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 definitions for "chronic pain" and "urgent health care service," and expands the scope of services that do not require prior authorization to include 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 is designed to streamline access to necessary therapies and improve transparency in health care coverage decisions.

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