GOVERNOR HEALEY ANNOUNCES FINAL REGS THAT ELIMINATE PRIOR AUTHORIZATION REQUIREMENTS FOR ROUTINE AND ESSENTIAL HEALTH CARE

The following information was released by the office of the Governor of Massachusetts:

Governor Maura Healey today announced that the Division of Insurance (DOI) has finalized updated regulations that eliminate prior authorization requirements for routine and essential health care, including cancer scans and medications for chronic conditions like asthma, diabetes and heart disease.

The regulations will reduce delays and eliminate barriers that too often prevent patients from getting timely health care. Prior authorization requires patients and providers to obtain approval from insurance companies before certain treatments, services or medications can be provided, which can add unnecessary delays, stress and costs.

During the public comment period additional provisions were added to eliminate prior authorization for radiology imaging used after a cancer diagnosis to determine the stage of the cancer or determine the best treatment method, as well as to ensure that prior authorization approval for chronic conditions, like cancer, continue throughout the entire course of treatment.

"We're making it easier, faster and cheaper for Massachusetts residents to get the care that they need," said Governor Healey. "If your doctor says you need a treatment or medication, you deserve to get it in a timely manner without jumping through hoops. These new regulations will help people with cancer, diabetes, asthma, heart conditions, mental health concerns and more. I'm grateful for the leadership of Commissioner Caljouw and the team at DOI, and all of the patients, providers, hospitals, insurers and advocates who partnered with us to make this possible. We're going to continue to work together to lower health care costs for everyone."

"Health care access and affordability remain top concerns for people across Massachusetts," said Lieutenant Governor Kim Driscoll. "These new rules will cut down on unnecessary delays, stress and costs by making it easier for patients and families to access essential care."

"These reforms will ensure Massachusetts residents get the care they need when they need it," said Insurance Commissioner Michael Caljouw. "We would not be here without the collaborative approach of stakeholders towards the crafting of these meaningful changes."

"Health care access is essential to strong communities and a competitive economy," said Economic Development Secretary Eric Paley. "By reducing delays and eliminating unnecessary barriers to treatment, these reforms will help patients get care faster and make the health care system more reliable for residents and providers across Massachusetts."

"We applaud the Healey Administration for prioritizing much-needed reforms to the prior authorization process, which will help Massachusetts residents get the timely health care they need and deserve," said Dr. Benjamin L. Ebert, president and CEO of Dana-Farber Cancer Institute. "The reforms announced today will allow patients and families to focus on treatment and healing while also giving doctors and nurses more time to care for their patients. We look forward to continuing our collaboration with the Administration and our healthcare partners to enhance the progress made today, ensuring that prior authorization works better for everyone."

The reforms are the result of months of review and feedback from patients, providers, hospitals, insurers, and advocates across Massachusetts. The new regulations prohibit the use of prior authorization requirements for a wide range of health care services, including emergency and urgent care, primary care, preventive services, radiology imaging after a cancer diagnosis, maternity care, outpatient substance use disorder treatment, physical and occupational therapy and medications for serious mental illness and certain chronic conditions.

The regulations also establish new patient protections, including requiring insurers to respond to urgent requests within 24 hours when delays could seriously impact a patient's health. Patients with chronic conditions, including cancer, who receive authorization for treatment will also have approvals honored for the duration of their treatment as long as they remain stable.

Additional reforms will help ensure continuity of care for patients who switch insurance plans by requiring insurers to honor existing authorizations for at least 90 days. Insurers will also be required to publicly post prior authorization requirements and notify providers in advance before making changes to their policies.

The regulations will reduce administrative burdens on providers and insurers alike, reducing costs while helping patients receive care more quickly and consistently. According to the Council for Affordable Quality Healthcare, the health care industry spent approximately $1.3 billion on administrative costs related to prior authorization in 2023. That is a 30 percent increase over the previous year and can be largely attributed to the rise in the volume of prior authorizations.

Examples of how these reforms will help patients include:

A patient with a chronic condition like diabetes, asthma or heart disease, or who has a serious persistent mental illness, will no longer have to obtain prior authorization for their medication.

A cancer patient receiving treatment will maintain approval throughout the course of treatment if their condition remains stable.

A patient who was recently diagnosed with cancer will not have to wait for prior authorization before getting the MRI or CT scan needed to determine what stage their cancer is or what treatment is required.

A patient with rheumatoid arthritis who has an existing authorization for his treatment but recently switched to a new insurer will have that prior authorization honored for at least three months.

An insurer will be required to respond to a prior authorization request from a multiple sclerosis patient experiencing a relapse and needing steroid injections to prevent permanent nerve damage within 24 hours.

A provider who recently diagnosed their patient with a new condition will more easily be able to identify if a prior authorization is required for a particular course of treatment.

Patients facing urgent medical situations will receive faster responses from insurers when time-sensitive care is needed.

