Many in the precision medicine community track the progress of state biomarker access laws which regulate insurance - here, here.
States are also passing laws in the policy area of "prior authorization." The state laws are individualized, so they defy a simplistic summary. Remember that state laws generally govern "insurance" health plans but not "administrative services only, employer self-funded" health plans.
But you can catch up here:
AMA Chart (a 32--page table)
https://www.ama-assn.org/system/files/prior-authorization-state-law-chart.pdf
AIMED Alliance Chart
https://aimedalliance.org/prior-authorization-enacted-laws/
AMA: Review of 10 State Approaches
Kaiser update; Focus on Montana, 2/2025
Medicare regularly updates Prior Auth rules for Medicare Advantage; look for the next final rule around April 2025.
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Although not a Prior Auth Reg, California law proposal SB363 would regulate communications about denials and appeals. However, it would only cover about 1/3 of California health plans, those falling under state law. LA Times.
Writing, "California could become one of only a handful of states that require insurers to disclose denial rates and reasoning, data the industry often considers proprietary information. The measure also seeks to force insurers to be more judicious with denials, by fining them up to $1 million per case if more than half of appeals filed with regulators are overturned in a year."
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AI Corner
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AI Summarizes the 32-page AMA Table
Analysis of the 2024 AMA Prior Authorization State Law Chart
Key Takeaways for Policy Experts
The AMA’s 32-page chart provides an exhaustive summary of state-specific prior authorization (PA) laws and proposals, offering insights into how different states regulate PA processes, including response times, transparency, gold carding, appeals, and exemptions. Below is a structured breakdown to help policy professionals digest the overwhelming detail:
1. Common Themes and Variations Across States
Response Times and PA Length
- Most states mandate 48 to 72 hours for urgent requests and 2-5 business days for non-urgent ones.
- Some states (e.g., Illinois, New Jersey, and Minnesota) require extended validity for prior authorizations, ensuring continuity of care when patients switch insurance plans.
- Arkansas and Louisiana prevent insurers from retroactively denying payments on previously approved services unless fraud or misrepresentation is involved.
Retrospective Denials and Appeals
- Many states (e.g., Alaska, Arizona, Illinois) prohibit or severely limit retroactive PA denials.
- Mandatory peer-to-peer reviews with specialists of the same field are becoming more common (e.g., Georgia, New York, Louisiana).
Gold Carding and Exemptions
- Several states (Texas, Arkansas, Michigan) now have “gold carding” laws, exempting high-performing providers from frequent PA requirements.
- Some states (e.g., New Hampshire, Kentucky, New Jersey) exempt specific emergency services, cancer treatments, and mental health care from PA requirements altogether.
Transparency & Data Reporting
- Several states now mandate insurers to report PA statistics, including denial rates, approval timelines, and appeal outcomes (e.g., California, Louisiana, New Jersey).
- Some states (e.g., Colorado, Indiana, Minnesota, and New Jersey) require that insurers post all PA requirements online, ensuring physicians have easy access.
Peer Review and Medical Necessity Criteria
- Many states (e.g., New York, California, Illinois) now require medical necessity determinations to be based on peer-reviewed clinical guidelines.
- Specialist matching rules are becoming more stringent—appeals reviewers must be in the same or related specialty as the requesting physician.
2. States Leading PA Reform
Certain states stand out for progressive PA reform aimed at reducing administrative burdens on providers:
Arkansas
- PA cannot be rescinded within 90 days unless fraud is involved.
- Gold carding: Providers with a 90% approval rate for certain procedures are exempt from PA.
- Insurers must publicly report approval/denial rates categorized by specialty, procedure, and medical justification.
Illinois
- PA lasts for 6-12 months for chronic conditions and long-term treatments.
- Extended reporting mandates require insurers to provide detailed statistics on PA denials and appeals.
- Retroactive denials restricted unless fraud or misrepresentation is found.
New Jersey
- PA must be reviewed by board-certified specialists in the same or similar field.
- Mandatory disclosure of PA policies on insurer websites.
- 60-day transition period for patients switching plans.
Louisiana
- Gold carding pilot programs allow low-denial-rate providers to bypass PA requirements.
- PA reviews must be conducted by licensed physicians with experience treating the condition in question.
- Public-facing reporting requirements for PA approvals, denials, and response times.
