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DRAFT ONLY
NOT APPROVED FOR
INTRODUCTION
HOUSE BILL NO.
Prior authorization regulations.
Sponsored by: Joint Labor, Health & Social Services Interim Committee
A BILL
for
1 AN ACT relating to the insurance code; requiring health
2 insurers and contracted utilization review entities to
3 follow prior authorization regulations as specified;
4 providing legislative findings; providing definitions;
5 requiring rulemaking; making conforming amendments; and
6 providing for effective dates.
7
8 Be It Enacted by the Legislature of the State of Wyoming:
9
10 Section 1. W.S. 26-55-101 through 26-55-113 are
11 created to read:
12
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1 CHAPTER 55 – ENSURING TRANSPARENCY IN PRIOR AUTHORIZATION
2 ACT
3
4 ***********************************************************
5 *******************
6 STAFF COMMENT
7
8 For the Committee's information, the Centers for Medicare
9 and Medicaid Services is in the process of creating a new
10 rule regarding prior authorization. The rule should become
11 effective January 1, 2026. It is unclear at this time what
12 the new rule will entail.
13
14 ***********************************************************
15 *******************
16
17 26-55-101. Short title.
18
19 This act shall be known and may be cited as the "Ensuring
20 Transparency in Prior Authorization Act."
21
22 26-55-102. Legislative findings.
23
24 (a) The legislature finds and declares that:
25
26 (i) The patient-physician relationship is
27 paramount and should not be subject to third party
28 intrusion;
29
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1 (ii) Prior authorization programs place cost
2 savings ahead of optimal patient care;
3
4 (iii) Prior authorization programs shall not be
5 permitted to hinder patient care or intrude on the practice
6 of medicine.
7
8 26-55-103. Definitions.
9
10 (a) As used in this act:
11
12 (i) "Adverse determination" means a decision by
13 a health insurer or contracted utilization review entity to
14 deny, reduce or terminate benefit coverage for health care
15 services furnished or proposed to be furnished because the
16 services are not medically necessary or are experimental or
17 investigational. A decision to deny, reduce or terminate
18 health care services that are not covered for reasons other
19 than their medical necessity or experimental or
20 investigational nature is not an "adverse determination"
21 for purposes of this act;
22
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1 (ii) "Authorization" means an approved prior
2 authorization request;
3
4 (iii) "Chronic or long term care condition"
5 means a condition that lasts not less than three (3) months
6 and requires ongoing medical attention, limits activities
7 of daily living or both;
8
9 (iv) "Enrollee" means a person eligible to
10 receive health care benefits by a health insurer pursuant
11 to a health plan or other health insurance coverage. The
12 term "enrollee" includes an enrollee's legally authorized
13 representative;
14
15 (v) "Health care service" means health care
16 procedures, treatments or services provided by a licensed
17 health care facility or provided by a licensed physician.
18 The term "health care service" also includes the provision
19 of pharmaceutical products or services and durable medical
20 equipment.
21
22 (vi) "Health insurer or contracted utilization
23 review entity" means a person or entity that performs prior
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1 authorization for one (1) or more of the following
2 entities:
3
4 (A) An employer with employees in Wyoming
5 who are covered under a health benefit plan, disability
6 insurance as defined by W.S. 26-5-103 or a health insurance
7 policy;
8
9 (B) An insurer that writes health insurance
10 policies;
11
12 (C) A preferred provider organization or
13 health maintenance organization.
14
15 (vii) "Medically necessary health care services"
16 means health care services that a reasonable physician
17 would provide to a patient for the purpose of preventing,
18 diagnosing or treating an illness, injury, disease or its
19 symptoms in a manner that is:
20
21 (A) In accordance with generally accepted
22 standards of medical practice;
23
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1 (B) Clinically appropriate in terms of
2 type, frequency, extent, site and duration;
3
4 (C) Not primarily for the economic benefit
5 of the health plans and purchasers or for the convenience
6 of the patient, treating physician or other health care
7 provider.
8
9 ***********************************************************
10 *******************
11 STAFF COMMENT
12
13 The Committee may wish to consider using the definition of
14 "medical necessity" under W.S. 26-40-102(a)(iii) to avoid
15 confusion between the two definitions. It reads:
16
17 (iii) "Medical necessity" means:
18
19 (A) A medical service, procedure or supply provided
20 for the purpose of preventing, diagnosing or treating an
21 illness, injury, disease or symptom and is a service,
22 procedure or supply that:
23
24 (I) Is medically appropriate for the symptoms,
25 diagnosis or treatment of the condition, illness, disease
26 or injury;
27
28 (II) Provides for the diagnosis, direct care and
29 treatment of the patient's condition, illness, disease or
30 injury;
31
32 (III) Is in accordance with professional,
33 evidence based medicine and recognized standards of good
34 medical practice and care; and
35
36 (IV) Is not primarily for the convenience of the
37 patient, physician or other health care provider.
