Creates provisions relating to prior authorization of health care services
HB 618 would create a new set of Missouri statutes governing when health carriers and utilization review entities may require prior authorization for health care services. Beginning January 1, 2026, a carrier generally could not require prior authorization for a provider unless, in the most recent 12-month evaluation period, it approved or would have approved less than 90% of that provider’s prior authorization requests for the relevant service, or less than 90% of all requests from that provider across services. The bill also allows hospitals to qualify for exemptions based on a value-based care agreement, a CMS Five-Star Quality Rating of 3 or higher, or a 91% approval threshold, while exempting critical access hospitals and hospitals not in the CMS rating system from that hospital-specific provision.
The bill limits the exemption from prior authorization for certain categories of care, including pharmacy services and imaging services up to $100,000 each, cosmetic procedures that are not medically necessary, and investigative or experimental treatments. Those dollar caps would be adjusted annually for inflation starting in 2027. The bill also sets rules for how approval rates are calculated, excludes appealed denials and out-of-benefit-plan requests from the calculation, requires use of a provider identifier, permits internal audits and rescission of exemptions under certain conditions, and voids exemptions if the provider is later found by a court to have committed fraud or abuse.
HB 618 also adds procedural protections and transparency requirements. Carriers or utilization review entities must notify providers within 25 days of a determination, provide supporting data, establish an appeal process, and maintain an online portal showing prior authorization decisions and related status information. The bill further prohibits carriers from denying or reducing payment for a service that had prior authorization unless the provider knowingly misrepresented the service to obtain payment or failed to substantially perform the service. It also creates a 90-day medication grace period when a patient’s health plan changes after prior authorization has already been granted.
The bill’s impact on state law is to substantially restrict prior authorization practices in Missouri’s commercial health insurance market and to create a provider-performance-based exemption framework that could reduce administrative burden for providers with high approval rates. It expressly does not apply to MO HealthNet, except that Medicaid managed care organizations are treated as health carriers for these purposes, and it does not apply to providers who have not participated in a plan for at least one full evaluation period. The bill also preserves licensure limits and does not require payment for services outside a provider’s license.
The overall sentiment appears strongly favorable in the House, as reflected by the 148-4 third-reading vote. No committee transcript was provided, so there is no recorded debate to identify detailed arguments, but the vote suggests broad support for easing prior authorization requirements. Likely points of contention include the administrative and utilization-management impact on insurers, the 90% approval threshold and audit/rescission standards, and whether the bill could increase costs or reduce oversight, while supporters likely view it as a patient- and provider-friendly reform that reduces delays in care.
HB 618 would add five new sections to Chapter 376, RSMo, creating a new statutory framework that limits when health carriers and utilization review entities may impose prior authorization requirements. It would also impose notice, appeal, portal, and payment-protection requirements on carriers, while carving out MO HealthNet and certain providers and services. The bill would affect health carriers, utilization review entities, hospitals, physicians, and other health care providers by changing prior authorization rules and creating exemptions tied to approval rates and quality measures.
The available voting history indicates strong support for the bill in the House, with passage on third reading by a 148-4 vote. No committee discussion transcript was provided, so there is no direct record of floor or committee debate. Based on the vote margin and the bill’s subject matter, the general sentiment appears to favor reducing prior authorization burdens and increasing transparency for providers and patients.
The main likely points of contention are the bill’s restrictions on insurer prior authorization authority, the 90% approval-rate trigger for exemptions, and the operational burden of audits, appeals, and portal reporting. Insurers and utilization review entities may object that the bill limits cost-control and medical-management tools, while providers and patient advocates are likely to support the reduction in administrative delays. Additional tension may arise over the carveouts for pharmacy and imaging services, the exclusion of MO HealthNet, and the bill’s treatment of hospitals based on CMS ratings or value-based care arrangements.