Generally revise insurance laws related to prior authorization of chronic conditions
HB 398 revises Montana’s utilization review and prior authorization rules for health insurance plans. The bill requires health insurers and their utilization review organizations to honor a prior certification for at least the first three months after a covered person changes health plans, so long as the service remains covered under the new plan. It also requires existing certifications to continue to be honored when a person moves to another product offered by the same insurer, and it protects previously approved services from being affected by later changes in coverage or approval criteria for the remainder of the authorization period or the plan year, whichever is shorter.
The bill also tightens who may make adverse determinations and review grievances. In general, adverse determinations must be made by a physician or by a health care professional in the same profession as the requesting provider, and grievance reviews must be done by a physician with the appropriate specialty and an unrestricted license. The bill further requires adverse determinations to be made under the clinical direction of a licensed physician medical director. It also updates the statutory definition of “adverse determination” and extends the validity of certifications for approved services from three months to six months, while keeping a 12-month validity period for services treating chronic conditions, subject to FDA guidance or patient safety concerns.
The bill’s impact is primarily on Title 33, chapter 32 of the Montana Code Annotated, which governs utilization review by health insurers and utilization review organizations. It adds new operational requirements for insurers, strengthens continuity of care protections for insured patients, and narrows the qualifications of reviewers making medical necessity and grievance decisions. Covered persons with ongoing or previously authorized treatment, especially those with chronic conditions, are the main beneficiaries, while insurers and utilization review vendors must adjust their review processes and staffing to comply.
The general sentiment around HB 398 appears strongly favorable and bipartisan. It passed the House and Senate with large margins, including unanimous committee approval in both chambers and only a small number of floor votes in opposition. The voting history suggests broad agreement that the bill improves continuity of care and ensures that medical review decisions are made by appropriately qualified clinicians.
There is little visible contention in the available record, but the bill’s requirements could raise concerns for insurers and utilization review organizations about administrative burden, staffing, and reduced flexibility in prior authorization and grievance review processes. Any opposition likely centers on the added cost and operational constraints of requiring physician-level review and longer certification periods, while supporters appear focused on patient protections, continuity of treatment, and more clinically informed decision-making.
HB 398 amends Montana’s insurance utilization review statutes, specifically sections 33-32-102 and 33-32-107, MCA, and adds new codified requirements within Title 33, chapter 32. It extends the duration of approved certifications, creates continuity-of-care protections when a covered person changes plans or products, and imposes stricter licensure, specialty, and experience requirements on individuals making adverse determinations or reviewing grievances. The bill affects health insurance issuers, utilization review organizations, physicians, other health care professionals, and covered persons receiving prior authorized services, especially those with chronic conditions.
The bill was received positively overall and moved with strong bipartisan support. It passed committee unanimously in both chambers and cleared floor votes by wide margins, indicating broad legislative agreement with its patient-protection and clinical-review provisions. The limited number of dissenting votes suggests only modest opposition.
The main policy tension is between patient continuity and insurer utilization management. Supporters favor longer-lasting authorizations, continuity when switching plans, and requiring physician or similarly qualified clinical review to reduce denials that may be made by less specialized reviewers. Potential critics are insurers and utilization review organizations, who may view the bill as increasing administrative costs, limiting flexibility in prior authorization decisions, and constraining non-physician review staff. No detailed committee debate is available, so the record shows little explicit controversy beyond these likely implementation concerns.