States Leading on Prior Authorization Reform

April 9, 2024

State governments are increasingly considering legislation to streamline prior authorizations processes, which Association for Clinical Oncology (ASCO) members say delay patient care, adversely affect cancer care outcomes, and divert providers from patient care. States have regulatory authority over fully insured health benefit plans (group and individual plans) and health benefit plans administered by the state itself (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 to leverage that impact to reform prior authorization.

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.

In February, a major prior authorization reform bill became law in Mississippi following nearly unanimous approval from state lawmakers. ASCO and the Mississippi Oncology Society (MOS) worked with members of the medical community to support reintroduction and passage of the bill after it was vetoed by Governor Tate Reeves in 2023, despite overwhelming support from lawmakers.

“MOS made prior authorization the top issue to tackle over the last two legislative sessions. In 2023, we were able to pass a bill, but the Governor vetoed it,” said MOS Executive Director Angela Ladner. “We continued to work with our Department of Insurance and other medical specialty organizations to prepare for 2024. We truly appreciate the support of ASCO and thank them for their willingness to send letters to the decisionmakers to get this legislation over the line.”

Following the success in Mississippi, Wyoming Governor Mark Gordon signed HB 14 into law in early March after it unanimously passed both chambers of the state Legislature. ASCO and the Wyoming State Oncology (WSOS) Society supported the bill.

Both laws shorten determination timelines, extend the validity of prior authorization for treatments for chronic conditions—including chemotherapy—to 12 months, and improve the review and appeals process by requiring that adverse determinations are made by a physician who practices in the same specialty as the prescribing physician. Both laws will also increase transparency by requiring insurers to clearly post utilization management practices and prior authorization statistics online. The Wyoming law also offers providers who have a 90% or higher prior authorization approval rate over a 12-month period an exemption from prior authorization requirements.

These 2024 laws come after hard-fought wins from the 2023 session in New Jersey and Washington, D.C.—both of which passed laws overhauling prior authorization. Those laws were the result of multi-year efforts involving the advocacy of both physicians and their patients.

Passage of these four laws is encouraging, but they reflect just the tip of the iceberg at the state level. Interest in state-level prior authorization reform has steadily increased in recent years. Since the 2024 state legislative sessions began in January, lawmakers in 29 states have introduced legislation designed to improve some aspect of prior authorization—from shortening determination timelines, to establishing electronic systems, to exploring exemptions. As of mid-March, ASCO has partnered with 15 state affiliates to voice support for active legislation.

ASCO is encouraged by the momentum behind prior authorization reform at the state level and will continue to monitor state prior authorization legislation via the Association’s state bill tracker and work with coalition partners to advance this advocacy priority. If you have any questions about these efforts, please contact ASCO’s Associate Director, State Advocacy Sarah Lanford

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