Bill > H4616

This bill aims to improve the health insurance prior authorization process by introducing several key provisions. Health insurers (carriers) will be required to publish a searchable online list of all items, services, and medications that require prior authorization, and they cannot request prior authorization for anything not on this list. Carriers must annually report detailed data to the state insurance division about prior authorization requests, including approval and denial rates, processing times, and appeal outcomes. The bill mandates that utilization review criteria must be scientifically derived, evidence-based, and developed with physician input. Insurers will be prohibited from retrospectively denying already-approved authorizations unless fraud is involved, and they must respond to prior authorization requests within specific timeframes. For patients who are stable on a treatment, insurers must continue coverage for at least 90 days after enrollment or if a treatment is removed from a formulary. The bill also introduces regulations for the use of artificial intelligence in prior authorization decisions, ensuring that such tools do not discriminate and do not solely determine coverage decisions. Additionally, a task force will be established to study prior authorization's impact on healthcare costs and access, with a report due by July 31, 2026. The provisions will be implemented in stages, with most taking effect on January 1, 2026, and some specific sections having different implementation dates.

Health and Social Services

Joint Committee on Financial Services (Joint)

https://malegislature.gov/Bills/194/H4616