States Get in on the Prior Authorization Crackdown

Last month, my colleague Lauren Sausser told you about the Biden administration’s crackdown on insurance plans’ prior authorization policies, with new rules for certain health plans participating in federal programs such as Medicare Advantage or the Affordable Care Act marketplace. States are getting in on the action, too.

Prior authorization, sometimes called pre-certification, requires patients to endure their health insurers’ reviewing some medical treatments before deciding to cover them — or not. It’s a tool the plans say reins in costs and protects patients from unnecessary or ineffective medical treatment. Patients and doctors hate it.

But the new Centers for Medicare & Medicaid Services rules are limited.

So, doctors and hospitals are backing efforts by states to pass their own restrictions.

Last year, lawmakers in 29 states and District of Columbia considered some 90 bills to limit prior authorization requirements, according to the American Medical Association, with notable victories in New Jersey and D.C. The physicians association expects more bills this year.

Here in Missouri, Republican state Rep. Melanie Stinnett introduced legislation to exempt certain providers from always having to request authorization for care — a program often called “gold carding.” Stinnett said she was regularly frustrated by prior authorization hurdles in her work as a speech pathologist before joining the legislature in 2023.

“The stories all kind of look similar: It’s a big fight to get something done on the insurance side for approval,” Stinnett said. “Then sometimes, even after all of that fight,it feels like it may have not been worthwhile because some people then have a change at the beginning of the year with their insurance.”

That’s what happened to Christopher Marks, a 40-year-old truck driver from Kansas City, Mo.

Marks noticed an immediate improvement in his Type 2 diabetes symptoms last year when his doctor prescribed him the medication Mounjaro — which has a wholesale price of more than $1,000 a month.But when his doctor followed the typical prescribing pattern and increased his dose,Marks’s health insurer declined to pay for it.

Marks had a Cigna plan that he purchased on the federal Affordable Care Act marketplace, healthcare.gov. After two appeals over a month and a half, Cigna agreed to cover the higher dose. A few months later, he said, when it was time to up his dose once more, he was denied again. By November, he decided it wasn’t worth sparring with Cigna anymore since the insurer was leaving the marketplace in Missouri at the start of this year. He decided to stay on the lower dose until his new insurance kicked in.

“That is beyond frustrating. People shouldn’t have to be like, ‘It’s not worth the fight to get my medical treatment,’” Marks said.

Cigna spokesperson Justine Sessions said the company uses prior authorizations for popular drugs such as Mounjaro to help ensure patients get the right medications and dosages.

“We strive to make authorizations quickly and correctly, but in Mr. Marks’s case, we fell short and we greatly regret the stress and frustration this caused,” she said.

Under Stinnett’s bill, a medical provider’s prior authorization requests during a six-month evaluation period would be reviewed by health plans. Providers whose requests were approved by a plan at least 90 percent of the time would be exempt from having to submit further prior authorization requests for patients on that plan for the next six months.

The exemptions would also apply to hospitals and other facilities that meet the threshold. They would have to continue hitting the 90 percent approval mark to keep the exemption.

Five states have passed some form of gold-carding program: Louisiana, Michigan, Texas, Vermont and West Virginia. The AMA is tracking active gold carding bills in 13 states, including Missouri.

A 2022 survey of 26 health insurance plans conducted by the industry trade group AHIP found that just over half of those plans had used a gold-carding program for medical services while about a fifth had done so for prescriptions.

Marks purchased insurance for this year on the federal marketplace from Blue Cross and Blue Shield of Kansas City. In January, his doctor re-prescribed the higher dose of Mounjaro that Cigna had declined to cover. A little over a week later, Marks said, his new insurance approved his prescription “without any fuss.”

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Bram Sable-Smith:
brams@kff.org,
@besables