State of Play: Prior Authorization

October 24, 2023

Over the next few months, we'll be sharing summaries of state action on the Association for Clinical Oncology's (ASCO) key policy priorities. This first article examines recent action on prior authorization.

With current political dynamics slowing federal prior authorization reform, states are increasingly considering legislation to streamline the burdensome insurance practice that delays care and increases clinician burnout. States have regulatory authority over fully insured health benefit plans (group and individual plans) and health benefit plans administered by the state (Medicaid and state employee benefit plans). These plans typically cover 20-40% of a state’s population. This means that state governments can impact plan design through either legislation or regulatory action, and during the past decade, a majority of states have been working toward such solutions to reform prior authorization.

During the 2023 state legislative session, ASCO tracked 51 prior authorization bills in 29 states. Many bills include language from the American Medical Association’s (AMA) model legislation and aim to improve insurer response times; prohibit retroactive denials of preauthorized care; allow adverse determinations only by a physician of the same specialty; require insurers to be transparent about approvals, denials, and wait times; and reduce volume through exemption programs—all policies ASCO supports.

Virginia and Washington enacted laws this year requiring insurers to establish and maintain electronic prior authorization systems. ASCO submitted letters in support of these bills jointly with the Virginia Association of Hematologists and Oncologists (VAHO) and the Washington State Medical Oncology Society (WSMOS), respectively. Electronic prior authorization has the potential to improve transparency and efficiency and reduce physician burden.

The Virginia and Washington laws follow a Texas “gold card” law enacted in 2021 that allows clinicians with a strong track record of prior authorization approvals to receive an exemption from payer-imposed prior authorization requirements, and clinicians started receiving exemptions in the autumn of 2022. The Texas law inspired similar efforts in Louisiana and Michigan, both of which enacted gold-carding bills in 2022, and a number other states that introduced prior authorization exemption bills which ultimately failed.

The 2022 legislative session also saw overhauls to the prior authorization process in Pennsylvania and Michigan based on the AMA model. Both new laws reduce the time insurers have to respond to prior authorization requests and require insurers to provide an online method for prior authorization submission. They also mandate that any adverse determination be made by a physician in the same specialty as the service provided. Lawmakers in Mississippi overwhelmingly also supported legislation to reform the prior authorization process, but Governor Tate Reeves vetoed the bill. The Mississippi Oncology Society (MOS) anticipates prior authorization reform becoming law during the 2024 legislative session.

ASCO is encouraged by the momentum behind prior authorization reform at the state level and will continue to monitor state prior authorization legislation via our state bill tracker and work with coalition partners to advance this advocacy priority. If you have any questions, please contact Sarah Lanford.

Bookmark ASCO in Action for updates on prior authorization reform, as well as news, advocacy, and analysis on cancer policy.