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1
2 (B) A medical service, procedure or supply shall not
3 be excluded from being a medical necessity under this
4 section solely because the service, procedure or supply is
5 not in common use if the safety and effectiveness of the
6 service, procedure or supply is supported by:
7
8 (I) Peer reviewed medical literature, including
9 literature relating to therapies reviewed and approved by a
10 qualified institutional review board, biomedical compendia
11 and other medical literature that meet the criteria of the
12 National Institutes of Health's Library of Medicine for
13 indexing in Index Medicus (Medline) and Elsevier Science
14 Ltd. for indexing in Excerpta Medicus (EMBASE); or
15
16 (II) Medical journals recognized by the
17 Secretary of Health and Human Services under Section
18 1861(t)(2) of the federal Social Security Act.
19
20 ***********************************************************
21 *******************
22
23 (viii) "Medications for opioid use disorder"
24 means the use of medications to provide a comprehensive
25 approach to the treatment of opioid use disorder. Food and
26 drug administration-approved medications used to treat
27 opioid addiction include methadone, buprenorphine, alone or
28 in combination with naloxone, and extended-release
29 injectable naltrexone;
30
31 (ix) "Prior authorization" means the process by
32 which health insurers or contracted utilization review
33 entities determine the medical necessity or medical
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1 appropriateness of otherwise covered health care services
2 prior to rendering such health care services. "Prior
3 authorization" also includes any health insurer or
4 contracted utilization review entity's requirement that an
5 enrollee or health care provider notify the health insurer
6 or contracted utilization review entity prior to providing
7 a health care service;
8
9 (x) "Urgent health care service" means a health
10 care service for which the application of the time periods
11 for making a non-expedited prior authorization decision
12 could, in the opinion of a physician with knowledge of the
13 enrollee's medical condition:
14
15 (A) Seriously jeopardize the life or health
16 of the enrollee or the ability of the enrollee to regain
17 maximum function; or
18
19 (B) Could subject the enrollee to severe
20 pain that cannot be adequately managed without the care or
21 treatment that is the subject of the review. For purposes
22 of this act, urgent health care service shall include
23 mental and behavioral health care services.
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1
2 (xi) "This act" means W.S. 26-55-101 through 26-
3 55-113.
4
5 26-55-104. Disclosure and review of prior
6 authorization requirements.
7
8 (a) Each health insurer or contracted utilization
9 review entity shall make any current prior authorization
10 requirements and restrictions easily accessible on its
11 website to enrollees, health care professionals and the
12 general public. Each health insurer or contracted
13 utilization review entity shall directly furnish those
14 requirements and restrictions within twenty-four (24) hours
15 after being requested by a health care provider.
16 Requirements and restrictions provided or posted under this
17 subsection shall be described in detail but also in easily
18 understandable language. Content published by a third party
19 and licensed for use by a health insurer or contracted
20 utilization review entity may be made available through the
21 health insurer or contracted utilization review entity's
22 secure password-protected website, provided that the access
23 requirements of the website do not unreasonably restrict
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1 access to any current prior authorization requirements and
2 restrictions.
3
4 (b) Each health insurer or contracted utilization
5 review entity shall not implement a new or amended prior
6 authorization requirement or restriction unless its website
7 has been updated to reflect the new or amended prior
8 authorization requirement or restriction.
9
10 (c) Each health insurer or contracted utilization
11 review entity shall provide contracted health care
12 providers and enrollees written notice of any new or
13 amended prior authorization requirement or restriction
14 implemented under the health insurer's medical policy or
15 the health insurance contract not less than sixty (60) days
16 before the new or amended prior authorization requirement
17 or restriction is implemented.
18
19 (d) Health insurers or contracted utilization review
20 entities shall make statistics available regarding prior
21 authorizations and adverse determinations on their website
22 in a readily accessible format. The statistics shall
23 include categories for:
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1
2 (i) The physician specialty;
3
4 (ii) The medication or diagnostic test or
5 procedure;
6
7 (iii) The indication offered;
8
9 (iv) The reason for the adverse determination;
10
11 (v) Whether the adverse determination was
12 appealed;
13
14 (vi) Whether the adverse determination was
15 upheld or reversed on appeal;
16
17 (vii) The time between submission of the prior
18 authorization request and the authorization or initial
19 adverse determination.
20
21 26-55-105. Persons qualified to make adverse
22 determinations.
23
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1 (a) Each health insurer or contracted utilization
2 review entity shall ensure that all adverse determinations
3 are made by a physician or other appropriate licensed
4 health care professional who has:
5
6 (i) Sufficient medical knowledge in a specific
7 practice area or specialty;
8
9 (ii) Knowledge of the coverage criteria;
10
11 (iii) A current and unrestricted license to
12 practice within the scope of their medical profession in a
13 state, territory, commonwealth of the United States or the
14 District of Columbia.
15
16 26-55-106. Consultation prior to issuing an adverse
17 determination.
18
19 If a health insurer or contracted utilization review entity
20 is preparing to deny or considering rejecting the medical
21 necessity of a health care service, the health insurer or
22 contracted utilization review entity shall notify the
23 enrollee's health care provider that medical necessity is
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1 being questioned. Before the health insurer or contracted
2 utilization review entity issues an adverse determination,
3 the enrollee's health care provider shall have the
4 opportunity to discuss the medical necessity of the health
5 care service with the person who will be responsible for