The Prior Authorization Reform Movement
States are increasingly passing legislation to limit prior authorization requirements and reduce authorization delays. Reforms include: gold carding (reducing authorization for high-performing providers), step therapy requirements (requiring clinical exceptions processes), authorization timeframe requirements (24-72 hours for processing), and transparency requirements (requiring insurers to disclose authorization criteria).
State laws typically apply to all insurers operating in that state, including both self-insured employer plans (which are exempt from some state insurance laws) and regulated insurance plans.
States with Gold Carding Laws
States with gold carding laws include California, Connecticut, Delaware, Florida, Georgia, Illinois, Kansas, Louisiana, Maryland, Michigan, Mississippi, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Vermont, and Washington. These states exempt high-performing providers from routine prior authorization for evidence-based treatments.
States with Step Therapy Reform Laws
Most states have passed step therapy reform laws creating exceptions processes for medications or treatments when step therapy is not appropriate for the patient. These laws typically require insurers to have reasonable clinical exception processes and timelines for exception requests.
States with Authorization Timeframe Requirements
Many states have enacted legislation requiring expedited prior authorization processing: 24 hours for urgent requests, 72 hours for standard requests. Some states require initial denial decisions be made within these timeframes, with appeals extending timelines.
State Insurance Commissioner Resources
Find your state's insurance laws and complaint processes through your state Department of Insurance. Most states post recent legislation and provide consumer guidance on prior authorization rights. Your state commissioner's office is the enforcement agency for state insurance laws.
Federal Reform Efforts
Federal legislation to standardize prior authorization has been proposed multiple times. The AMA and healthcare organizations continue advocating for federal reform, particularly to implement gold carding federally and standardize authorization timelines.