Understanding the New Laws on Prior Authorization: What It Means for You and Your Healthcare
If you’ve ever been told by your doctor that you need a certain medication or procedure, only to find out your insurance company requires “prior authorization,” you’re not alone. Prior authorization is a process used by insurance companies to determine whether they will cover a prescribed treatment, test, or medication. While it was originally designed to control costs and ensure medical necessity, it’s become a major source of frustration and delay for patients and doctors alike.
Prior authorization can mean long waits for approval, forcing patients to delay or even skip necessary care. In some cases, these delays can lead to worse health outcomes, increased stress, and unnecessary complications. This is especially challenging for those with chronic illnesses who need consistent care, medication, or treatment.
WHAT’S CHANGING NOW?
This year, nearly a dozen states, including Vermont, Minnesota, Wyoming, Colorado, Illinois, Mississippi, Maine, Maryland, Oklahoma, and Virginia, have passed new laws aimed at reforming the prior authorization process. These laws, which have been fiercely advocated for by state medical societies and the American Medical Association (AMA), are designed to make healthcare more accessible and reduce the unnecessary burden on patients and providers.
KEY CHANGES TO KNOW ABOUT
Key Changes You Should Know About:
Reducing Delays in Care: Many of these new laws aim to cut down on the number of procedures and treatments that require prior authorization. This helps reduce the time patients spend waiting for approvals, which can often be days or even weeks.
Improving Transparency: Some states are now requiring insurance companies to be more transparent about their prior authorization processes. This means clearer information on which medications and procedures need prior approval and why. It also includes more public reporting on how often prior authorization requests are approved or denied.
Longer Validity for Chronic Conditions: For people with chronic illnesses, like diabetes or rheumatoid arthritis, some states are ensuring that prior authorizations remain valid for longer periods. In Minnesota, for instance, authorizations for treatments of chronic conditions won’t expire as long as the treatment plan stays the same. This means fewer interruptions in care and less hassle for patients and their doctors.
Standardizing Processes Across Insurers: Some new laws require that a patient’s new insurer honors prior authorizations from the patient’s previous health plan for a certain period (like 90 days). This helps prevent disruptions when a patient changes insurers.
WHY THESE REFORMS MATTER
Over 90% of doctors report that prior authorization often leads to care delays, according to the AMA’s annual survey of physicians. These delays can mean serious health consequences, especially for those dealing with urgent or chronic health issues. By streamlining the process and reducing unnecessary barriers, these new laws aim to improve access to timely care, prevent avoidable health complications, and reduce the administrative burden on healthcare providers.
Examples of State Action:
Vermont: Now requires that patients with chronic conditions do not need repeated prior authorizations for ongoing, unchanged treatments. Insurers must respond to urgent authorization requests within 24 hours, and new insurers must accept the previous health plan’s authorizations for up to 90 days.
Minnesota: Has strengthened its laws to prevent prior authorization for non-medication parts of cancer and mental health care. For chronic conditions, authorizations do not expire if the treatment remains unchanged, which will be effective starting in January 2026.
Wyoming: Introduced a “gold card” program that exempts physicians from prior authorization requirements if they consistently receive approvals for certain procedures or medications. This state also requires quicker responses from insurers, such as within 72 hours for urgent requests.
WHAT’S NEXT?
These state-level wins are part of a broader movement to reduce the burdens of prior authorization. More states, such as Massachusetts, are considering similar laws. At the national level, the AMA is also supporting the Improving Seniors’ Timely Access to Care Act of 2024, a federal bill that aims to reform prior authorization practices within Medicare Advantage plans.
HOW THIS IMPACTS YOU
These changes could mean less waiting time, fewer repeated approvals for ongoing treatments, and more straightforward access to the care you need. As more states take action, and with potential federal reforms on the horizon, these steps represent meaningful progress in reducing the barriers created by prior authorization.
ACTIONS YOU CAN TAKE
Stay Informed: Follow updates on these important policy changes by following us on Instagram, where we share the latest updates with our community as quickly as possible!
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Contact Your Legislators: Reach out to your state and federal representatives to express your support for reforms that reduce prior authorization burdens. Your voice can help push for more changes in your state or even at the national level.
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Share Your Story: If you’ve experienced delays or challenges due to prior authorization, share your experience with Rise & Rally. Real stories from people impacted by these issues help build awareness and drive change.
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Join the Movement: Get involved with Rise & Rally by signing up for our newsletter, joining our events, or donating to support our advocacy efforts. Together, we can work towards a more equitable healthcare system for all.
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Legal Disclaimer
The information provided in this blog post is for educational and informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment, or legal advice. Always seek the advice of your physician or other qualified health provider, as well as a lawyer or representative, with any questions you may have regarding a medical condition, treatment plan, or legal concerns. The views and opinions expressed in this blog post are those of the author(s) and do not necessarily reflect the official policy or position of Rise & Rally. Any action you take upon the information presented in this blog post is strictly at your own risk. Rise & Rally assumes no responsibility for errors or omissions in the content of this blog post or for any consequences resulting from the use of the information provided.