HF3578 Summary

• Health carriers must not retrospectively deny coverage for services that did not require prior authorization unless fraud or misinformation occurred, and cannot deny coverage for services already received solely due to lack of prior authorization if the service would have been covered with authorization.

• Prior authorization is prohibited for emergency services, substance use disorder medications, generic and equivalent drugs, outpatient mental health and substance use disorder treatment, certain cancer treatments, preventive services, pediatric hospice services, and neonatal abstinence programs.

• Utilization review organizations must establish an automated prior authorization application programming interface for in-network providers by January 1, 2025, and implement a percentile-based exemption process (70th percentile) for providers with high authorization rates by January 1, 2026.

• Authorizations for chronic health conditions lasting longer than one year do not expire unless treatment standards change, and services under value-based contracts cannot require prior authorization.

• Each utilization review organization must report annual prior authorization data to the commissioner of commerce by September 1, and the commissioner must analyze utilization management tools and report recommendations to the legislature by January 15, 2026.