Utah 2025 Regular Session

Utah Senate Bill SB0274 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	Enrolled Copy S.B. 274
	1	+	03-05 11:22 2nd Sub. (Salmon) S.B. 274
	2	+	Raymond P. Ward proposes the following substitute bill:
2	3		1
3	4		Health Insurance Preauthorization Revisions
4	5		2025 GENERAL SESSION
5	6		STATE OF UTAH
6	7		Chief Sponsor: John D. Johnson
7	8		House Sponsor: Katy Hall
8	9		2
9	10
10	11		3
11	12		LONG TITLE
12	13		4
13	14		General Description:
14	15		5
15	16		This bill amends provisions related to health insurance preauthorization.
16	17		6
17	18		Highlighted Provisions:
18	19		7
19	20		This bill:
20	21		8
21	22		▸ requires health insurers to provide information related to preauthorization to the
22	23		9
23	24		Department of Insurance, patients, and health care providers; and
24	25		10
25	26		▸ creates a repeal date.
26	27		11
27	28		Money Appropriated in this Bill:
28	29		12
29	30		None
30	31		13
31	32		Other Special Clauses:
32	33		14
33	34		None
34	35		15
35	36		Utah Code Sections Affected:
36	37		16
37	38		AMENDS:
38	39		17
39	40		31A-22-650, as enacted by Laws of Utah 2019, Chapter 439
40	41		18
41	42		63I-1-231, as last amended by Laws of Utah 2023, Chapter 28
42	43		19
43	44
44	45		20
45	46		Be it enacted by the Legislature of the state of Utah:
46	47		21
47	48		Section 1. Section 31A-22-650 is amended to read:
48	49		22
49	50		31A-22-650 . Health care preauthorization requirements.
50	51		23
51	52		(1) As used in this section:
52	53		24
53	54		(a) "Adverse preauthorization determination" means a determination by an insurer that
54	55		25
55	56		health care does not meet the preauthorization requirement for the health care.
56	57		26
57	58		(b) "Authorization" means a determination by an insurer that for health care with a
58	59		27
59	60		preauthorization requirement:
60	61		28
61		-	(i) the proposed drug, device, or covered service meets all requirements, restrictions, ~~S.B. 274 Enrolled Copy~~
	62	+	(i) the proposed drug, device, or covered service meets all requirements, restrictions,
62	63		29
63	64		limitations, and clinical criteria for authorization established by the insurer;
	65	+	2nd Sub. S.B. 274 2nd Sub. (Salmon) S.B. 274 03-05 11:22
64	66		30
65	67		(ii) the drug, device, or covered service is covered by the enrollee's insurance policy;
66	68		31
67	69		and
68	70		32
69	71		(iii) the insurer will provide coverage for the drug, device, or covered service subject
70	72		33
71	73		to the provisions of the insurance policy, including any cost sharing
72	74		34
73	75		responsibilities of the enrollee.
74	76		35
75	77		(c) "Device" means a prescription device as defined in Section 58-17b-102.
76	78		36
77	79		(d) "Drug" means the same as that term is defined in Section 58-17b-102.
78	80		37
79	81		(e) "Insurer" means the same as that term is defined in Section 31A-22-634.
80	82		38
81	83		(f) "Preauthorization requirement" means a requirement by an insurer that an enrollee
82	84		39
83	85		obtain authorization for a drug, device, or service covered by the insurance policy,
84	86		40
85	87		before receiving the drug, device, or service.
86	88		41
87	89		(2)(a) An insurer may not modify an existing requirement for authorization unless, at
88	90		42
89	91		least 30 days before the day on which the modification takes effect, the insurer:
90	92		43
91	93		(i) posts a notice of the modification on the website described in Subsection
92	94		44
93	95		31A-22-613.5(6)(a); and
94	96		45
95	97		(ii) if requested by a network provider or the network provider's representative,
96	98		46
97	99		provides to the network provider by mail or email a written notice of modification
98	100		47
99	101		to a particular requirement for authorization described in the request from the
100	102		48
101	103		network provider.
102	104		49
103	105		(b) Subsection (2)(a) does not apply if:
104	106		50
105	107		(i) complying with Subsection (2)(a) would create a danger to the enrollee's health or
106	108		51
107	109		safety; or
108	110		52
109	111		(ii) the modification is for a newly covered drug or device.
