Bill > H0611

This bill, the Idaho Prior Authorization Reform Act, aims to improve the process by which health insurance issuers, which are companies that provide health benefit plans, require pre-approval, known as prior authorization, for certain medical services. The act establishes clear definitions for terms like "adverse determination" (when a request is denied) and "medically necessary" (care that a qualified professional would provide for a patient's health). It mandates that insurers must publicly disclose all prior authorization requirements and the criteria used to make decisions on their websites, ensuring transparency for healthcare providers and patients. The bill sets specific timeframes for responding to prior authorization requests, with expedited requests for urgent conditions needing a response within 24 hours and standard requests within five business days, or two business days for pharmaceuticals. It also requires that appeals of adverse determinations be reviewed by qualified physicians and that approved prior authorizations for ongoing treatments for chronic conditions generally remain valid for 12 months. Furthermore, the act requires insurers to make standardized electronic prior authorization processes available and to accept electronic submissions using specific industry standards, with deadlines for implementation. The Department of Insurance is given authority to enforce these provisions, including imposing fines for non-compliance, and insurers must report data on their prior authorization practices annually. The bill also addresses situations where an insurer fails to comply with the requirements, leading to services being automatically deemed authorized, and outlines procedures for handling potentially fraudulent requests.

Business and Industry

Health and Welfare Committee (House)

https://legislature.idaho.gov/sessioninfo/2026/legislation/H0611/