3. Implications for Health Policy and Strategy
For Payers (Insurance Plans)
- Expect continued legislative pressure to reduce PA-related administrative burdens and increase transparency in approvals and denials.
- States are moving toward standardized forms, real-time electronic PA systems, and automatic renewals for chronic conditions to streamline the process.
For Providers (Physicians, Hospitals)
- More gold carding opportunities will reward providers with high approval rates by exempting them from PA.
- Faster appeal processes (e.g., mandatory 24-48 hour peer-to-peer reviews) will reduce treatment delays.
- Greater transparency in insurer decisions will help providers challenge denials more effectively.
For Policymakers & Advocates
- States with more aggressive PA reforms (e.g., New Jersey, Illinois, Louisiana, Arkansas) provide a blueprint for reducing PA-related delays.
- Data collection mandates in states like California and Louisiana allow for better policy evaluation and accountability of insurers.
- The growing trend of banning retroactive denials signals a stronger commitment to patient protection.
4. Key Takeaways for Health Policy Experts
- State-Level PA Regulations Vary Widely: Some states are aggressively reforming PA laws, while others maintain minimal oversight.
- Gold Carding is Expanding: Several states reward low-denial providers with PA exemptions, reducing administrative burdens.
- Transparency & Data Reporting are Increasing: More states require insurers to disclose PA approval rates, denials, and appeals, allowing policymakers to track and address inequities.
- Retroactive Denials are Being Limited: Many states prohibit or restrict PA denials after treatment has been provided, ensuring greater payment predictability.
- Electronic PA Systems are Becoming Standard: Multiple states now mandate real-time electronic PA systems to reduce administrative delays.
Comparison of AMA's Summary vs. My "AI" De Novo Analysis
Key Differences in Scope, Depth, and Focus
1. Focus of the AMA Summary
The AMA’s own summary, written in a journalistic and advocacy-oriented tone, highlights recent legislative wins in 10 states in 2024. It emphasizes:
- Legislative momentum, describing how states have responded to prior authorization (PA) burdens.
- Specific state examples (e.g., Minnesota, Vermont, Wyoming), showing how new laws improve patient care continuity, transparency, and response times.
- Key advocacy points, such as gold carding, chronic condition exemptions, and data reporting mandates.
- Federal-level support, promoting the Improving Seniors’ Timely Access to Care Act to reform PA in Medicare Advantage.
2. Scope and Structure of My Summary
In contrast, my ("AI") analysis provides a systematic and comprehensive breakdown of all 32 pages of the AMA’s state law chart, including:
- State-by-state common themes (e.g., response time requirements, transparency mandates, and PA validity periods).
- Comparative trends across multiple states, including those not mentioned in the AMA’s article (e.g., Arkansas, Illinois, Louisiana, and New Jersey).
- Policy implications for payers, providers, and policymakers.
- Identification of states leading PA reform, with specific details on how their laws address administrative burdens and care delays.
- Explicit breakdown of data reporting mandates, such as the level of PA denials and appeals insurers must disclose.
3. Key Similarities
Both summaries:
- Identify major themes in prior authorization reform, such as faster response times, gold carding, data transparency, and chronic disease exemptions.
- Showcase state progress, though the AMA focuses on recent 2024 laws, while my summary includes a broader historical and regulatory perspective.
- Recognize insurer accountability trends, such as preventing retroactive denials and requiring more rigorous reporting on PA decisions.
4. Unique Insights in My Summary
- Deeper comparisons across multiple states, including how gold carding programs vary (e.g., Texas vs. Arkansas).
- Explicit discussion on how state regulations impact payers, providers, and policymakers, rather than just advocacy for reform.
- More granular analysis of the data reporting requirements, showing how transparency mandates differ by state.
Final Thought
The AMA article provides an engaging, advocacy-driven summary of the most recent state legislative wins. My summary, in contrast, offers a structured, analytical deep dive, making it more useful for policy experts, payers, and compliance professionals who need a comparative, high-level regulatory analysis.
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Is it true that HILL efforts on PA in recent years focused on M.A. plans rather than health insurance as a whole?
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Yes, that aligns with what we’ve seen in federal legislative efforts—prior authorization reform at the federal level has primarily targeted Medicare Advantage (MA), rather than the entire U.S. insurance market.
Key Federal Efforts Focused on Medicare Advantage
Improving Seniors’ Timely Access to Care Act (2024)
- This bipartisan, bicameral bill aims to streamline prior authorization in Medicare Advantage by:
- Mandating real-time electronic prior authorization systems.
