Bill > HB618

This bill creates new provisions relating to prior authorization of health care services, establishing a framework to reduce administrative burdens on healthcare providers. Beginning January 1, 2026, health carriers and utilization review entities will be prohibited from requiring prior authorization for healthcare services if they have approved at least 90% of prior authorization requests from a specific provider during the previous 12-month evaluation period. Hospitals can qualify for prior authorization exemptions by entering into value-based care agreements, achieving a high quality rating, or demonstrating a high approval rate for prior authorization requests. The bill excludes certain services like pharmacy services, imaging services, cosmetic procedures, and experimental treatments from these exemptions. Health carriers must provide detailed notifications to providers about authorization determinations, maintain an online portal for tracking requests, and cannot deny payment for pre-authorized services unless the provider knowingly misrepresented the service or failed to substantially perform it. The legislation also includes provisions for annual adjustments to monetary limitations, appeals processes, and protections for patients whose health coverage changes. The bill does not apply to MO HealthNet, except for Medicaid managed care organizations, and includes safeguards to ensure providers only perform services within their licensed scope.

Budget and Finance, Business and Industry, Government Affairs

https://house.mo.gov/Bill.aspx?bill=HB618&year=2025&code=R