or

self-insured employer at the time of the initial prescription.

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The documentation of medical necessity shall be on a form

prescribed by the department.

(VIII) Within eighteen (18) calendar months following the

effective date of the prescription drug formulary selected under

this subclause, the Pennsylvania Compensation Ratings Bureau

shall calculate the savings achieved through the implementation

of the prescription drug formulary. For the calendar year

immediately following this calculation, the amount of savings

shall be used to provide an immediate reduction in rates, equal

to the savings, applicable to employers' workers' compensation

policies.

Amend Bill, page 3, by inserting between lines 4 and 5

(ii) The department shall assign a request for utilization

review to a utilization review organization at random. The

utilization review organization shall issue a written report of

its findings and conclusions within the time frame required by

the nationally recognized accreditation standards adopted by the

department under subparagraph (v). In no case shall the report

of findings and conclusions be issued more than thirty (30) days

after the receipt of a request.

* * *

Amend Bill, page 3, lines 7 and 8, by striking out "as a

utilization review entity under section 2151" in line 7 and all

of line 8 and inserting

or accreditation by a nationally recognized organization

with certification or accreditation standards appropriate for

resolving utilization issues for workers' compensation programs.

The following shall apply:

(A) Within thirty (30) days of the effective date of this

clause, the department shall publish notice in the Pennsylvania

Bulletin of the specific nationally recognized certification or

accreditation that will be required in order to be approved as a

utilization review organization.

(B) Upon publication under subclause (A), an entity without

the appropriate certification or accreditation may not engage in

utilization review under this act, except that an entity

approved as a utilization review organization by the department

prior to the effective date of this clause may continue to

engage in utilization review for up to eighteen (18) calendar

months after the publication of notice under subclause (A). If

the department determines that an entity approved as a

utilization review organization by the department prior to the

effective date of this clause is actively attempting to achieve

the selected certification or accreditation, the entity shall

not be required to apply for reauthorization during the

eighteen-month period. A utilization review organization shall

adhere to the review standards of the selected nationally

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recognized certification or accreditation organization for all

utilization review where the date of the injury is at least

eighteen (18) calendar months after the publication of notice

under subclause (A).

selected nationally recognized certification or accreditation

organization to provide for the certification or accreditation

process for utilization review organizations and employes of

utilization review organizations, including the costs of any

audits required for the certification or accreditation process.

The department shall make reasonable attempts to negotiate a

reduction of the cost of the certification or accreditation

process. An entity approved as a utilization review organization

by the department prior to the effective date of this clause,

including a surviving association that results from the merger

of two or more utilization review organizations under 15 Pa.C.S.

Ch. 3 Subch. C (relating to merger), shall be eligible to

participate in the initial certification or accreditation

process at no cost to the entity. After January 1, 2020, an

entity approved as a utilization review organization shall be

eligible to participate in the process to renew its

certification or accreditation at no cost to the entity. An

entity for which the department has incurred costs under this

subclause shall reimburse the department for its costs related

to the most recent certification or accreditation for the

entity, if the entity does not successfully obtain the initial

or renewal certification or accreditation. The actual amount of

the cost to the department for the certification or

accreditation process under this subclause, not to exceed one

million five-hundred thousand dollars ($1,500,000) annually,

shall be transferred to the department from the Workers'

Compensation Administration Fund.

(D) The department shall conduct outreach to all entities

approved as utilization review organizations by the department

prior to the effective date of this clause. The outreach shall

include providing each entity with notice of the requirements of

this clause, guidance on how this clause will be enforced by the

department and information on how the entity may participate in

the required certification or accreditation process at no cost

under subclause (C).

Amend Bill, page 4, by inserting between lines 11 and 12

Section 3. Within eight months of the effective date of this

act, the Department of Labor and Industry shall propose

regulations to implement the amendment or addition of section

306(f.1)(3)(vi)(J) and (6)(ii) and (v) of the act.

Amend Bill, page 4, line 12, by striking out "3" and

inserting

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