The regulations will take effect on June 5, 2026, with patients expected to begin benefiting from these changes later this year.

Statements of Support

Michael Curry, Esq., President and CEO, Massachusetts League of Community Health Centers:

"Delayed care is inaccessible care, and inaccessible care means sicker patients, worsened health outcomes, and higher costs. But under Governor Healey's leadership, Massachusetts is showing that improving access, outcomes, and reducing costs all go hand in hand. For health center patients, timely access to care and services is paramount to meeting their unique needs. I commend the Healey-Driscoll administration and our partners at the Division of Insurance for their efforts to remove administrative burdens and improve the prior authorization process. This is a vital step towards ensuring all Massachusetts residents can get care when and where they need it."

Manny Lopes, CEO, Fallon Health:

"At Fallon Health, we believe patients should be able to access the right care at the right timeand today's announcement is an important step forward. We thank Governor Healey and Commissioner Caljouw for advancing thoughtful prior authorization reforms that improve access while strengthening quality, equity, and affordability across Massachusetts."

Danna Mauch, PhD, President and CEO, Massachusetts Association for Mental Health (MAMH):

"MAMH applauds Governor Healey's leadership in eliminating prior authorization for acute mental health treatment and medications that are critical elements of clinical care needed for children and adults living with serious mental health conditions. In exercising her executive authority, Governor Healey not only eliminates delays associated with longer regulatory and legislative processes but also strikes down barriers to timely access to care - avoiding disability, morbidity, and mortality risked by delays in access to the right care at the right time in the right place."

Steve Walsh, President and CEO, Massachusetts Health and Hospital Association (MHA):

"MHA and our members commend Commissioner Caljouw and his team for the many months of thoughtful work and determination that went into these regulations. We are also deeply grateful to the entire Healey-Driscoll Administration for advancing progress on an issue that, for too long, has delayed patients' access to timely care, compounded the strain on healthcare workers, and contributed to rising healthcare costs. We are especially encouraged that DOI will be empowered to monitor and refine the state's approach to prior authorization over time. These regulations represent an important step forward and have the potential to meaningfully improve affordability and access for patients across the commonwealth."

Lora Pellegrini, President and CEO, Massachusetts Association of Health Plans (MAHP):

"Massachusetts health plans support efforts to streamline prior authorization and improve the experience for patients and providers, while preserving important safeguards that help ensure care is evidence-based, clinically appropriate, and affordable. Prior authorization remains an important tool to protect patients, promote quality, and help manage rising health care costs at a time when affordability is the number one concern for Massachusetts families and employers.

MAHP member plans are all in on finding solutions to the Commonwealth's affordability crisis and have invested heavily in automation, electronic prior authorization, and standardized processes that reduce burden and improve access to care. But administrative reforms alone will not lower premiums or make health care more affordable. Those efforts must be paired with meaningful action to address the underlying drivers of cost growth including rising hospital prices, outpatient facility costs, and prescription drug spending.

As these regulations move forward, it will be critical to maintain the tools and flexibility needed to support patient safety, respond to changing utilization patterns, and protect affordability for consumers and employers alike."

Jennifer Lemmerman, Executive Director, Health Care for All:

"The Governor's effort to streamline the use of prior authorization, reduce costly administrative burdens, and improve consumer protections will bring much-needed relief to patients across the Commonwealth. Too often, overuse of prior authorization delays medically necessary care and creates added stress and confusion for consumers. At Health Care For All, we hear every day from people struggling to access the care they need because of these barriers. This action by the Division of Insurance is a vital step that will improve continuity of care for patients and help protect treatment for chronic conditions. We are grateful for the Healey-Driscoll Administration's leadership in tackling barriers to care and look forward to continuing to partner with state leaders, the Massachusetts Legislature and health care stakeholders to seek creative solutions to the health care challenges we face today."

Matt Selig, Executive Director, Health Law Advocates:

"These new regulations from the Healey-Driscoll Administration will make health care more accessible for consumers with serious medical conditions. With these steps to reduce unnecessary complications in our health care system, their Administration is making sure many more of our state's residents will receive the health care they need, when they need it, without incurring staggering medical bills."

Dr. Olivia Liao, president of the Massachusetts Medical Society:

"Today's final regulations represent a meaningful step toward streamlining and right-sizing prior authorization practices in Massachusetts. We are grateful to the Healey-Driscoll Administration and to Commissioner Caljouw and staff at the Division of Insurance for their sustained efforts to address burdensome prior authorization requirements that have historically delayed our patients' access to care and exacerbated physician burnout. The Division thoughtfully incorporated feedback from the Medical Society and other stakeholders that will tangibly reduce unnecessary care disruptions and improve the practice of medicine. One such change that will immediately improve patient care and reduce administrative burden is eliminating annual prior authorization requirements for patients with chronic conditions who are stable and benefiting from their current treatment. We look forward to continuing our work with the Administration to address additional reforms to improve care delivery and the patient experience."