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H 31

An act relating to claim edit standards and prior authorization requirements

2025-2026 Regular Session Introduced by Alyssa Black

Third-party entities must accept Idaho DHW-issued prior authorizations for Medicaid-covered services, keeping Medicaid as payer of last resort.

House message: Governor approved bill on March 5, 2025
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Bill Summary · H 31

Summary of Idaho H 31 (2025)

Overview

Idaho House Bill 31 amends federal-state medical assistance law to require third parties that administer or require prior authorization for items or services for Medicaid-eligible individuals to accept the state’s prior authorization. The purpose is to ensure Medicaid remains the payer of last resort when the state plan or a waiver covers a service or item.

  • Status: Signed by the Governor; Chapter 27, Session Law 2025
  • Effective date: July 1, 2025
  • Emergency: The bill includes an emergency clause making the act effective upon the stated date
  • Introduced: January 21, 2025

What the bill does (highlights)

  • Section 7 (the core change): If a responsible third party requires prior authorization for an item or service for a medical assistance recipient, that third party must accept an authorization issued by Idaho’s Department of Health and Welfare (DHW) as if the authorization came from the third party. This applies when the item or service is covered under the state plan or an applicable waiver.

  • The bill maintains and clarifies existing subrogation and reimbursement mechanisms:

    • DHW’s subrogation rights to recover medical assistance costs paid on behalf of a recipient.
    • Requirements for recipients to notify DHW of third-party claims and the Department’s priority right to reimbursement from any third-party recovery.
    • Procedures for handling settlements or judgments, including how reimbursement to the state is determined and how attorney fees are accounted for.
    • Provisions for directing third parties to pay DHW directly when appropriate and ensuring third parties are liable if they distribute funds in violation of such notices.
    • Presumptions if settlement allocations are not itemized (the presumption is that settlements first cover medical expenses paid by the state).

  • Financial administration: The bill creates/allocates funding in the Medical Assistance Account to cover the state share of medical assistance expenses, with the Department holding primary rights to recover from third parties as described.

  • Fiscal impact: The accompanying fiscal note states no net state or local revenue impact and no net expenditure impact from the legislation.

Who is affected

  • Medical assistance recipients (Medicaid beneficiaries) in Idaho.
  • Idaho DHW (Department of Health and Welfare), particularly the Medical Assistance program and its subrogation/reimbursement processes.
  • Third-party payers and providers that require prior authorization for Medicaid-covered services or items.
  • Attorneys involved in recovering reimbursements from third-party settlements or judgments.

Key provisions and details

  • The essential compliance requirement is in Section 7: third-party pre-authorization processes must honor the state-issued prior authorization.
  • The existing subrogation framework (Sections 3–6) remains in effect, detailing:
    • DHW’s subrogation rights and notification obligations.
    • Reimbursement hierarchy, priority rights, and methods of obtaining payment from third parties.
    • Handling of attorney fees and allocation of settlement funds when medical expenses are involved.
    • Presumptions in the absence of explicit allocation in settlements.

Timeline and procedural notes

  • Introduction and committee actions occurred in early 2025.
  • Passed both chambers in March 2025.
  • Signed by the Governor and published as Chapter 27 on March 11, 2025.
  • Effective date: July 1, 2025 (due to emergency designation).

Summary interpretation

H 31 codifies a requirement that third-party entities (that impose prior authorization) recognize and accept Idaho DHW-issued prior authorizations for Medicaid-covered services/items. This helps ensure Medicaid remains the payer of last resort and aligns third-party practices with the state’s Medicaid authority, while preserving established subrogation and reimbursement mechanics. The fiscal note indicates no net fiscal impact at the state or local level.

Compiled from official sources — confirm details with the bill’s official record.

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