When it comes to reining in how insurers can use prior authorization, state legislatures have been busy this year.
Since January, nearly a dozen states have passed laws for which state medical societies and the AMA have fiercely advocated to reduce the care delays and wasted time that patients and physicians experience as a result of prior authorization requirements run amok.
Specifics of the laws vary from state to state, but broadly speaking they aim to cut the growing volume of prior authorization requirements, reduce patient care delays, increase the data that must be publicly reported and improve transparency about which medications and procedures require prior authorization.
Vermont, Minnesota, Wyoming, Colorado, Illinois, Mississippi, Maine, Maryland, Oklahoma and Virginia passed prior authorization legislation this year that includes one or more of those themes after state medical societies pushed for change. The AMA supported the states with resources such as model legislation, legislative analysis and more.
More states could pass laws before the year is over, including Massachusetts. The Bay State’s legislature is considering a bill that would require a patient’s new insurer to honor prescription drug prior authorizations from the previous health plan for at least 90 days after the patient enrolls. In addition, when medications and treatments prescribed for chronic disease management receive prior authorization, the approval would need to remain valid for the length of the prescription, up to 12 months.
The state wins and continued movement on prior authorization bills come after the District of Columbia and nine states passed prior authorization reform laws last year.
The AMA is fixing prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles.
Minnesota changes approach
Minnesota enacted strong prior authorization legislation in 2020 to shorten response timelines, ensure physicians are involved in decision-making, and increase transparency. Minnesota law had already included language saying that prior authorization could not be required for emergency services.
But folks at the Minnesota Medical Association were hearing that prior authorization was still getting worse for the state’s patients and physicians, with prior authorization required for a growing number of procedures and the requirements themselves becoming increasingly complex. Emergency medicine was an area where state law already prohibited prior authorization.
“We took a look at that statute and we said: OK, what else do we want to add to that? We focused on those services where when there is any kind of a delay there is a problem,” said Dave Renner, director of advocacy at the Minnesota Medical Association. “It’s a different approach to say: Let’s try to start reducing how often prior auth is being used.”
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Ultimately, Minnesota enacted legislation that prevents the use of prior authorization for the nonmedication parts of cancer care and mental health care. For a chronic condition, prior authorization does not expire as long as the treatment doesn’t change. So, a person with type 2 diabetes or rheumatoid arthritis will not need to go back and get a prior authorization every six months or every year. The exemptions are set to take effect in January 2026.
All insurers and utilization-review organizations must report to the state health department annually on how often they use prior authorization and how often they approve or deny requests. The earlier law required that insurance companies put the data on their own websites, which some companies were better at doing than others.
“This standardizes the data and allows it to be analyzed,” Renner said. “We will have a better understanding of how and when prior authorization is being used and whether that makes sense. For example, why are we requiring prior authorization for services that get approved 98% of the time? Does that result in delayed care for patients?”
The AMA advocates critical national and state-level reforms that must be made to improve prior authorization, including gold-carding programs, making prior authorization valid for the length of treatment for those with chronic conditions, and requiring that new health plans honor a previous payer’s prior authorization for a minimum of 90 days.
States aim to protect patients
Lawmakers in states across the country are making strides in reducing prior authorization burdens, as more than 90% of physicians report that prior authorization leads to care delays, according to the AMA’s annual nationwide survey of 1,000 practicing physicians.
In Vermont, Gov. Phil Scott signed a bill that says patients with chronic conditions do not have to continually get new prior authorizations for treatment that is unchanged and that insurers must respond to urgent prior authorization requests within 24 hours. The Vermont measure also requires that a new insurer accept a previous health plan’s prior authorization for up to 90 days. The law requires that physicians and health plans report to the legislature about the impact the law is having.
In Wyoming, lawmakers enacted legislation that, among other things, creates a “gold card” program that exempts physicians from prior authorization when they have a track record of consistently being approved for certain procedures or medications and requires that prior authorizations for patients with chronic conditions remain valid for longer periods of time.
The Wyoming measure also requires plans to respond to prior authorization requests faster—within 72 hours for urgent situations and five calendar days for nonurgent situations—and provides a grace period during which insurers must honor previous prior authorizations when the patient switches plans.
At the national level, the AMA also strongly supports the Improving Seniors’ Timely Access to Care Act of 2024, bipartisan and bicameral federal legislation that would reform prior authorization procedures in Medicare Advantage.
