Healthcare (Insurance)

Prior authorization; requiring physician review for denial. Prohibits a health insurance carrier from making an adverse determination of a prior authorization request (i) for prescription drugs unless such denial has been reviewed and approved by a licensed physician or, if a licensed physician is not available, by a licensed pharmacist or (ii) for health care services unless such adverse determination has been reviewed and approved by (a) a licensed physician; (b) in the case of mental health services, a licensed mental health provider if a licensed physician is unavailable; or (c) in the case of dental services, a licensed dentist if a licensed physician is unavailable.

Health insurance; reimbursement rates. Requires health insurance carriers to reimburse in-network providers for covered mental health services and outpatient treatment at rates negotiated between the health carrier and the in-network provider, provided that such rates are no less than 100 percent of the applicable reimbursement rate under Medicare for the same provider and service.

Health insurance; claims experience information. Provides that provisions requiring insurers to provide policyholders with certain claims experience information apply to all employee welfare benefit plans and include pharmacy benefits claims.

Health insurance; requirements for certain opioid antagonists. Requires each health insurer, corporation providing health care subscription plans, and health maintenance organization whose policy, contract, or plan includes coverage for prescription drugs to include coverage for at least one other opioid antagonist used for overdose reversal dispensed pursuant to an oral, written, or standing order of a prescriber and ensure that cost-sharing for at least one opioid antagonist used for overdose reversal is included on the lowest cost tier of the insurer's, corporation's, or health maintenance organization's prescription drug formulary. The bill provides that such coverage shall be exempt from any prior authorization or step therapy requirement on coverage of benefits. As introduced, this bill was a recommendation of the Joint Commission on Health Care. This bill is identical to SB 257.

State employee health insurance plan; coverage for prosthetic devices. Provides that the plan established by the Department of Human Resource Management for the provision of health insurance coverage for state employees shall include coverage for medically necessary prosthetic devices and their repair, fitting, replacement, and components.

Health insurance; coverage for speech therapy as a treatment for stuttering. Requires health insurance carriers whose health care plans include coverage for habilitative services and rehabilitative services, as such terms are defined in the bill, to provide coverage for habilitative speech therapy and rehabilitative speech therapy, as such terms are defined in the bill, as a treatment for stuttering. The bill provides that such coverage is not (i) subject to any maximum annual benefit limit, including any limits on the number of visits an insured may make to a speech-language pathologist; (ii) limited based on the type of disease, injury, disorder, or other medical condition that resulted in the stuttering; or (iii) subject to utilization review or utilization management requirements, including prior authorization or a determination that the habilitative or rehabilitative speech therapy services are medically necessary. The bill applies to health care plans delivered, issued for delivery, or renewed on and after January 1, 2027.

Life insurance; health insurance; unfair discrimination; pre-exposure prophylaxis for prevention of human immunodeficiency virus. Prohibits any person from refusing to insure, refusing to continue to insure, or limiting the amount or extent of life insurance or accident and sickness insurance coverage available to an individual or charge an individual a different rate for the same coverage based solely on the status of such individual as having received pre-exposure prophylaxis for the prevention of human immunodeficiency virus.