Part 4: How Does the Prior Authorization Reform Act Address the Duration of a Prior Authorization Approval?

July 16, 2021

During the Spring Legislative Session in Springfield, the General Assembly unanimously approved the Prior Authorization Reform Act (House Bill 711), which is now on Governor Pritzker’s desk. This top ISMS initiative requires that substantive and important changes be made to insurer prior authorization (PA) practices.

Physician Advocate is taking a deep dive into the various components of this important legislation. This week’s focus is the duration of a prior authorization approval.

The current problem: Prior authorization requests are required for certain services or medications, and depending on how long a patient’s medical condition lasts, the physician may need to submit multiple prior authorization requests for the same service or drug, even if there have been no changes in the patient’s medical status. The need to renew prior authorization approvals for patients who are stable on a prescribed treatment can cause significant disruptions in patient care that may result in shorter recovery times or worse patient outcomes overall.

How House Bill 711 helps: It sets specific time frames for how long a prior authorization approval would be valid for acute and chronic conditions, including required time frames if a patient changes state-regulated health insurance plans in the middle of treatment.

The Prior Authorization Reform Act would require state-regulated health insurance companies to follow these time frames:

• Acute conditions
  Prior authorization approvals for acute conditions would be valid for the lesser of six months, the length of treatment as determined by the patient’s healthcare professional, or until the renewal of the plan.

• Chronic or long-term conditions
  Prior authorization approvals for chronic or long-term conditions would be valid for the lesser of 12 months or length of treatment as determined by the patient’s healthcare professional.

• Continuity of care when a patient switches to a new insurer
  State-regulated health insurers would be required to honor existing prior authorization approvals for at least the initial 90 days of an enrollee’s coverage with a new health insurer.

Did you miss previous installments of our series “Unpacking Prior Authorization Reform”?

• Part 1: How Would the Prior Authorization Reform Act Increase Transparency?
• Part 2: How Does the Prior Authorization Reform Act Address Timelines?
• Part 3: How Does the Prior Authorization Reform Act Address Adverse Determinations?

If you have questions, please contact ISMS Senior Vice President of State Legislative Affairs Erin O'Brien by email.