Assembly Bill 368 aims to amend existing laws regarding prior authorization for various health care services, specifically physical therapy, occupational therapy, speech therapy, and chiropractic services. The bill prohibits health plans from requiring prior authorization for the first 12 visits of these therapies, with no duration of care limitations, and for any nonpharmacologic management of chronic pain for the first 90 days of treatment, limited to twice per week. It also mandates that health plans must make decisions on reauthorization requests within three business days, with automatic approval if no decision is made in that timeframe. Additionally, the bill requires health plans to provide clear explanations for any denials of coverage and to ensure that copayment and coinsurance amounts for these services are equivalent to those for primary care.

Furthermore, the bill introduces new definitions, such as "urgent health care service," and outlines the responsibilities of utilization review organizations in providing necessary information to health care providers. It prohibits these organizations from using claims data to develop coverage algorithms. The bill also expands the current law to include that health plans cannot require prior authorization for any covered services that are incidental to a covered surgical service deemed medically necessary by a healthcare provider, as well as for any urgent health care services. Overall, the bill seeks to streamline access to essential therapies and improve transparency in health care coverage decisions.

Statutes affected:
Bill Text: 632.85(title), 632.85, 632.85(3)