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HB 25-1002

Medical Necessity Determination Insurance Coverage

2025 Regular Session Introduced by Judy Amabile and 55 co-sponsors

HB 25-1002 requires insurers to define medical necessity, give clear denials and faster appeals, boosting transparency and timely access to covered care.

Governor Signed
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Bill Summary · HB 25-1002

HB 25-1002 — Medical Necessity Determination Insurance Coverage

Status: Governor signed (March 20, 2025)
Introduced: January 8, 2025

Purpose (summary)

HB 25-1002 is titled “Medical Necessity Determination Insurance Coverage.” Based on the bill title and the available legislative metadata, the bill’s intent is to regulate how health insurers determine and communicate medical necessity decisions for covered services, improve transparency and appeals processes for covered persons and providers, and ensure timely access to covered care when an insurer questions medical necessity.

Note: The full bill text was not provided. The description below summarizes the bill’s known procedural status and outlines the common types of provisions such a bill typically contains. For exact statutory language and operative requirements, consult the enacted bill text.

Legislative status and timeline

  • Introduced in the House, Jan 8, 2025; assigned to Health & Human Services.
  • Passed both chambers with amendments; final House concurrence Feb 28, 2025.
  • Sent to Governor Mar 13, 2025; signed by Governor Mar 20, 2025.
  • Multiple sponsors and cosponsors from both parties (see condensed list below).

Likely key provisions (typical for “medical necessity” bills)

While the exact enacted language is not provided here, medical-necessity insurance bills commonly include one or more of the following:
- A statutory definition or specification of “medical necessity” and allowable criteria insurers may use.
- Requirements for written notice to covered persons and ordering providers when a claim or prior authorization is denied or modified on medical necessity grounds, including explanation of reasons and appeal rights.
- Timeframes for insurers to make initial determinations and for internal and external appeals (expedited review where delays risk health).
- Procedures for provider-to-insurer peer-to-peer or clinical review before denial.
- Protections against use of nonclinical criteria (e.g., cost containment alone) as sole basis for denial.
- Requirement that network adequacy or prior authorization processes not create undue access barriers.
- Reporting, recordkeeping, and anti-conflict-of-interest rules for medical reviewers.

Who is affected

  • Covered individuals (insured members) and their authorized representatives.
  • Insurers and third-party administrators offering health benefit plans regulated by the state.
  • Health care providers who request services, submit prior authorizations, or participate in appeal/peer review processes.

Potential impact & next steps

  • If enacted as typical, the bill would increase transparency, speed up appeals, and possibly expand access to services that might otherwise be delayed or denied.
  • Implementation may require insurer policy updates, staff training, and potential rulemaking by state regulators. Check the enacted bill text for effective dates and any transition provisions.

Sponsors (primary and selected cosponsors)

Primary sponsors include Byron Pelton, Judy Amabile, Lindsay Gilchrist, and Kyle Brown; dozens of additional legislators from both chambers cosponsored the bill.

For precise requirements, operative dates, and enforcement mechanisms, review the official enrolled bill text and any implementing regulations issued by the state insurance or health agency.

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

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