110	112		53
111	113		(c) An insurer may not revoke an authorization for a drug, device, or covered service if:
112	114		54
113	115		(i) the network provider submits a request for authorization for the drug, device, or
114	116		55
115	117		covered service to the insurer;
116	118		56
117	119		(ii) the insurer grants the authorization requested under Subsection (2)(c)(i);
118	120		57
119	121		(iii) the network provider renders the drug, device, or covered service to the enrollee
120	122		58
121	123		in accordance with the authorization and any terms and conditions of the network
122	124		59
123	125		provider's contract with the insurer;
124	126		60
125	127		(iv) on the day on which the network provider renders the drug, device, or covered
126	128		61
127	129		service to the enrollee:
128	130		62
129	131		(A) the enrollee is eligible for coverage under the enrollee's insurance policy; and
130		-	- 2 - Enrolled Copy S.B. 274
131	132		63
132	133		(B) the enrollee's condition or circumstances related to the enrollee's care have not
	134	+	- 2 - 03-05 11:22 2nd Sub. (Salmon) S.B. 274
133	135		64
134	136		changed;
135	137		65
136	138		(v) the network provider submits an accurate claim that matches the information in
137	139		66
138	140		the request for authorization under Subsection (2)(c)(i); and
139	141		67
140	142		(vi) the authorization was not based on fraudulent or materially incorrect information
141	143		68
142	144		from the network provider.
143	145		69
144	146		(3)(a) An insurer that receives a request for authorization shall treat the request as a
145	147		70
146	148		pre-service claim as defined in 29 C.F.R. Sec. 2560.503-1 and process the request in
147	149		71
148	150		accordance with:
149	151		72
150	152		(i) 29 C.F.R. Sec. 2560.503-1, regardless of whether the coverage is offered through
151	153		73
152	154		an individual or group health insurance policy;
153	155		74
154	156		(ii) Subsection 31A-4-116(2); and
155	157		75
156	158		(iii) Section 31A-22-629.
157	159		76
158	160		(b) If a network provider submits a claim to an insurer that includes an unintentional
159	161		77
160	162		error that results in a denial of the claim, the insurer shall permit the network
161	163		78
162	164		provider with an opportunity to resubmit the claim with corrected information within
163	165		79
164	166		a reasonable amount of time.
165	167		80
166	168		(c) Except as provided in Subsection (3)(d), the appeal of an adverse preauthorization
167	169		81
168	170		determination regarding clinical or medical necessity as requested by a physician
169	171		82
170	172		may only be reviewed by a physician who is currently licensed as a physician and
171	173		83
172	174		surgeon in a state, district, or territory of the United States.
173	175		84
174	176		(d) The appeal of an adverse determination requested by a physician regarding clinical
175	177		85
176	178		or medical necessity of a drug, may only be reviewed by an individual who is
177	179		86
178	180		currently licensed in a state, district, or territory of the United States as:
179	181		87
180	182		(i) a physician and surgeon; or
181	183		88
182	184		(ii) a pharmacist.
183	185		89
184	186		(e) An insurer shall ensure that an adverse preauthorization determination regarding
185	187		90
186	188		clinical or medical necessity is made by an individual who:
187	189		91
188	190		(i) has knowledge of the medical condition or disease of the enrollee for whom the
189	191		92
190	192		authorization is requested; or
191	193		93
192	194		(ii) consults with a specialist who has knowledge of the medical condition or disease
193	195		94
194	196		of the enrollee for whom the authorization is requested regarding the request
195	197		95
196	198		before making the determination.
197	199		96
198	200		(f) An insurer shall specify how long an authorization is valid.
199		-	- 3 - S.B. 274 Enrolled Copy
200	201		97
201	202		(4)(a) An insurer that removes a drug from the insurer's formulary shall:
	203	+	- 3 - 2nd Sub. (Salmon) S.B. 274 03-05 11:22
202	204		98
203	205		(i) permit an enrollee, an enrollee's designee, or an enrollee's network provider to
204	206		99
205	207		request an exemption from the change to the formulary for the purpose of
206	208		100
207	209		providing the patient with continuity of care; and
208	210		101
209	211		(ii) have a process to review and make a decision regarding an exemption requested
210	212		102
211	213		under Subsection (4)(a)(i).
