{"id":3234,"date":"2026-06-21T11:05:32","date_gmt":"2026-06-21T11:05:32","guid":{"rendered":"https:\/\/bostonrelocationinsider.com\/?p=3234"},"modified":"2026-06-21T11:05:32","modified_gmt":"2026-06-21T11:05:32","slug":"mass-has-new-limits-on-insurers-much-hated-prior-authorizations-heres-what-to-know","status":"publish","type":"post","link":"https:\/\/bostonrelocationinsider.com\/?p=3234","title":{"rendered":"Mass. has new limits on insurers\u2019 much-hated prior authorizations. Here\u2019s what to know."},"content":{"rendered":"
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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. <\/span><\/p>\n

Read more Employers want more AI-fluent workers. It\u2019s testing young graduates\u2019 loyalties.<\/a><\/p>\n

The arduous process, known as prior authorization, eats up their time and delays care for Shaprio\u2019s patients experiencing pressing ailments like chest pain, intestinal infections, and even cancer. <\/span><\/p>\n

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. <\/span><\/p>\n<\/div>\n

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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. <\/span><\/p>\n

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.<\/span><\/p>\n

Governor Maura Healey and supporters say the reforms will make accessing care faster and cheaper while lessening some of the paperwork burden for providers. <\/span><\/p>\n

\u201cThese changes will make the health care system work better for patients and providers while helping people get the right care at the right time,\u201d Healey said in a statement. <\/span><\/p>\n

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. <\/span><\/p>\n

What is harder to predict, experts say, is just how much of an impact these rules will actually have for patients and doctors.<\/span><\/p>\n

The state\u2019s 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 \u201cfully insured,\u201d meaning their insurer takes on the financial responsibility for paying out medical claims.<\/span><\/p>\n

The regulations will not apply to \u201cself-insured\u201d employers that pay health care claims directly \u2014 the majority of employers. That means large employers could still choose to require prior authorizations in the areas Healey has restricted.<\/span><\/p>\n

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. <\/span><\/p>\n

\u201cFor providers, there will still be a substantial amount of uncertainty and administrative burden related to prior authorization\u201d because of the differing rules based on insurance type, said Dr. Aaron Schwartz, assistant professor of health policy at the University of Pennsylvania\u2019s Perelman School of Medicine. <\/span><\/p>\n

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Experts, including Schwartz, said it will take time to see whether the changes help patients get care sooner. <\/span><\/p>\n

Blue Cross Blue Shield of Massachusetts, the state\u2019s 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. <\/span><\/p>\n

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. <\/span><\/p>\n

\u201cThese are some areas we see fraud that, without any prior authorization, we\u2019d be blind to,\u201d a Blue Cross spokesperson said. <\/span><\/p>\n

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. <\/span><\/p>\n

For years, Massachusetts\u2019 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. <\/span><\/p>\n

Friday\u2019s regulations represent a sort of compromise. <\/span><\/p>\n

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\u2019s entire treatment, as long as the patient remains in stable condition. Insurers must also respond to requests within 24 hours when a patient\u2019s life is in danger. <\/span><\/p>\n

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.<\/span><\/p>\n

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\u2019s members are committed to working with providers and regulators to put the changes in place. <\/span><\/p>\n

\u201cBut administrative reforms alone will not lower premiums or make health care more affordable,\u201d Pellegrini said in a statement. \u201cThose efforts must be paired with meaningful action to address the underlying drivers of cost growth \u2014 including rising hospital prices, outpatient facility costs, and prescription drug spending.”<\/span><\/p>\n

Caljouw, the insurance commissioner, admitted the regulations aren\u2019t going to make everyone \u2014 or even anyone \u2014 perfectly happy.<\/span><\/p>\n

\u201cEverybody wants a little bit more, a little bit less, depending on their perspective,\u201d Caljouw said. \u201cThat makes me confident that we\u2019ve landed a comprehensive and balanced set of reforms.\u201d <\/span><\/p>\n

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Patients may not notice major changes right away, as the state works with insurers and medical offices to enact them. <\/p>\n","protected":false},"author":1,"featured_media":3233,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[9],"tags":[],"class_list":["post-3234","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-business"],"yoast_head":"\nMass. has new limits on insurers\u2019 much-hated prior authorizations. 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