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HB 649

RELATING TO SMALL BOAT HARBORS.

2025 Regular Session Introduced by Mark Hashem

HB 649 requires insurers and UROs to base utilization reviews on current evidence, with MD-led review, transparent criteria, and protections against biased decisions.

Carried over to 2026 Regular Session.
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Bill Summary · HB 649

Summary — HB 649: Ensure Timely and Clinically Sound Utilization Review

Status: Regular message sent to Senate (introduced in the House)
Subject: Health; insurance regulation; patient rights; utilization review

Purpose / Intent

HB 649 is intended to strengthen the clinical integrity, timeliness, and transparency of utilization review (UR) performed by insurers and utilization review organizations (UROs). The bill aims to ensure UR determinations are evidence‑based, made under appropriate clinical oversight, consistent with nationally recognized standards, and sufficiently flexible to allow individualized clinical judgments. It also clarifies and expands statutory definitions used in UR (for example, “prior authorization,” “urgent health care service,” and “closely related service”).

Key provisions

  • Definitions

    • Introduces/clarifies defined terms relevant to UR, including:
    • “Closely related service” — services provided same day as an authorized service that a licensed provider reasonably may perform in conjunction with or instead of the originally authorized service.
    • “Course of treatment.”
    • “Prior authorization” — insurer/URO process to determine medical necessity/appropriateness before services are rendered.
    • “Urgent health care service” — includes mental and behavioral health services and is defined by risk to life, function, or uncontrolled pain.

  • Program documentation and governance

    • Requires each insurer to prepare and maintain a UR program document describing all delegated/non‑delegated functions, clinical criteria, appeals processes, data collection methods, organizational structure, confidentiality safeguards, and program management responsibilities.

  • Clinical review criteria and operations

    • UR clinical criteria must be:
    • Based on applicable nationally recognized medical standards and government guidelines.
    • Reflect current medical/scientific evidence (peer‑reviewed literature).
    • Evaluated at least annually and flexible enough to permit case‑by‑case deviations when clinically justified.
    • Criteria for substance‑use treatment placement must follow ASAM Patient Placement Criteria or insurer‑adopted criteria.

  • Clinical decision‑maker requirements

    • Qualified health care professionals must administer UR under MD direction.
    • Noncertifications (denials) must be evaluated and issued by a medical doctor:
    • Licensed in the State,
    • Of the same specialty as the treating physician for the condition or service,
    • With relevant experience treating the condition.
    • Medical directors must provide clinical oversight of noncertifications.

  • Protections and fairness

    • UR compensation structures must not include direct or indirect incentives that could adversely influence clinical decisions (language on incentives included).
    • Program must include mechanisms for consistent application of criteria and meaningful appeals of noncertifications.
    • Concurrent review and expedited processes for urgent services are recognized/defined.

Who is affected

  • Insurers and health plans (including managed care plans) and UROs — new documentation, oversight, and operational requirements.
  • Health care providers — clearer definitions (e.g., closely related services), potentially fewer improper denials and stricter specialty‑matched review.
  • Patients — intended improvements in timeliness, clinically appropriate access to care, and appeal protections.
  • Regulators — potential oversight and verification responsibilities.

Procedural / timeline notes

  • Introduced in the House and referred to relevant committees (Health / Insurance-related committees). (See legislative history for committee actions and readings.)
  • The bill establishes program and operational standards; implementation will require insurers/UROs to update UR policies and procedures and to ensure specialty‑matched clinical reviewers are available.

If you want, I can:
- Produce a side‑by‑side comparison of current law vs. the changes HB 649 would make; or
- Extract and summarize the bill’s full procedural history and current status from the legislative record.

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

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