Health care coverage: prior authorizations.

Plain English Breakdown

The bill summary and digest do not provide specific details on enforcement or penalties beyond stating it would impose a state-mandated local program.

Health Care Coverage: Prior Authorizations

AB-539 requires health care service plans and insurers to keep prior authorizations valid for at least one year or until the end of prescribed treatment, whichever is shorter.

What This Bill Does

• Requires that a prior authorization from a health plan or insurer must stay in effect for at least one year after it's given.
• If the treatment lasts less than one year, the authorization stays valid throughout the entire course of the treatment.
• Makes it illegal for health care service plans to change or cancel an authorization once it has been used by a healthcare provider.

Who It Names or Affects

• Health care service plans and insurers
• People who receive health care services

Terms To Know

Prior Authorization

A permission given by a health plan or insurer before a medical treatment can be provided.

Health Care Service Plan

An organization that provides health care services to members under a contract.

Limits and Unknowns

• Does not specify what happens if the authorization is needed for more than one year but treatment continues.
• The bill does not explain how long it will take for these changes to be put into place after being signed into law.

Official Summary Text

AB 539, as amended, Schiavo.
Health care coverage: prior authorizations.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law provides that a health care service plan or a health insurer that authorizes a specific type of treatment by a health care provider shall not rescind or modify this authorization after the provider renders the health care service in good faith and pursuant to the authorization.
This bill would require a prior authorization for a health care service by a health care service plan or a health insurer to remain valid for a period of at least one year from the date of
approval.
approval, or throughout the course of prescribed treatment, if less than one year.
Because a violation of the bill by a health care service plan would be a crime, the bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.

Current Bill Text

Download Bill PDF