Prior authorization reforms in Massachusetts went into effect June 5.
Democratic Gov. Maura Healey finalized the regulations in May, following through on her earlier plan to tackle prior authorization.
Here are six things to know about the reforms:
1. The regulations prohibit prior authorization requirements for emergency and urgent care, primary care, radiology imaging following a cancer diagnosis, preventive services, maternity care, physical and occupational therapy, outpatient substance use disorder treatment, and medications for serious mental illness and some chronic health conditions.
2. Insurers must respond to urgent prior authorization requests within 24 hours. Patients with chronic conditions who have authorization should get approvals for the duration of their treatment as long as they are stable.
3. Insurers need to honor existing authorizations for at least 90 days when patients switch plans.
4. Insurers will need to post prior authorization requirements and alert providers ahead of making policy changes.
5. The reforms may not be a silver bullet. The Boston Globe reported that Massachusetts Insurance Commissioner Michael Caljouw said these regulations are not widely applicable. Regulatory authority only covers about half of enrollees in the state’s commercial plans. For example, self-insured plans are exempt from state regulations.
6. “Prior authorization remains an important tool to protect patients, promote quality and help manage rising healthcare costs at a time when affordability is the number one concern for Massachusetts families and employers. Massachusetts Association of Health Plans member plans are all in on finding solutions to the Commonwealth’s affordability crisis,” Lora Pellegrini, MAHP president and CEO, said in a May 14 news release. “Administrative reforms alone will not lower premiums or make health care more affordable. Those efforts must be paired with meaningful action to address the underlying drivers of cost growth — including rising hospital prices, outpatient facility costs, and prescription drug spending.”
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