Massachusetts limits prior authorization for routine care, requires 24-hour urgent decisions and creates affordability working group

Governor Healy on Thursday announced statewide changes meant to speed patients’ access to treatment by eliminating prior-authorization requirements for a broad set of drugs, services and equipment and by requiring insurers to respond to urgent requests within 24 hours.

The governor said the rules will remove prior authorization for categories that include primary and emergency care, chronic disease management, vaccines, reproductive and maternity care, physical therapy and substance use services. "We're cutting the red tape that stands between you and health care," Healy said, adding that the goal is to prevent routine approvals—often granted "99% of the time"—from imposing months-long delays on patients.

Insurance Commissioner Mike Caljo said all insurers doing business in Massachusetts will be subject to the forthcoming regulations and pledged cooperative implementation with providers and plans. The administration also said plans must publicly disclose prior-authorization practices and honor existing authorizations when a covered person changes plans to avoid interruptions in care.

A central operational change is a required 24-hour response time for urgent prior-authorization requests, which Healy called "the quickest turnaround of any state in the country." The administration said regulations would be filed this week to implement the changes; officials did not say the exact effective date for every provision.

The announcement also established a health care affordability working group to develop further reforms. The group will be co-chaired by former state health secretary Kate Walsh and Lisa Murray, Massachusetts state president at Citizens Bank, and will include representatives from hospitals, health centers, employers, health plans and patient-advocacy organizations. Secretary Kiyami Mahania said the group will address where care should be delivered, payment innovations, waste reduction and how clinicians can work at the top of their licenses using technology.

Patient testimony underscored the rationale for the changes. A Massachusetts resident, who identified herself as Melissa, described a 2017 autoimmune neurologic illness and said she waited about three months for prior-authorization approval for an expensive immunotherapy. She said the delay led to severe physical decline and lasting harm. "In the world of neurology, an illness like mine, three months is like three years," she said, and described the proposed 24-hour urgent-review rule as the kind of change that could prevent similar outcomes.

The governor set a public goal for the working group to deliver concrete recommendations by June and said the administration would continue monitoring the Health Policy Commission’s work. He also criticized recent federal actions, saying they "took $1,000,000,000,000 out of health care," a statement presented in his remarks as a political context for state action. The administration did not present independent verification of that figure at the event.

Next steps: the administration will file regulations this week and convene the working group; officials said they expect insurers and providers to coordinate on implementation but did not provide a detailed timetable for when specific prior-authorization categories will cease to be enforced.