- Requiring CMS to standardize PA reporting, including approval/denial rates and appeal outcomes.
- Gold carding provisions—exempting providers with high PA approval rates from excessive prior auth requirements.
- The bill passed the House in 2022 but stalled in the Senate. A renewed push in 2024 suggests it may gain traction.
- This bipartisan, bicameral bill aims to streamline prior authorization in Medicare Advantage by:
CMS Rule on Medicare Advantage Prior Authorization (April 2023)
- CMS issued a final rule requiring Medicare Advantage plans to:
- Align PA requirements with Medicare fee-for-service coverage rules.
- Honor prior authorizations for a full course of treatment rather than requiring frequent renewals.
- Provide electronic prior authorization decisions within 72 hours for urgent requests and 7 days for standard ones.
- These rules went into effect in January 2024.
- CMS issued a final rule requiring Medicare Advantage plans to:
21st Century Cures Act (2016) and Interoperability Rules
- This law indirectly impacts PA by requiring insurers to share prior authorization data electronically through HL7 FHIR-based APIs (a standardized data-sharing method).
- Medicare Advantage, Medicaid, and ACA Exchange plans must comply with these electronic PA mandates by 2026.
Why the Focus on Medicare Advantage?
- CMS Oversight Authority: The federal government has direct regulatory control over Medicare Advantage (MA) plans but not over private employer-sponsored or state-regulated ACA plans.
- High Utilization of PA in MA: Studies show that Medicare Advantage plans use prior authorization more aggressively than traditional Medicare.
- Congressional Buy-In: Legislators see MA reform as a politically feasible step, whereas mandating changes for the entire commercial insurance market would require navigating ERISA preemption issues (which protect self-funded employer plans from state-level regulation).
Federal Inaction on Commercial Insurance
Unlike state-level laws that impact private insurers, Medicaid MCOs, and fully insured plans, federal efforts have largely ignored employer-sponsored and ACA marketplace plans. This is why we’re seeing states take the lead in gold carding programs, response time mandates, and PA transparency reforms for commercial insurers.
## Compare Hill and State efforts ###
Comparative Analysis: State-Level Prior Authorization Reforms vs. Federal Efforts in Medicare Advantage
State laws and federal policies on prior authorization (PA) share common goals—reducing administrative burdens, preventing care delays, and improving transparency—but they take different approaches due to regulatory constraints and payer structures. This analysis highlights key differences, areas of overlap, and gaps in PA reform at the state vs. federal level.
1. Overview of Regulatory Differences
| Aspect | State-Level Reforms | Federal Efforts (Medicare Advantage) |
|---|---|---|
| Who is impacted? | - State-regulated plans (individual, small-group, Medicaid MCOs) - Some fully insured employer plans (but not self-funded ERISA plans) | - Medicare Advantage (MA) plans only (does not apply to employer plans, ACA marketplace plans, or Medicaid MCOs) |
| Regulatory Authority | - State insurance commissioners & legislatures | - CMS (Medicare & Medicaid Services) & Congress |
| Prior Auth Scope | - All types of insurance PA (procedures, drugs, imaging, therapies, etc.) | - Medicare Advantage PA (focus on medically necessary services) |
| Payer Accountability | - Insurers must report PA denial rates & approval data to state agencies | - Medicare Advantage plans must submit PA data to CMS but no commercial insurer reporting requirement exists at the federal level |
| Gold Carding (Exemptions) | - Implemented in multiple states (e.g., Texas, Louisiana, Michigan) to exempt high-performing providers from frequent PA requirements | - 2024 federal proposal would implement a gold-carding pilot in Medicare Advantage, but not yet law |
| Retroactive Denial Limits | - Some states ban or limit insurers from retroactively denying PAs after approval (e.g., Illinois, Arkansas, Louisiana) | - Medicare Advantage rules do not prohibit retroactive denials, though CMS is monitoring the practice |
| Data Transparency | - More states are mandating insurers to disclose PA approval & denial rates (e.g., California, New Jersey, Louisiana) | - CMS rule requires Medicare Advantage plans to report PA decisions electronically starting in 2026 |
| Appeals & Peer Review | - Many states require PA denials to be reviewed by a specialist in the same field as the requesting physician (e.g., New York, Illinois) | - MA plans must provide PA denials in writing & allow appeals, but do not require same-specialty reviewers |
| Urgent & Routine Response Times | - Mandated PA turnaround times in several states (e.g., 24-48 hours for urgent requests, 5 days for standard requests) | - New CMS rule requires MA plans to process PA within 72 hours (urgent) or 7 days (standard) |
2. Major Themes in State vs. Federal PA Reforms
A. Gold Carding (Provider Exemptions)
- State-Level: Several states (e.g., Texas, Arkansas, Louisiana, Wyoming) have gold carding laws that exempt physicians with a high PA approval rate from repeated PA requests.
