Amendment #33 to H4643

Prior Authorization Report and Reform

Ms. Decker of Cambridge moves to amend the amendment by adding the following sections:-

"SECTION XXXX. (a) The health policy commission, in collaboration with the center for health information and analysis and the division of health insurance, shall conduct an analysis and report on the use of prior authorization for health care services and its impact on cost, quality, and access.

(b) The report shall include, but not be limited to: (1) an assessment and inventory of admissions, items, services, treatments, procedures, and medications that require prior authorization, and that (i) have a high rate of approval or denial for standard and expedited requests, and those subject to appeal; (ii) the timeline for review and adjudication for standard and expedited requests, and those subject to appeal; (2) total health care expenditures associated with the submission and processing, including appeals, of prior authorization determinations; (3) an analysis of the impact of prior authorization requirements on patient access to and cost of care by patient demographics, geographic region and type of service; (4) identification of admissions, items, services, treatments, procedures, and medications subject to prior authorization that have low variation in utilization across providers and carriers or low denial rates across carriers; (5) identification of admissions, items, services, treatments, procedures, and medications subject to prior authorization for certain chronic disease services that negatively impact chronic disease management; (6) review and analysis of the integration of standardized electronic prior authorization attachments, standardized forms, requirements and decision support into electronic health records and other practice management software to promote transparency and efficiency; (7) review and analysis of “gold-carding status” or waiver of prior authorization based on a carrier’s standards or policies and whether such status is available to all providers in a carrier’s network; and (8) recommendations regarding the simplification of health insurance prior authorization standards and processes to improve health care access and reduce the burden on health care providers;

(c) The report shall be informed by data and information submitted by carriers to the division and shall include but not be limited to the following:

(1) a list of all admissions, items, services, treatments, procedures, and medications that require prior authorization;

(1) the number and percentage of standard prior authorization requests that were approved, individualized for each admission, item, service, treatment, procedure, and medication;

(3) the number and percentage of standard prior authorization requests that were denied, individualized for each admission, item, service, treatment, procedure, and medication;

(4) the number and percentage of standard prior authorization requests that were initially denied and approved after appeal, individualized for each admission, item, service, treatment, procedure, and medication;

(5) the number and percentage of prior authorization requests for which the timeframe for review was extended, and the request was approved, individualized for each admission, item, service, treatment, procedure, and medication;

(6) the number and percentage of expedited prior authorization requests that were approved, individualized for each admission, item, service, treatment, procedure, and medication;

(7) the number and percentage of expedited prior authorization requests that were denied, individualized for each admission, item, service, treatment, procedure, and medication;

(8) the average and median time that elapsed between the submission of a request and a determination by the payer, plan, or issuer, for standard prior authorizations, individualized for each admission, item, service, treatment, procedure, and medication; and

(9) the average and median time that elapsed between the submission of a request and a decision by the payer, plan or issuer, for expedited prior authorizations, individualized for each admission, item, service, treatment, procedure, and medication;

(10) the average and median time that elapsed to process an appeal submitted by a health care provider initially denied by the payer, plan, or issuer, for standard prior authorizations, individualized for each admission, item, service, treatment, procedure, and medication; and

(11) the average and median time that elapsed to process an appeal submitted by a health care provider initially denied by the payer, plan or issuer, for expedited prior authorizations, individualized for each admission, item, service, treatment, procedure, and medication.

(d) The report and any legislative recommendations shall be submitted to the chairs of the joint committee on health care financing, the house and senate committees on ways and means not later than 9 months from the effective date of this act.

SECTION XXXX. (a) Notwithstanding any general or special law to the contrary the division of health insurance shall develop and implement rules, regulations, bulletins or other guidance to (1) prohibit carriers from imposing prior authorization requirements for any generic medication or on admissions, items, services, treatments, procedures, and medications that have: (i) low variation in utilization across health care providers; (ii) low denial rates across carriers; and (iii) an evidence-base for the treatment or management of certain chronic diseases; (2) implement a comprehensive set of uniform prior authorization forms for different health care services and benefits, as required by section 25 of chapter 176O of the General Laws; and (3) implement a means of making publicly available, and for each carrier to make publicly available, through a website or alternative means, a listing of all items, services, treatments, procedures, or medications subject to prior authorization by each individual carrier.

SECTION XXXX.  Section X1 shall be effective on July 31, 2025."

Additional co-sponsor(s) added to Amendment #33, as changed to H4643

Prior Authorization Report and Reform