State Prior Authorization Trends
Hospitals and health systems are struggling to manage an avalanche of Medicare Advantage prior authorization denials. State prior authorization requirements across the United States can provide a roadmap for where the federal government may target reform in this area in the future. The R1 Regulatory team regularly reviews state legislature agendas for pending measures of impact to healthcare providers. This article identifies prior authorization developments across multiple states and Washington D.C. to highlight trends in this area and help determine where the federal government will make reform efforts going forward.
Prior Authorization Disclosure Requirements
One of the most common actions taken by states is to require prior authorization entities (e.g., health insurers, HMOs or contracted utilization review entities) to list all healthcare services and drugs that require prior authorization on their public-facing website, often using clear and ordinary language. Many states also require prior authorization entities to provide 60 days’ notice to impacted parties (e.g., hospitals, physician practices) before making any additions or amendments to the list.
States with disclosure requirements include:
- Arkansas: Code Ann. § 23-99-1104
- Illinois: 215 Ill. Comp. Stat. 200/20
- Louisiana: Rev. Stat. Ann. 22 § 1020.62(C)
- Mississippi: Code Ann. § 41-145-NEW-005
- Montana: Code Ann. § 33-32-106
- Tennessee: Code §§ 56-7-3712 , 3719
- Texas: Ins. Code §§ 1301.1351, 1352
- Washington: Rev. Code 48.43.830(1)(d)
- Washington D.C.: C. Code § 31-3875.02
- West Virginia: Va. Code § 9-5-32(b)(3)
- Wyoming: Stat. § 26-55-103
Prohibition on Prior Authorization Requirements for Mental and Behavioral Health
Multiple states are trying to reduce barriers for patients seeking treatment for substance use disorders, such as drug and alcohol addiction. As a result, a growing number of states are prohibiting prior authorization entities from requiring authorization before a patient can receive coverage for drugs used to treat opioid, alcohol or other substance use disorders. Notably, in addition to substance abuse disorder protections, Illinois provides protections for mental, emotional and nervous conditions.
States with substance abuse disorder protections include:
- Arkansas: Code Ann. § 23-99-1119
- Illinois: 215 Ill. Comp. Stat. 5/370c
- Tennessee: Code § 56-7-3710
- Washington: Rev. Code 48.43.761
- Wyoming: Stat. § 26-55-109
Deadlines to Review Prior Authorization Requests for Urgent and Non-urgent Services
Several states are imposing deadlines for prior authorization determinations that differentiate between urgent and non-urgent services. Although exact requirements vary, the general definition of urgent services is non-emergency services that could seriously jeopardize the life or health of the patient without expedited review. Urgent services in these states are required to be reviewed more quickly than non-urgent services, though the exact period across states is not consistent.
States differentiating between the urgency of services include:
- Arkansas: Code. Ann. § 23-99-1105 – 1107
- Illinois: 215 Ill. Comp. Stat. 200/25, 30
- Louisiana: Rev. Stat. Ann. S. 22 § 1260.44
- Mississippi: Code Ann. § 41-145-NEW-007, 008
- Montana: Code Ann. §§ 33-32-212, 215
- Rhode Island: I. Gen. Laws § 27-18.9-6
- Tennessee: Code §§ 56-7-3704(a)(2), 3705
- Washington: Rev. Code 48.43.830(1)(b)
- Washington D.C.: C. Code § 31-3875.03
- West Virginia: Va. Code § 9-5-32(d)
- Wyoming: Stat. §§ 26-55-107, 108
Gold Carding, Length of Prior Authorization Approval and Other Performance Programs
A common complaint is that prior authorization prevents providers from treating patients quickly while waiting for approval. Gold carding and similar programs allow providers whose requests are consistently approved to forego some prior authorization requests for a certain period of time. Many states have begun to implement gold carding or similar programs, such as allowing an approved prior authorization to be valid from anywhere between several months to a year.
States with performance incentives or length of approval protections include:
- Arkansas: Code. Ann. § 23-99-1120
- Illinois: 215 Ill. Comp. Stat. 200/60, 65
- Mississippi: Code Ann. § 41-145-NEW-013
- Montana: Code Ann. § 33-32-107
- Tennessee: Code § 56-7-3709
- Texas: Ins. Code § 4201.653
- Washington D.C.: C. Code § 31-3875.04
- West Virginia: Va. Code § 9-5-32(k)
- Wyoming: Stat. §§ 26-55-110, 112
Prior authorization is an important issue for patients and providers and states have taken notice and action. As more states continue to make progress in this area, it becomes increasingly likely that the federal government will become more involved, looking to create uniform regulations or requirements. Evaluating the similarities across states provides an indication of where uniform changes are most likely to be made.
Methodology
Each section above provides a general description of the requirement, identifies several states that have implemented such requirement, and links to the specific regulations. Although states are grouped together in each section, it should not be assumed that the regulations of each state are identical. Rather, the groupings indicate states that have addressed a specific area. Links to the text of each regulation have been provided to assist with conducting a full accounting of each state’s requirement in each area. Additionally, the omission of any state from this list does not indicate that it doesn’t have any of the above protections in place.
Feedback and questions
Contact the R1 Regulatory Compliance & Regulatory Affairs Team at RegulatoryCompliance@r1rcm.com with any questions.
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