04/07/2022

Governor Whitmer Signs SB 247 Prior Authorization into Law

More than three years ago, MSHO joined forces with physicians, patients, other health professionals, and advocacy associations, to form Health Can’t Wait.  This coalition was formed to develop and enact into law legislation that would put Michigan patients first and end delayed access to vital health care services. Throughout this time, MSHO physicians and our coalition partners shared countless stories of the ways prior authorization caused unnecessary and costly care delays and interfered in medical decision-making. We are happy to report that after years of hard work your voices have been heard!

“Today’s action by Gov. Whitmer to sign this overwhelmingly bipartisan legislation will directly help patients across Michigan,” said state Senator VanderWall, R-Ludington. “This new law reforms the prior authorization process, which has created barriers and inefficiencies with access and quality of care in the health care system. It will promote transparency of practices used by insurers, allowing enrollees and health care providers to be fully informed while making coverage and care decisions.” 

Senate Bill 247 would reform the prior authorization process to do the following:

• Require an insurer to make available, by June 1, 2023, a standardized electronic prior authorization request transaction process.
• Require prior authorization requirements to be based on peer-reviewed clinical review criteria.
• Require an insurer to post on its website if it implemented a new prior authorization requirement or restriction or amended an existing requirement or restriction.
• Require an insurer to notify, on issuing a medical benefit denial, the health professional and insured or enrollee of certain information, including the right to appeal the adverse determination, and require an appeal of the denial to be reviewed by a health professional.
• For a medical benefit that is not a prescription drug benefit, an insurer shall notify contracted health care providers via the insurer's provider portal of the new or amended requirement or restriction not less than 60 days before the requirement or restriction is implemented.
• For a prescription drug benefit, an insurer shall notify contracted health care providers via the insurer's provider portal of the new or amended requirement or restriction not less than 45 days before the requirement or restriction is implemented. 
• Prohibits an insurer or its designee utilization review organization from affirming the denial of an appeal unless the appeal was reviewed by a licensed physician.
• For urgent requests, beginning June 1, 2023, the prior authorization is considered granted if the insurer fails to act within 72 hours of the original submission.  For non-urgent requests, beginning June 1, 2023, the prior authorization is considered granted if the insurer fails to act within 9 calendar days of the original submission.  After May 31, 2024, a non-urgent prior authorization is considered granted if the insurer fails to act within 7 calendar days of the original submission.
• Requires an insurer to adopt a program that promotes the modification of prior authorization requirements of certain prescription drugs, medical care, or related benefits, based on the performance of the health care providers with respect to adherence to nationally recognized evidence-based medical guidelines and other quality criteria (i.e., BCBSM “gold carding” program).