State Advocacy

What We're Doing at the State Level

Get caught up on the health care issues facing the psoriasis and psoriatic arthritis community and learn what NPF, with your help, is doing to create positive change.

A group of advocates stand outside a government building.

Health care is changing, and not only at the national level.

The states are taking action on a range of health care issues that are important to people with psoriasis and psoriatic arthritis. Some states are ahead of the curve; others are catching up. In all states, the National Psoriasis Foundation (NPF) is advocating for the psoriatic disease community. Here’s a look at some of our achievements – and our ideas on how we can move forward.

Access to Comprehensive Health Coverage

Health care only works when patients can enroll in plans that meet their needs and access care without jumping through unnecessary hoops. NPF advocacy works with state governments and health plans to enact policies that ensure patient access and comprehensive health benefits.

Step Therapy and Prior Authorization

Step therapy and prior authorizations are utilization management tools used by health insurers and third-party administrators. They are designed to manage health care costs by monitoring the use of services and treatments and steering patients toward lower cost options.

On the surface, these utilization management tools sound like a good idea. It’s true that they can successfully control costs. But in some instances, these practices may do more harm than good. They can create significant barriers to care and delay access to the best therapy, while potentially worsening a patient’s condition. A 2019 NPF patient survey found that 41% of people with psoriatic disease have experienced step therapy.

NPF works to pass state bill that create safeguards for utilization management tools, including a clear and prompt process for requesting an exception. To date, over 25 states have enacted step therapy protections.

Recent state victories include:

North Carolina Step Therapy Reform

SB 361 became law in July, 2020

Louisiana Step Therapy Reform

HB 263 became law in June, 2020.

South Dakota Step Therapy Reform

SB 155 became law in March, 2020.

Washington State Step Therapy Reform

HB 1879 became law in April, 2019.

Wisconsin Step Therapy Reform

SB 26 became law in July 2020.

Read other NPF comments on utilization management in our archive.

Letter Archive


Medicaid provides health coverage for eligible low-income adults, elderly adults, children, pregnant women and people with disabilities. Medicaid is administered by the states, according to federal requirements, and is funded jointly by states and the federal government. NPF monitors and engages in state Medicaid programs to improve access and administration of benefits. Recently, NPF has supported Medicaid expansion and engaged with state Medicaid Bureaus to advocate for common formularies that meet the needs of people with psoriatic disease.

State Waivers

Each state has the flexibility to submit waivers to the federal government to make changes in their health care marketplace or Medicaid programs. These waivers can be progressive and expand coverage for patients or they can be regressive and restrict coverage. For example, NPF has supported state waivers to establish reinsurance programs to help stabilize the marketplace. Alternatively, NPF has opposed waivers to create work requirements for Medicaid, as these create administrative barriers for already vulnerable individuals.

Our recent actions on waivers include:

Wyoming, 2019

New Hampshire, 2020

Georgia, 2019

Non-Discriminatory Benefit Design

NPF works to combat health plan designs that discriminate against people with psoriatic disease. We are especially concerned about non-ACA compliant health plans that do not cover pre-existing conditions or essential health benefits. When states are considering policies to loosen protections for pre-existing conditions, NPF joins forces with fellow patient advocacy groups to speak up for our communities.

Some recent examples include:

Short-term limited-duration (STLD) plans are a form of non-ACA compliant health plans that are intended to fill short-term gaps in coverage. In recent years, the federal government has given states the flexibility to expand the duration of STLD plans. These changes pose a risk to the psoriatic disease community because the lower-premiums plans look attractive while shopping but do not cover essential health benefits or pre-existing conditions. NPF has opposed expanded flexibilities for these non-ACA compliant plans.

Visit our letter archive for recent NPF letters on Medicaid, state waivers, and pre-existing conditions.

Out-of-Pocket Costs

Predictable Costs

People should be able to budget for the year, and this means they need predictable costs for their prescriptions. Under the current system, many treatments for psoriatic disease require patients to pay a coinsurance – a percentage of the drug cost – which they do not know until the pharmacy counter. When facing high out-of-pocket costs, people do not use their medications appropriately. According to several studies, prescription abandonment rates increase significantly when cost-sharing exceeds $100. Thus, non-treatment and under-treatment of psoriatic disease are significant problems.

NPF works to promote transparent and predictable costs for treatments for state marketplace health plans:

Per Prescription Caps

One policy solution to combat unpredictable cost sharing is creating per prescription caps. To date, states like California, Louisiana, and Maryland have monthly per prescription caps, but there is more work to be done. Recently, NPF has supported capping insulin prescriptions because people with psoriatic disease are at a higher risk of diabetes. We have weighed in on insulin caps in California and Maryland.

Copay Only Plans

NPF supports “copay only” plan designs, which have a flat dollar copayment for each coverage level in at least 25 percent of a carrier’s health care benefit plans. This creates predictable costs, allowing patients to financially plan. To date, Colorado and Montana have instituted these protections and NPF has weighed in on proposals to do so in other states like Oregon.

Standard Benefit Plans

States now have the flexibility to include in their state-based health exchanges standardized benefit plans, which try to strike a balance between services and premium costs. These plans often have services and prescription drugs that are not subject to a deductible, better transparency in the formulary and plan design, and more inclusion of essential health benefits. NPF sees these plans as a way to address high out-of-pocket costs and other access to care barriers. Recently, NPF worked with lawmakers in Washington state and New Mexico in support of policies to lower out-of-pocket costs in the new standard plan.

Insurance Barriers

There are insurance plan programs that can make your costs higher. Sometimes they are hidden. Our work aims to change them, make them transparent and reduce surprise costs for patients.

Copay Accumulators

NPF recognizes the importance of copay assistance programs and their ability to limit health care costs for patients. With the development of biologics in the last decade, copay assistance programs have proven to be critical for many individuals who otherwise could not afford a biologic treatment through their insurance plan. In fact, a 2019 NPF patient survey found that 54% of patients taking biologic treatments through commercial insurance use copay manufacturer assistance.

Recently, insurance carriers have stopped counting copay assistance toward a patient’s maximum out-of-pocket cost, through what are called “copay accumulator programs.” NPF believes that all payments made by or on behalf of the patient should be applied to the out-of-pocket maximum and works to pass these policies in the states. Four states have passed these protections so far, including Arizona and West Virginia. We continue working to expand these protections to other states, such as Kentucky.

Surprise Billing

Health insurance plans cover in-network services at a lower rate than out-of-network services. While individuals have the ability to check that their primary care provider or specialists are in-network before receiving care, this careful shopping is not possible in emergencies or for procedures with large care teams. Surprise medical bills occur when a patient is billed for out-of-network care that they thought was covered by their insurance. NPF advocates for patient protections against surprise billing.

Pharmacy Benefit Managers

Pharmacy Benefit Managers (PBMs) administer the drug benefit program for an employer or health plan. PBMs process and pay prescription drug claims and are responsible for creating and updating the health plan’s drug formulary. NPF advocates for patient-friendly policies that improve transparency by combating gag clauses in states like Alabama and reduces out-of-pocket costs in states like Oregon.

Streeter, S.B., Schwartzberg, L., Husain, N., Johnsrud, M. (2011). Patient and Plan Characteristics Affecting Abandonment of Oral Oncolytic Prescriptions. J Oncol Pract. 2011 May; 7(3 Suppl): 46s–51s

See More of Our Recent Work

Visit our letter archive to see our most recent activity and the work we've done over time.

Go to the archive

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