Health care coverage: prior authorizations.

Senator Becker's health care coverage proposal would eliminate prior authorization requirements for medical services that health plans and insurers consistently approve. Under the measure, if a health plan or insurer approves 90% or more of prior authorization requests for a specific service during a calendar year, that service would become exempt from prior authorization requirements for the following year, beginning April 1.

The bill establishes a standardized calculation method for determining approval rates. Plans and insurers must divide the total number of approved or modified requests, including those approved on appeal, by the total number of prior authorization decisions issued for each service during the previous calendar year. By March 15 annually, health plans and insurers must publish lists of exempt services on their websites and update all relevant policy documents to reflect these changes.

Prior authorization, as defined in the bill, encompasses any process requiring advance or concurrent review of medical necessity before services can be provided, including preauthorization, precertification, and prior approval requirements. The measure applies to both health care service plans regulated under the Knox-Keene Act and health insurers overseen by the Department of Insurance. Willful violations by health plans would constitute a crime under existing state law.