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SF 231

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2025-2026 Regular Session Introduced by Jeff Howe and 3 co-sponsors

SF 231 amendment tightens prior authorizations: faster URO responses, annual reviews to drop unnecessary approvals, a pilot exempting providers, plus reporting and oversight.

Referred to Transportation
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Bill Summary · SF 231

Summary — SF 231 (Amendment S‑3014): Prior authorizations and exemptions by health benefit plans and utilization review organizations

Status & procedural history
- Bill: SF 231 (amended by S‑3014). Title amended to address prior authorizations and exemptions by health benefit plans and utilization review organizations.
- Introduced: Feb 10, 2025. Committee report approved; referred to Transportation (initial referral reflects original bill number assignment; amendment shifts subject matter to insurance/health).
- Key actions: Amendment S‑3014 filed Mar 4, 2025; placed on calendar; S‑3014 adopted Apr 16, 2025; HF 303 substituted/withdrawn on Apr 16, 2025.
- Related: Companion HF 887.

Purpose / intent
The amendment reshapes SF 231 into a law governing prior authorization practices for health benefit plans and utilization review organizations (UROs). Its goals are to (1) speed decision times for prior authorizations, (2) reduce unnecessary administrative burden by eliminating redundant prior authorization requirements, (3) create a pilot program that exempts qualified providers from some prior authorizations, and (4) increase reporting and oversight by the insurance division/commissioner.

Key provisions
1. Timeframes and acknowledgement requirements for URO responses
- UROs must respond to prior authorization requests:
- Urgent requests: within 48 hours of receipt.
- Nonurgent requests: within 10 calendar days of receipt.
- Nonurgent requests (complex/unique circumstances or unusually high volume): within 15 calendar days.
- UROs must provide a receipt/acknowledgement to the requesting provider within 24 hours of receiving the request.

  1. Annual review to eliminate unnecessary prior authorizations

    • UROs must, at least annually, review all services requiring prior authorization and eliminate requirements for services that are routinely approved at such a frequency that prior authorization does not meaningfully improve quality or reduce spending enough to justify the administrative cost.

  2. Reporting by UROs

    • UROs must submit an annual report to the commissioner (per procedures/deadlines set by the commissioner) documenting the annual review findings and performance metrics. Required metrics include (but may not be limited to):
      • Volumes and approval rates, including counts/percentages of complex nonurgent requests approved.
      • Average and median times from submission to determination for urgent and nonurgent requests (aggregated).
      • Other operational data the commissioner requires to assess prior authorization burden and URO performance.

  3. Complaints and confidentiality

    • Complaints about a URO’s compliance may be directed to the insurance division; the division must notify the URO of complaints.
    • Complaints submitted under this authority are not public records under chapter 22.

  4. Prior Authorization Exemption Pilot Program (health carriers)

    • Deadline to implement: on or before Jan 15, 2026, for any carrier delivering, issuing, continuing, or renewing plans in the state on/after Jan 1, 2026 that uses prior authorizations.
    • Each carrier must implement a pilot that exempts a subset of participating providers (including at least some primary care providers) from certain prior authorization requirements.
    • Public posting: carriers must publish program details on their websites for each plan, including eligibility criteria, services exempted, estimated number and specialties of eligible providers, percentage who are primary care, and contact information.
    • Reporting: by Jan 15, 2027, each carrier must submit to the commissioner a report containing results and analysis of the pilot, including costs and savings, recommendations for continuation/expansion, stakeholder feedback, and administrative costs of administering prior authorization under the pilot.

Who is affected
- Health carriers (insurers, HMOs) delivering health benefit plans in the state.
- Utilization review organizations that perform prior authorization functions.
- Health care providers (especially primary care providers targeted in the exemption pilot) who request prior authorizations or may be eligible for exemptions.
- Consumers/patients, who may experience faster determinations and changes in prior authorization availability.
- Insurance division/commissioner, responsible for receiving reports, oversight, and implementing reporting requirements.

Potential impacts
- Faster turnaround for urgent and nonurgent prior authorization determinations and earlier acknowledgement of requests.
- Possible reduction in administrative burden if carriers/UROs eliminate routinely approved prior authorizations or expand exemptions to qualifying providers.
- Increased transparency through carrier web postings and URO annual reports; greater regulatory oversight by the insurance division.
- Short‑term implementation costs for carriers and UROs to run the exemption pilot, track metrics, and report; potential longer‑term savings if prior authorization requirements are reduced where they are ineffective.
- Confidential handling of complaint information limits public access to specific complaints but requires internal notification and regulatory review.

Effective/timeline highlights
- Carriers must implement pilot programs by Jan 15, 2026 (for plans in effect Jan 1, 2026 or later).
- Carrier pilot reports to the commissioner due by Jan 15, 2027.
- URO annual reviews and reporting schedule to follow deadlines established by the commissioner.

Limitations / open questions
- The amendment delegates specific reporting procedures and deadlines to the commissioner; exact metrics and formats will be determined administratively.
- The statutory language requires elimination of some prior authorizations but leaves judgment about which services qualify subject to the URO’s annual review and commissioner oversight.

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

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