HB618--PRIORAUTHORIZATIONOFHEALTHCARESERVICES(Stinnett)
COMMITTEEOFORIGIN:StandingCommitteeonInsurance
Thisbillprovidesthatahealthcarrierorutilizationreview
entitycannotrequirehealthcareproviderstoobtainprior
authorizationforhealthcareservices,exceptundercertain
circumstances.
BeginningJanuary1,2026,priorauthorizationisnotrequired
unlessadeterminationismadethatlessthan90%ofprior
authorizationrequestssubmittedbythehealthcareproviderinthe
previousevaluationperiod,asdefinedinthebill,wereorwould
havebeenapproved.
Thebillestablishesseparatethresholdsforrequiringprior
authorizationforindividualhealthcareservicesorrequiring
priorauthorizationforallhealthcareservices.
Hospitalsmustmeetoneofthreeconditionsforexemption:
(1)Enterintoavalue-basedcareagreement;
(2)AchieveascoreofthreeorhigherontheCenterforMedicare
andMedicaidServicesFive-StarQualityRatingSystem;or
(3)Haveatleast91%ofpriorauthorizationrequestsapproved.
CriticalaccesshospitalsandthosenotparticipatingintheCenter
forMedicareandMedicaidServicesFive-Starsystemare
automaticallyexemptfromtheseconditions.
Exemptionsmaybeaudited,uptoamaximumoftwotimesperyear,
andrevokedunderspecificconditions,suchasapprovalrates
droppingbelow90%orasignificantincreaseinexemptprocedures.
Additionally,exemptionsarevoidifprovidersarefoundguiltyof
fraudorabuse.
Theexemptionfrompriorauthorizationrequirementswillnot
include:
(1)Pharmacyservices,nottoexceedtheamountof$100,000;
(2)Imagingservices,nottoexceedtheamountof$100,000;
(3)Cosmeticproceduresthatarenotmedicallynecessary;or
(4)Investigativeorexperimentaltreatments. Theamountsforthepharmacyservicesandimagingserviceslisted
abovewillincreasedeveryyear,roundedtothenearestthousand
dollars,beginningJanuary1,2027,basedontheConsumerPrice
Index.
Onlineportalsmayberequiredforpriorauthorizationsubmissions.
Patientswithanewhealthplanreceivea90-daygraceperiodfor
previouslyauthorizedmedications.
Thebillspecifiesrequirementsfornotifyingtheproviderof
determinations inthebill,requirescarriersandutilization
reviewentitiestomaintainanonlineportalgivingproviders
accesstocertaininformation,andprovidesthatprior
authorizations mayberequiredbeginning25businessdaysafter
noticetotheprovideruntiltheendoftheevaluationperiod.
Failuretonotifyprovidersofadeterminationasrequiredinthe
billwillconstitutepriorauthorizationoftheapplicablehealth
careservices.
Lastly,nohealthcarrierorutilizationreviewentitycandenyor
reducepaymentstoahealthcareproviderwhohadaprior
authorization, unlesstheprovidermadeaknowingandmaterial
misrepresentation withtheintenttodeceivethecarrieror
utilizationreviewentity,orunlessthehealthcareservicewas
notsubstantiallyperformed.
ThisbillwillnotapplytoMedicaid,exceptwithregardtoa
Medicaidmanagedcareorganizationasdefinedbylaw.Thebill
alsodoesnotapplytoproviderswhohavenotparticipatedina
healthbenefitplanofferedbythecarrierforatleastonefull
evaluationperiod.
Thisbillshouldnotbeconstruedtoauthorizeproviderstoprovide
servicesoutsidethescopeoftheirlicenses,nortorequirehealth
carriersorutilizationreviewentitiestopayforcareprovided
outsidethescopeofaprovider'slicense.