HB 618 - This act enacts provisions relating to prior authorization of health care services.
Beginning January 1, 2026, health care providers shall not be required to obtain prior authorization for a health care service unless the health carrier or utilization review entity determines that in the most recent evaluation period, as defined in the act, less than 90% of the prior authorization requests submitted by that provider for that health care service were approved or would have been approved.
Also beginning January 1, 2026, health care providers shall not be required to obtain prior authorization for any health care services unless the health carrier or utilization review entity has approved or would have approved less than 90% of all prior authorization requests submitted by that provider for health care services.
Health carriers or utilization review entities may elect to have certain hospitals determine which of certain conditions, laid out in the act, the hospital will comply with in order to obtain a prior authorization exemption under the act.
Exemptions from prior authorization under the act shall not apply to: pharmacy services, not to exceed the amount of $100,000; imaging services, not to exceed $100,000; cosmetic procedures that are not medically necessary; or investigative or experimental treatments. Maximum dollar amounts for these exceptions shall be adjusted annually for inflation as described in the act.
The act further specifies certain prior authorization requests that shall not be included in making determinations under the act, specifies identification methods for the providers, includes provisions for the auditing and retraction of determinations under the act, allows for health carriers and utilization review entities to require providers to use an online portal to submit prior authorization requests, requires adverse determinations under the act to be reviewed by a clinical peer of the provider, and requires a grace period for patients who have received prior authorization for a 90-day supply of medication.
Health carriers and utilization review entities shall notify providers within 25 days after a determination is made under the act, shall include in the notification certain information used in making the determination, shall establish an appeals process for the providers, and shall maintain an online prior authorization portal as described in the act.
No health carrier or utilization review entity shall deny or reduce payment to a health care provider for a health care service for which the provider has prior authorization, except as described in the act.
This act shall not apply to MO HealthNet services not provided through a managed care organization, or to providers who have not participated in a health benefit plan offered by the health carrier for at least one full evaluation period.
This act is similar to SB 230 (2025), SB 983 (2024), HB 1976 (2024), SB 576 (2023), and HB 1045 (2023).
ERIC VANDER WEERD