SF3706

Purpose

• To change how health insurance plans handle prior authorization (the process to approve certain care before it's covered). The bill aims to remove prior authorization requirements for many kinds of care, including emergencies, most outpatient mental health and substance use treatment (with some medication-related exceptions), certain cancer treatments, many preventive services, and long-term medications. It would still require prior authorization for medications used in some cases and directs how determinations are processed when needed. It also adds coverage expectations for vaccines and certain preventive services and for hospice and neonatal abstinence-related care. The changes would apply to plans offered, issued, or renewed on or after January 1, 2026.

Main Provisions

• Emergency care: No prior authorization may be required for emergency confinement or emergency services. The enrollee or their authorized representative must notify the plan as soon as reasonably possible after the emergency begins.

• Outpatient mental health and outpatient substance use disorder treatment: No prior authorization for the services themselves. Prior authorizations would still apply for medications used for these treatments, processed under existing rules (initial determinations and appeals).

• Antineoplastic (cancer) treatment: No prior authorization for cancer treatment that is not a medication, when it follows NCCN guidelines. Prior authorizations would still apply for medications used to treat cancer, processed under the same existing procedures as above (initial determinations and appeals).

• Immunizations and preventive services: No prior authorization for services and immunizations that have a high rating (A or B) from the U.S. Preventive Services Task Force, immunizations recommended by the CDC’s ACIP, and certain preventive services and screenings for women described in federal regulations.

• Pediatric hospice and neonatal abstinence programs: No prior authorization for pediatric hospice services or for treatment delivered through a neonatal abstinence program operated by pediatric pain or palliative care specialists.

• Long-term medications: No prior authorization for drugs prescribed for and used on an ongoing basis by the enrollee for the six months prior to the request (i.e., ongoing maintenance medications).

Significant Changes to Existing Law

• Eliminates prior authorization requirements for:

  • Emergency confinement and emergency services.
  • Outpatient mental health and outpatient substance use disorder treatment (excluding medications for these treatments).
  • Certain non-medication cancer treatments that align with NCCN guidelines.
  • Many immunizations and high-priority preventive services (USPTF A/B rated, ACIP-recommended vaccines, and specified women’s preventive services).
  • Pediatric hospice services and services in neonatal abstinence programs.
  • Drugs used on an ongoing basis for at least the previous six months.

• Maintains prior authorization for:

  • Medications used in outpatient mental health and outpatient SUD treatment.
  • Medications used for antineoplastic cancer treatment (even when the cancer treatment itself may not be a medication).

• Sets an effective date for these changes: January 1, 2026, with the new rules applying to health benefit plans offered, issued, or renewed on or after that date.

Effective Date and Scope

• Effective January 1, 2026.
• Applies to health benefit plans offered, sold, issued, or renewed on or after that date.

Notable Definitions / Context (as described in the bill)

• Prior authorization (prior authorization requirements)
• Emergency confinement and emergency services
• Outpatient mental health treatment
• Outpatient substance use disorder treatment
• Antineoplastic cancer treatment
• NCCN guidelines (National Comprehensive Cancer Network)
• Medications (pharmacologic treatments)
• Initial determinations and appeals (processing steps for medication-related determinations)
• USPSTF (U.S. Preventive Services Task Force) ratings (A or B)
• Immunizations and ACIP guidance (CDC)
• Preventive services and screenings for women (as described in federal regulations)
• Pediatric hospice services
• Neonatal abstinence program (and pediatric pain/palliative care subspecialists)
• Enrollees’ ongoing medications (six-month usage window)

Relevant Terms - prior authorization - utilization review organization - health plan - emergency confinement - emergency service - outpatient mental health - outpatient substance use disorder treatment - medications - antineoplastic cancer treatment - NCCN guidelines - initial determinations - appeals - United States Preventive Services Task Force (USPSTF) - immunizations - Advisory Committee on Immunization Practices (ACIP) - Centers for Disease Control and Prevention (CDC) - immunizations rating A or B - preventive services - screenings for women (CFR 45.147.130) - pediatric hospice services - hospice provider (licensed under 144A.75 to 144A.755) - neonatal abstinence program - pediatric pain or palliative care subspecialists - six months (ongoing drug use/usage window) - health benefit plans - January 1, 2026 (effective date)