House Study Bill 19 - Introduced HOUSE FILE _____ BY (PROPOSED COMMITTEE ON COMMERCE BILL BY CHAIRPERSON LUNDGREN) A BILL FOR An Act relating to prior authorizations and exemptions by 1 health benefit plans and utilization review organizations. 2 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 3 TLSB 1514YC (2) 91 nls/ko
H.F. _____ Section 1. Section 514F.8, Code 2025, is amended by adding 1 the following new subsections: 2 NEW SUBSECTION . 1A. a. A utilization review organization 3 shall respond to a request for prior authorization from a 4 health care provider as follows: 5 (1) Within forty-eight hours after receipt for urgent 6 requests. 7 (2) Within ten calendar days after receipt for nonurgent 8 requests. 9 (3) Within fifteen calendar days after receipt for 10 nonurgent requests if there are complex or unique circumstances 11 or the utilization review organization is experiencing an 12 unusually high volume of prior authorization requests. 13 b. Within twenty-four hours after receipt of a prior 14 authorization request, the utilization review organization 15 shall notify the health care provider of, or make available to 16 the health care provider, a receipt for the request for prior 17 authorization. 18 NEW SUBSECTION . 2A. A utilization review organization 19 shall, at least annually, review all health care services for 20 which the health benefit plan requires prior authorization and 21 shall eliminate prior authorization requirements for health 22 care services for which prior authorization requests are 23 routinely approved with such frequency as to demonstrate that 24 the prior authorization requirement does not promote health 25 care quality, or reduce health care spending, to a degree 26 sufficient to justify the health benefit plans administrative 27 costs to require the prior authorization. 28 NEW SUBSECTION . 3A. Complaints regarding a utilization 29 review organizations compliance with this chapter may be 30 directed to the insurance division. The insurance division 31 shall notify a utilization review organization of all 32 complaints regarding the utilization review organizations 33 noncompliance with this chapter. All complaints received 34 pursuant to this subsection shall not be considered public 35 -1- LSB 1514YC (2) 91 nls/ko 1/ 4
H.F. _____ records for purposes of chapter 22. 1 Sec. 2. PRIOR AUTHORIZATION EXEMPTION PROGRAM. 2 1. On or before January 15, 2026, all health carriers 3 that deliver, issue for delivery, continue, or renew a health 4 benefit plan in this state on or after January 1, 2026, and 5 that require prior authorizations, shall implement a pilot 6 program that exempts a subset of participating health care 7 providers, at least some of whom shall be primary health care 8 providers, from certain prior authorization requirements. 9 2. Each health carrier shall make available on the health 10 carriers internet site for each health benefit plan that the 11 health carrier delivers, issues for delivery, continues, or 12 renews in this state, details about the health benefit plans 13 prior authorization exemption program, including all of the 14 following information: 15 a. The health carriers criteria for a health care provider 16 to qualify for the exemption program. 17 b. The health care services that are exempt from prior 18 authorization requirements for health care providers who 19 qualify under paragraph a. 20 c. The estimated number of health care providers who are 21 eligible for the program, including the health care providers 22 specialties, and the percentage of the health care providers 23 that are primary care providers. 24 d. Contact information for the health benefit plan for 25 consumers and health care providers to contact the health 26 benefit plan about the exemption program, or about a health 27 care providers eligibility for the exemption program. 28 3. On or before January 15, 2027, each health carrier 29 required to implement a prior authorization exemption 30 program pursuant to subsection 1 shall submit a report to the 31 commissioner of insurance that contains all of the following: 32 a. The results of the exemption program, including an 33 analysis of the costs and savings of the exemption program. 34 b. The health benefit plans recommendations for continuing 35 -2- LSB 1514YC (2) 91 nls/ko 2/ 4
H.F. _____ or expanding the exemption program. 1 c. Feedback received by each health benefit plan from 2 health care providers and other interested parties regarding 3 the exemption program. 4 d. An assessment of the administrative costs incurred by 5 each of the health carriers health benefit plans to administer 6 and implement prior authorization requirements under the 7 exemption program. 8 EXPLANATION 9 The inclusion of this explanation does not constitute agreement with 10 the explanations substance by the members of the general assembly. 11 This bill relates to prior authorizations and exemptions by 12 health benefit plans and utilization review organizations. 13 The bill requires a utilization review organization 14 (organization) to respond to a request for prior authorization 15 (authorization) from a health care provider (provider) within 16 48 hours after receipt for urgent requests or within 10 17 calendar days for nonurgent requests, unless there are complex 18 or unique circumstances, or the organization is experiencing 19 an unusually high volume of authorization requests, then an 20 organization must respond within 15 calendar days. Within 21 24 hours after receipt of an authorization request, the 22 organization shall notify a provider of, or make available, a 23 receipt for the authorization request. 24 The bill requires an organization to annually review all 25 health care services for which authorization is required and to 26 eliminate authorization requirements for health care services 27 for which authorization requests are so routinely approved that 28 the authorization requirement is not justified as it does not 29 promote health care quality or reduce health care spending. 30 Complaints regarding an organizations compliance with 31 the bill may be directed to the insurance division, and 32 the insurance division shall notify an organization of all 33 complaints. Complaints received under the bill shall not be 34 considered public records. 35 -3- LSB 1514YC (2) 91 nls/ko 3/ 4
H.F. _____ The bill requires, on or before January 15, 2026, all 1 health carriers (carriers) that deliver, issue for delivery, 2 continue, or renew a health benefit plan (plan) in this 3 state on or after January 1, 2026, and that require prior 4 authorizations, to implement a pilot program that exempts a 5 subset of participating providers, including primary health 6 care providers, from certain authorization requirements. Each 7 carrier shall make available for each plan details about the 8 plans authorization exemption requirements on the carriers 9 internet site, including the carriers criteria for a provider 10 to qualify for the exemption program, the health care services 11 that are exempt from authorization requirements, the estimated 12 number of providers who are eligible for the program, including 13 the providers specialties and the percentage of the providers 14 that are primary care providers, and contact information for 15 consumers and providers to contact the plan about the exemption 16 program or a providers eligibility for the exemption program. 17 On or before January 15, 2027, each carrier required to 18 implement an authorization exemption program (program) under 19 the bill shall submit to the commissioner of insurance a 20 report containing the results of the program, including an 21 analysis of the costs and savings of the program, the plans 22 recommendations for continuing or expanding the program, 23 feedback received by each plan, and an assessment of the 24 administrative costs incurred by each of the carriers plans 25 to administer and implement authorization requirements under 26 the program. 27 -4- LSB 1514YC (2) 91 nls/ko 4/ 4