Relating To Prior Authorization.
HB954 creates a new Hawaii law called the Ensuring Transparency in Prior Authorization Act and establishes a broad regulatory framework for how health insurers and other utilization review entities handle prior authorization. The bill requires public posting of prior authorization rules and clinical criteria, advance notice before new or changed requirements take effect, and public reporting of approval, denial, appeal, and turnaround-time statistics. It also sets qualifications for physicians who make adverse determinations and appeal decisions, including specialty matching, active practice experience, and limits on conflicts of interest.
The bill imposes strict timelines for prior authorization decisions: non-urgent requests must generally be decided within 48 hours and urgent requests within 24 hours, with automatic approval if the entity fails to act or request needed information in time. It prohibits prior authorization for emergency health care services, pre-hospital transportation, and medications for opioid use disorder, and it requires emergency services to be covered and stabilized without discriminatory treatment of nonparticipating providers. The bill also limits retrospective denials, makes prior authorizations valid for at least one year, extends coverage for chronic or long-term care treatment, and requires insurers to honor prior authorizations when patients change plans or products under the same insurer.
HB954 would significantly affect Hawaii insurance law and utilization review practices by shifting more decision-making power toward treating providers and patients while constraining insurer discretion. It also creates an exemption process for providers whose prior authorization requests are approved at least 80 percent of the time, requires electronic prior authorization using the NCPDP SCRIPT standard by January 1, 2026, and directs annual reporting to the Insurance Commissioner and the Legislature. Noncompliance by a utilization review entity results in automatic approval of the requested service, making the bill a strong enforcement measure.
The overall sentiment reflected in the bill text is strongly supportive of reform and patient access, emphasizing transparency, reduced administrative burden, and protection of the physician-patient relationship. The findings section frames prior authorization as increasingly opaque and delay-producing, and the bill is written to curb insurer practices that are seen as prioritizing cost savings over care. No committee testimony or recorded votes were provided, so there is no additional public record here showing opposition or amendment debate.
The main points of contention likely center on the bill’s breadth and its automatic-approval penalties, which could be viewed by insurers as limiting utilization management and increasing costs, while providers and patient advocates would likely support the faster timelines and reduced paperwork. Other potentially disputed provisions include the 80 percent exemption threshold for providers, the prohibition on prior authorization for certain services and medications, and the requirement that appeal and denial decisions be made by similarly specialized physicians licensed in Hawaii.
HB954 would add a new chapter to the Hawaii Revised Statutes governing prior authorization and utilization review, imposing disclosure, timing, reporting, and personnel requirements on insurers, HMOs, PPOs, employers offering health benefits, and other entities administering health coverage. It would also create enforceable rights for enrollees and health care providers, including automatic approval remedies, continuity-of-care protections, and limits on retrospective denials and payment recoupment. The bill would require the Insurance Commissioner to adopt implementing rules and would expand state oversight through annual reporting and legislative review.
The bill’s tone and findings are strongly pro-reform and pro-patient, with a clear emphasis on transparency, timely access to care, and reducing insurer interference in medical decision-making. Based on the text alone, the measure appears to have been drafted in response to widespread criticism of prior authorization delays and administrative complexity. No votes or committee transcripts were provided, so there is no recorded legislative debate to indicate formal support or opposition beyond the bill’s own stated policy rationale.
The most likely areas of contention are the bill’s strict deadlines, automatic approval penalties, and limits on insurer utilization review authority. Insurers and utilization review entities may object to the 48-hour and 24-hour decision windows, the prohibition on prior authorization for emergency care and medications for opioid use disorder, and the requirement to honor prior authorizations across plan changes. Providers and patient advocates are likely to support these provisions, especially the specialty-matched review requirements, the 80 percent exemption standard, and the transparency mandates, which are designed to reduce delays and administrative burden.