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 and for any nonpharmacologic pain management for individuals with chronic pain for the first 90 days of treatment, with a limit of twice per week per service. It also mandates that health plans must issue decisions on reauthorization requests within three business days, and if they fail to do so, prior authorization is automatically granted. 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 services.

Furthermore, the bill introduces new definitions, such as "urgent health care service," and expands the scope of services that do not require prior authorization, including any covered service incidental to a surgical service deemed medically necessary by a healthcare provider. It also establishes requirements for utilization review organizations to provide medical evidence-based policy information to healthcare providers and prohibits the use of claims data in developing coverage algorithms. The bill's provisions are applicable to private health benefit plans and self-insured governmental health plans, reflecting a significant shift in how prior authorization is managed for essential health services.

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