(a) On or before July 1, 2026, the department shall issue instructions to health insurers to report all covered health care services subject to prior authorization, the percentage rate at which they are approved or modified by the health insurer or its delegated entity, and other statistics regarding prior authorization determinations as determined by the department. These instructions shall include a standard reporting template. (b) (1) On or before December 31, 2026, a health insurer shall report to the department, in accordance with the instructions issued pursuant to subdivision (a), the covered health care services subject to prior authorization, the percentage rate at which they are approved or modified by the health insurer or its delegated entity, data regarding requested or authorized duration, frequency, or level of care of the health care services, and other statistics regarding prior authorization determinations pursuant to subdivision (a). Data regarding modifications shall be reported separately from approvals in accordance with the instructions issued pursuant to subdivision (a). (2) If a health insurer delegates responsibility for decisions regarding prior authorization requests to another entity, the health insurer shall obtain information required to be reported by this section from each delegated entity and include that information in the health insurerâs report to the department. A health insurer shall require a delegated entity to comply with a request made pursuant to this paragraph. (c) (1) The department shall evaluate the reports received pursuant to this section and identify the health care services approved by health insurers or their delegated entities at a rate that meets or exceeds the threshold rate of 90 percent. For purposes of this paragraph, âapprovedâ may also include modified requests for the purpose of calculating the threshold rate as the department determines appropriate. (2) The department may consider all of the following factors when determining the appropriateness of removing prior authorization for a specific covered health care service, regardless of its approval percentage rate: (A) Utilization of a health care service in a manner inconsistent with current clinical practice guidelines published in peer-reviewed medical literature or United States Food and Drug Administration-approved indications, as applicable. (B) The potential for fraud, waste, and abuse. (C) The potential for cost savings from eliminating prior authorization, including out-of-pocket cost savings to the insured. (D) The potential for improvements in quality of care, health care outcomes, and timely access to care for insureds from eliminating prior authorization. (E) Other factors deemed appropriate by the department. (3) Before finalizing the list of covered health care services pursuant to this section, the department shall consult interested stakeholders. (4) On or before July 1, 2027, the department shall publish the list of covered health care services identified pursuant to paragraph (1). As of the date specified in subparagraph (A) of paragraph (5), a health insurer shall not impose prior authorization on a covered health care service included on the list published by the department pursuant to this paragraph. (5) The department shall issue instructions to health insurers regarding all of the following: (A) The date, which shall be no later than January 1, 2028, by which the health insurer and its delegated entities shall cease requiring prior authorization for the covered health care services identified pursuant to this subdivision. When issuing the date by which a health insurer and its delegated entities shall cease requiring prior authorization pursuant to this section, the department shall take into consideration the time necessary for insurers to update their policies. (B) Requirements for notifying providers of the change in prior authorization requirements. (C) The process by which a health
‹ Prev All California sections Next ›
Lexace provides legal information, not legal advice, and no attorney–client relationship is created. Statute text is provided for general information and may not reflect the most recent amendments; verify against the official state code.