An Act improving the health insurance prior authorization process
The bill focuses on making the health insurance prior authorization process more efficient. This is intended to reduce delays in receiving necessary medical care.
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H4616 — An Act improving the health insurance prior authorization process
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1Introduced
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2In Committee
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3Passed House
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4Passed Senate
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5To Executive
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6Enacted
This bill died with 194th General Court. It reached “Introduced” and never advanced before the session ended, so it can no longer move — a new version would have to be reintroduced in the current session.
This bill is no longer active — its legislative session has ended, so there is no live prognosis. It would have to be reintroduced in the current session to move again.
In plain language
This bill aims to improve the health insurance prior authorization process.
The bill focuses on making the health insurance prior authorization process more efficient. This is intended to reduce delays in receiving necessary medical care.
What this means for you
- Healthcare: Healthcare providers may experience fewer delays in getting approvals for treatments, leading to better patient care.
Summary
An Act improving the health insurance prior authorization process
Bill Text
- Full text Current
AI-generated reading aid from the bill's amendatory text — verify against the official bill.
The bill establishes new requirements for carriers related to prior authorization processes and data reporting.
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Chapter 26, Section 8
(a) All carriers licensed under chapters 175, 176A, 176B and 176G that provide medical or prescription drug benefits subject to utilization review consistent with section 12 of chapter 176O, shall make publicly available on their website a searchable list of all items, services and medications that require prior authorization. Prior authorization may not be requested for an item, service or medication that is not listed on the publicly available website.
Carriers must publicly post a list of items requiring prior authorization, enhancing transparency.
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Chapter 26, Section 8
(b) If a carrier contracts with another entity that manages or administers such benefits for the carrier, including a utilization review organization as defined in section 1 of said chapter 176O, that entity shall provide the carrier the information required under subsection (a) and that carrier shall post the required information publicly on the carrier’s website consistent with the requirements of subsection (a).
Contracted entities must also provide required information for the carrier to disclose publicly.
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Chapter 26, Section 8
(c) Carriers and utilization management organizations shall report annually, not later than July 1, to the division of insurance data regarding approval and denials of prior authorization requests, including request for drug benefits ...
Annual reporting of prior authorization data to the division of insurance is mandated.
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Chapter 32A, Section 4
Section 4C. The commission or an entity with which the commission contracts to provide or manage health insurance benefits, shall adopt utilization review criteria and conduct all utilization review activities under the criteria and in compliance with this section.
New section requires the commission to adopt and enforce utilization review criteria.
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Section 24B of chapter 175
A carrier ... shall be required to pay for health care services ordered by the treating health care provider if: (1) the services are a covered benefit under the insured’s health benefit plan; and (2) the services follow the carrier’s clinical review criteria...
Carriers must pay for covered services ordered by providers, protecting patient access.
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Section 12 of chapter 176O, subsection (a)
Utilization review criteria ... shall be applied consistently by a carrier or a utilization review organization and posted on a carrier or utilization review organization's public-facing website.→ The criteria shall be, to the maximum extent feasible, scientifically derived and evidence-based, and developed with the input of participating physicians ...Utilization review criteria must be evidence-based and derived with physician input.
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Section 12 of chapter 176O, subsection (a)
A carrier or utilization review organization shall not retrospectively deny authorization ... unless the approval was based upon fraudulent information material to the review.
Retrospective denial of authorization is restricted, favoring approved services.
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Section 12 of chapter 176O, subsection (b)
; provided, however, that if additional delay would result in significant risk to the enrollee’s health or well-being, a carrier or a utilization review organization shall respond not more than 24 hours following the receipt of all necessary information.
Timeframes for response to prior authorization requests are shortened, enhancing access.
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Section 12 of chapter 176O, subsections (g)-(i)
For an insured member who is stable on a treatment, service or course of medication ... a carrier or utilization review organization shall not restrict coverage ...
Coverage stability for ongoing treatments is mandated when members are in stable condition.
Sponsors
- Joint Committee on Financial Services · Primary
Sponsorship breakdown
Export CSV (upgrade) →1 sponsors · 0 co-sponsors · 203 not signed on
Sponsors (1)
- Joint Committee on Financial Services
Co-sponsors (0)
None.
Not signed on (203)
203 members have not signed on to this bill.
Show all 203 →"Not signed on" means a member has not sponsored or co-sponsored this bill — it does not imply opposition. Members flagged Voted No have a recorded No vote on this bill.
Subjects
Frequently asked questions
- What does H4616 do?
- An Act improving the health insurance prior authorization process
- Who sponsors H4616?
- H4616 is sponsored by Joint Committee on Financial Services.
- What is the current status of H4616?
- This bill died with 194th General Court. It reached “Introduced” and never advanced before the session ended, so it can no longer move — a new version would have to be reintroduced in the current session.
- Where can I track H4616?
- Track H4616 free on One Click Politics — get push/email alerts when it moves.
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Last checked for changes 4 months ago · updated continuously
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