212	214		103
213	215		(b) If an insurer makes a change to the formulary for a drug in the middle of a plan year,
214	216		104
215	217		the insurer may not implement the changes for an enrollee that is on an active course
216	218		105
217	219		of treatment for the drug unless the insurer provides the enrollee with notice at least
218	220		106
219	221		30 days before the day on which the change is implemented.
220	222		107
221	223		(5)(a) [Before April 1, 2021, and before April 1 of each year thereafter, ] Each April 1,
222	224		108
223	225		an insurer with a preauthorization requirement shall report to the department, for the
224	226		109
225	227		previous calendar year, the percentage of authorizations, not including a claim
226	228		110
227	229		involving urgent care as defined in 29 C.F.R. Sec. 2560.503-1, for which the insurer
228	230		111
229	231		notified a provider regarding an authorization or adverse preauthorization
230	232		112
231	233		determination more than one week after the day on which the insurer received the
232	234		113
233	235		request for authorization.
234	236		114
235	237		(b) Before March 1, 2026, and each March 1 thereafter, an insurer shall report to the
236	238		115
237	239		department the following for the previous calendar year:
238	240		116
239	241		(i) a list of services that have preauthorization requirements;
240	242		117
241	243		(ii) for pre-service preauthorization requests that were not urgent, the percentage of
242	244		118
243	245		individual service requests that:
244	246		119
245	247		(A) were approved;
246	248		120
247	249		(B) were denied;
248	250		121
249	251		(C) were approved after appeal;
250	252		122
251	253		(D) the time frame for review was extended, and the request was approved;
252	254		123
253	255		(E) were denied due to incomplete information from the health care provider; and
254	256		124
255	257		(F) were received through fax, phone, and electronic portal; and
256	258		125
257	259		(iii) for urgent pre-service preauthorization requests, the percentage of individual
258	260		126
259	261		service requests that:
260	262		127
261	263		(A) were approved;
262	264		128
263	265		(B) were denied;
264	266		129
265	267		(C) were denied due to incomplete information from the health care provider; and
266	268		130
267	269		(D) were received through fax, phone, and electronic portal.
268		-	- 4 - Enrolled Copy S.B. 274
269	270		131
270	271		(c) Data provided to the department under Subsections (5)(b)(ii) and (iii) shall be
	272	+	- 4 - 03-05 11:22 2nd Sub. (Salmon) S.B. 274
271	273		132
272	274		aggregated for all services.
273	275		133
274	276		(d) Subsection (5)(b) does not require an insurer to report information regarding
275	277		134
276	278		prescription drugs.
277	279		135
278	280		(e) The department shall compile the information described in Subsection (5)(b) and
279	281		136
280	282		publish the information on the department's website.
281	283		137
282	284		(6) An insurer may not have a preauthorization requirement for emergency health care as
283	285		138
284	286		described in Section 31A-22-627.
285	287		139
286	288		(7) For each adverse preauthorization determination made by an insurer, the insurer shall
287	289		140
288	290		provide to the enrollee and the enrollee's health care provider:
289	291		141
290	292		(a) a detailed and specific explanation that explains why the determination was made;
291	293		142
292	294		and
293	295		143
294	296		(b) a notice explaining the determination may be appealed and the process for appealing
295	297		144
296	298		the determination, including how to begin an expedited appeal process as described
297	299		145
298	300		in Section 31A-22-629.
299	301		146
300	302		(8) In accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, the
301	303		147
302	304		department may make rules to implement Subsection (5)(b).
303	305		148
304	306		Section 2. Section 63I-1-231 is amended to read:
305	307		149
306	308		63I-1-231 . Repeal dates: Title 31A.
307	309		150
308	310		(1) Section 31A-2-217, Coordination with other states, is repealed July 1, 2033.
309	311		151
310	312		(2) Subsection 31A-22-650(5)(b), regarding the reporting requirement that includes the
311	313		152
312	314		number of preauthorizations that were approved and denied, is repealed July 1, 2029.
313	315		153
314	316		(3) Subsection 31A-22-650(8), regarding the rulemaking for the preauthorization reporting
315	317		154
316	318		requirement, is repealed July 1, 2029.
317	319		155
318	320		Section 3. Effective Date.
319	321		156
320	322		This bill takes effect on May 7, 2025.
321	323		- 5 -