HB557 Summary

• Transfers regulation of utilization review (health insurance coverage determinations) from the Department of Public Health to the Department of Insurance, effective October 1, 2025.

• Requires coverage determinations be communicated within 72 hours for nonurgent care requests and 24 hours for urgent care requests, with automatic approval if determination is not communicated within required timeframe.

• Mandates all coverage determinations be reviewed by a licensed health care professional and prohibits artificial intelligence recommendations from overriding independent professional judgment.

• Requires health insurers to annually report the number of coverage denials to the Department of Insurance by category and reason, and make coverage criteria easily accessible to enrollees and providers in electronic format.

• Establishes a Department of Insurance ombudsman program to receive and investigate complaints about coverage denials, allows civil penalties up to $1,000 per violation or $10,000 for pattern violations, and permits enrollees to pursue civil damages against insurers.