The bill introduces new regulations for prior authorization requirements related to rehabilitative and habilitative services in individual and group health insurance plans. It specifies that prior authorization will not be necessary for the first twelve visits of each new episode of care, which is defined as treatment for a new or recurring condition for which an insured has not been treated by the provider within the previous ninety days. After these initial visits, prior authorization cannot be required more frequently than every six visits or every thirty days, whichever time period is longer. For patients diagnosed with chronic pain, the bill states that prior authorization is not required for the first ninety days following the diagnosis, with the same frequency limitations applying thereafter.

Additionally, the bill mandates that health insurance plans must respond to prior authorization requests within twenty-four hours. If the plan requires more information to make a decision, it must notify the patient and provider within twenty-four hours of the initial request. If the plan fails to respond in a timely manner, the prior authorization is deemed to be approved. The bill also establishes a procedure for obtaining retroactive authorization for medically necessary services and ensures that denials of prior authorization are subject to the same appeal rights as other denials under existing regulations. Furthermore, the bill clarifies that it does not prevent insurance plans from conducting retrospective medical necessity reviews. The provisions of this act are set to take effect on January 1, 2026.