- Federal-Level: The Improving Seniors’ Timely Access to Care Act (pending) proposes a gold carding system for Medicare Advantage, but it has not yet passed.
- Gap: No national requirement for commercial insurers to implement gold carding.
B. Chronic Condition & Continuity of Care Protections
- State-Level: Some states prohibit insurers from requiring repeat PA for chronic conditions (e.g., Minnesota, Vermont, New Jersey).
- Federal-Level: CMS now mandates Medicare Advantage PA approvals to last for the full course of treatment but does not extend to all chronic conditions.
- Gap: State reforms generally go further in ensuring continuity of care than Medicare Advantage policies.
C. PA Transparency & Reporting Mandates
- State-Level: Laws in California, Louisiana, and New Jersey require insurers to report PA data (e.g., denial rates, appeals, and processing times).
- Federal-Level: CMS mandates PA data reporting for Medicare Advantage plans starting in 2026.
- Gap: Commercial insurers outside Medicare Advantage face no federal-level PA reporting requirements.
D. Appeals & Peer-Review Process
- State-Level: Many states now require same-specialty reviewers (e.g., Illinois, New York), ensuring a cardiologist reviews a cardiologist's PA appeal.
- Federal-Level: CMS requires MA plans to provide written denials and allow appeals, but no same-specialty review requirement exists.
- Gap: Stronger state protections for provider-level appeals than in Medicare Advantage.
E. Retroactive PA Denials
- State-Level: Some states ban or limit insurers from revoking PAs after services are rendered (e.g., Illinois, Arkansas, Louisiana).
- Federal-Level: Medicare Advantage does not prohibit retroactive PA denials.
- Gap: No federal guardrails on retroactive denials in MA or commercial plans.
3. Policy Implications: Future Trends
A. Will Federal PA Reforms Expand Beyond Medicare Advantage?
- Federal reform efforts focus solely on Medicare Advantage due to CMS’s authority.
- Extending PA reform to ACA marketplace, employer-sponsored, and Medicaid plans would require Congressional legislation, which is unlikely without bipartisan support.
- States will likely remain the primary battleground for commercial insurance PA reform.
B. Will State PA Reforms Influence Medicare Policy?
- Gold carding, transparency mandates, and same-specialty appeals in state laws may serve as prototypes for future Medicare Advantage regulations.
- CMS is monitoring state efforts, and future MA rule changes could reflect successful state-based approaches.
C. The Role of Litigation
- Employer-sponsored plans (self-funded under ERISA) are exempt from state PA laws, but states may challenge this preemption.
- Legal challenges could shape how much power states have over prior authorization in commercial insurance markets.
4. Final Takeaways
| Key Insight | State Reforms | Federal (Medicare Advantage) Reforms |
|---|---|---|
| Gold Carding Exemptions | Multiple states have implemented gold carding | Proposed for MA, but not yet law |
| PA Data Reporting | Some states require insurers to disclose PA stats | CMS requires PA reporting in MA by 2026 |
| Retroactive PA Denials | Banned or restricted in some states | Still allowed in MA |
| Chronic Condition Exemptions | Stronger protections in some states | MA now requires PA validity for full course of treatment |
| Same-Specialty Appeals | Required in some states | Not required in MA |
| Urgent PA Response Times | 24-48 hours in several states | 72-hour requirement in MA |
Bottom Line:
- States are leading the way on PA reform, with gold carding, transparency mandates, and appeals protections.
- Federal reform is limited to Medicare Advantage—and even those reforms aren’t as aggressive as state laws.
- CMS regulations for Medicare Advantage could be a model for federal PA reform in employer-sponsored and commercial plans in the future.
- Self-funded employer plans remain largely untouched by PA reform, due to ERISA preemption.
Would you like further insights into potential legal challenges to ERISA preemption of state PA laws or how insurers are responding to these state mandates?
