On May 24 the New York Workers’ Compensation Board released Subject Number 046-1408 that announces the postponement of several changes that were previously planned for June 7. The Board has not yet announced a new implementation date but expects that it will be sometime in the summer of 2021.
There are three changes being delayed:
- The “Limited Release” of the Board’s new OnBoard prior authorization system.
Once the “Limited Release” period begins, payers will submit prior authorization requests (PARs) via OnBoard rather than using the existing paper forms. Claims administrators will review and respond to those PARs via OnBoard. The Board will also be able to act on PARs where a reviewer has not issued a timely response.
- The release of the new durable medical equipment fee schedule.
The new fee schedule will limit the maximum allowed reimbursement for listed items. It will also require healthcare providers to obtain prior authorization for durable medical equipment that is not listed on the fee schedule or that or that is listed as “PAR REQUIRED.”
- The application of the Board’s drug formulary to refill and renewal prescriptions.
Per regulation (12 NYCRR 441.3), the formulary was initially planned to apply first to “new prescriptions” in December of 2019 (six months after the regulation was adopted in June of 2019) and then to apply to refills and renewals of older prescriptions in June of 2020. The Board implemented the formulary for “new prescriptions” in December of 2019, as scheduled. However, the Board has been forced to delay the implementation date for refills and renewals several times over the past year, largely due to the COVID-19 pandemic.
It should be noted that Monday’s announcement by the Board does not address related deadlines that have already passed, for example:
- the May 1, 2021 deadline for payers/PBMs to notify injured workers and prescribers about the upcoming renewal/refill implementation; or
- the May 1, 2021 deadline for payers to provide their prior authorization contacts to be listed in OnBoard.
If you were already prepared for the June 7 deadline … Congratulations! You are now ahead of schedule. That said, it may be beneficial to confirm your PBM is aware of the postponement so that it remains complaint with the formulary timeframes. You should also make sure your claims administrator and review personnel/UR vendors are aware that the new prior authorization process will not go into effect until later this summer.
If you were not prepared for the June 7 deadline … This is an excellent opportunity to sit down and figure out what you need.
— Have your prior authorization contacts been updated?
— Has your PBM notified prescribers and injured workers about the upcoming formulary application date for refills and renewals?
— Do you have process flows for the new prior authorization processes? Is your team ready to adjust to the new system? If not, what changes do you need to make?
— What is your plan for handling DME PARs that include a requested price? Can you ensure that your partial approvals will include alternative prices that meet the regulatory criteria?
Health Care Providers
If you haven’t done so already:
— Make sure that you’re familiar with the Board’s OnBoard resources for health care providers.
— Be sure that you’re familiar with the DME fee schedule and prior authorization requirements.
— Ensure that you understand how the upcoming formulary application date could affect prescriptions that your patients have been on for years. If you’re not able to transition those patients to a formulary-compliant medication, ensure that you’re ready to submit formulary prior authorization requests with supporting documentation, to respond to questions from reviewers, and to respond to determinations.
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