Mass. has new limits on insurers’ much-hated prior authorizations. Here’s what to know.

Business admin June 21, 2026 0 Comments

Mass. has new limits on insurers’ much-hated prior authorizations. Here’s what to know.

Dr. Debra Shapiro and her staff spend hours in their Cambridge practice each week asking permission from insurers to prescribe their primary care patients certain medications and procedures.

The arduous process, known as prior authorization, eats up their time and delays care for Shaprio’s patients experiencing pressing ailments like chest pain, intestinal infections, and even cancer.

But on Friday, the Healey administration took steps to ease those headaches, issuing rules that limit when insurers can require prior authorization forprescriptions and tests, along with visits to certain providers.

The regulations are meant to restrict the red tape surrounding some essential services and medications for managing chronic diseases, including diabetes and asthma. They alsoestablish protections for patients who switch insurance providers. And they ban prior authorizations for physical, occupational, and speech therapies, maternity services, and medications for serious mental illness, among other changes.

The decision over which services and medications to exempt from prior authorizations were determined following hearings with stakeholders. Even health insurers, which view prior authorization as a critical tool for controlling health care spending, have signed onto the regulations.

Governor Maura Healey and supporters say the reforms will make accessing care faster and cheaper while lessening some of the paperwork burden for providers.

“These changes will make the health care system work better for patients and providers while helping people get the right care at the right time,” Healey said in a statement.

State Insurance Commissioner Michael Caljouw said it will likely take until the end of the year for patients to see any changes from the regulations. The state will hold a series of education sessions with insurers and providers before starting to enforce the measures.

What is harder to predict, experts say, is just how much of an impact these rules will actually have for patients and doctors.

The state’s regulatory authority only covers plans that account for about half of the people who purchase insurance in the commercial market, Caljouw said. Those are people whose employers are “fully insured,” meaning their insurer takes on the financial responsibility for paying out medical claims.

The regulations will not apply to “self-insured” employers that pay health care claims directly — the majority of employers. That means large employers could still choose to require prior authorizations in the areas Healey has restricted.

Other insurance plans that are exempt from the regulations include government insurance programs for low-income residents and seniors including MassHealth and Medicare, as well as the Group Insurance Commission that covers public employees, retirees, and their families.

“For providers, there will still be a substantial amount of uncertainty and administrative burden related to prior authorization” because of the differing rules based on insurance type, said Dr. Aaron Schwartz, assistant professor of health policy at the University of Pennsylvania’s Perelman School of Medicine.

Experts, including Schwartz, said it will take time to see whether the changes help patients get care sooner.

Blue Cross Blue Shield of Massachusetts, the state’s largest commercial insurer, offers both plans that are regulated by the Division of Insurance and plans that are not. The organization has not decided whether it will implement the new regulations for the plans not overseen by the division.

The insurer is seeking more details on certain provisions, including the elimination of prior authorizations for medications treating serious mental illness and outpatient substance use disorder services.

“These are some areas we see fraud that, without any prior authorization, we’d be blind to,” a Blue Cross spokesperson said.

Blue Cross Chief Medical Officer Dr. Sandhya Rao added that the organization already follows many of the new regulations. Less than 2 percent of insurance claims at Blue Cross are subject to prior authorization, she said.

For years, Massachusetts’ health care industry has been weighed down by skyrocketing costs and uncontrolled spending. As the state wades through the rubble of reduced federal insurance subsidies for low- and middle-income residents, and stares down impending work requirements for MassHealth enrollees, leaders are scrambling to find any way to bolster a shaky system.

Friday’s regulations represent a sort of compromise.

Under the reforms, affected insurers cannot require prior authorizations on services, supplies, and medications related to urgent care, post-acute care services on weekends or holidays, and imaging to determine the stage of a diagnosed cancer. Approvals for chronic disease management must remain valid for the patient’s entire treatment, as long as the patient remains in stable condition. Insurers must also respond to requests within 24 hours when a patient’s life is in danger.

At the same time, the regulations include a way for health insurers to raise concerns if they notice higher rates of usage driving greater spending over multiple quarters.

The Massachusetts Association of Health Plans, which represents insurers including Point32Health and the Mass General Brigham Health Plan, supported the reforms. CEO Lora Pellegrini said the organization’s members are committed to working with providers and regulators to put the changes in place.

“But administrative reforms alone will not lower premiums or make health care more affordable,” Pellegrini said in a statement. “Those efforts must be paired with meaningful action to address the underlying drivers of cost growth — including rising hospital prices, outpatient facility costs, and prescription drug spending.”

Caljouw, the insurance commissioner, admitted the regulations aren’t going to make everyone — or even anyone — perfectly happy.

“Everybody wants a little bit more, a little bit less, depending on their perspective,” Caljouw said. “That makes me confident that we’ve landed a comprehensive and balanced set of reforms.”