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AB 290

Relating to: special registration plates to support protecting pollinators and making an appropriation. (FE)

2025-2026 Regular Session Introduced by Deb Andraca and 25 co-sponsors

Reforms tighten and standardize prior authorization by insurers, requiring transparency, faster decisions, meaningful clinical review, and clear approvals validity.

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Bill Summary · AB 290

AB 290 — Prior Authorization Reforms (BDR 57-861) — Summary

Status: Enacted. Approved by the Governor and chaptered as Chapter 475, Statutes of 2025 (presented to Governor 09/24/2025; approved 10/09/2025).

Purpose
- Reform and add consumer protections and transparency around insurer prior authorization (PA) processes for medical and dental care.
- Speed decision timelines, improve clinical review quality, curb inappropriate denials and delays, and increase public reporting and oversight.

Who is affected
- Health carriers (insurers, nonprofit hospitals, HMO/MCOs as specified), utilization review organizations, providers (physicians, dentists, other authorized clinicians), insured patients, Medicaid/CHIP recipients (with some tailored provisions), state agencies (Commissioner of Insurance; Department of Health and Human Services), and potentially local governments (bill notes possible fiscal impact / contains an unfunded mandate).

Key provisions and changes
- Procedure publication and clinical criteria
- Carriers must include and publish on their websites the list of items/services requiring PA and the clinical review criteria used to evaluate PA requests.

  • Decision timelines

    • For non-Medicaid carriers: carriers must approve, deny, or request additional medically relevant information within 7 calendar days for non‑urgent care and within 48 hours for urgent care (final reprint replaces earlier 5-day/24-hour language).
    • For Medicaid/CHIP entities: modified timelines generally require action within 7 days (with some exceptions for drug or in-person assessment services).

  • Validity and portability of approvals

    • For carriers other than Medicaid/CHIP: approved PAs remain valid 12 months for continuous/chronic courses of care and 6 months for other care (earlier drafts had 12 months generally). New insurers must honor a prior insurer’s approved PA for the first 90 days of coverage under specified conditions.
    • For Medicaid/CHIP: PA approvals generally valid 12 months unless federal law differs.

  • Emergency services

    • Carriers may not require PA for covered emergency services, may not require notification earlier than the end of the next business day, and may not deny coverage for covered, medically necessary emergency services; certain presumptions of medical necessity are provided.

  • Clinical review, peer-to-peer and appeals

    • Adverse determinations must be made by appropriately authorized clinicians (physician/dentist/pharmacist where applicable) with relevant specialty and experience.
    • When medical necessity is questioned, the carrier must notify the requesting provider and offer an opportunity for a discussion (peer-to‑peer) with the clinician making the determination.
    • Appeals upholding an adverse determination must be decided by a clinician meeting higher qualifications (e.g., same/similar specialty, actively practicing).

  • Artificial intelligence / automated decision tools

    • For non-Medicaid carriers using AI/automated tools for PA processing: insurers must disclose use publicly and describe the tool and data used.
    • AI/automated tools may not be the sole basis for an adverse determination or for terminating/altering an approved PA unless independently reviewed by a qualified physician/dentist.

  • Reporting and transparency

    • Annual publication by carriers of PA statistics on their websites and submission of similar information to the Commissioner of Insurance for compilation.

Implementation, scope and exceptions
- The bill separates requirements applying to commercial carriers vs. Medicaid/CHIP (state/federal compliance preserved). Several technical amendments refined definitions, timelines, and applicability to managed care organizations.
- The bill contains an unfunded mandate and notes possible fiscal impacts on local governments and the State.

Stakeholder input / concerns
- Support: oncology and provider groups emphasized reduced delays to critical care, specialty peer review, and increased transparency.
- Regulatory concerns: the Division of Insurance highlighted definitional ambiguities (which could sweep in supplemental products), administrative/reporting burdens, and potential for misuse of PA portability and approvals.

Sponsors and authors
- Principal author(s): Assemblymember Duy Nguyen (and co-authors listed in bill versions); joint sponsors in later versions included several Assemblymembers and Senators; author list evolved through amendments.

Effective date
- Enacted in 2025 (Chapter 475, Statutes of 2025).

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

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