Massachusetts issues final prior authorization rule

The Massachusetts Division of Insurance (DOI) has finalized its prior authorization regulations, which went into effect on June 5. Implementation will be phased, with the DOI indicating that additional guidance will be issued through educational sessions planned throughout June. Carriers must submit implementation plans by September.

The regulations will prohibit prior authorization for several services, including primary care and rehabilitative therapies such as occupational, physical, and speech therapy. The final rule also expands on the proposed rules by adding targeted prohibitions for certain medications used to treat serious and persistent mental illness, as well as post-diagnosis, cancer-related imaging used for staging and treatment monitoring, except for PET scans. The regulations strengthen continuity of care requirements by requiring that prior authorization approvals for chronic conditions remain in place for the duration of a stable course of treatment.

This protection continues unless there is a change in medication, provider, or treatment plan. The rule further narrows the scope of prior authorization prohibitions related to chronic conditions. Rather than applying broadly, the requirement is now limited to specific medications for diabetes, asthma, and cardiovascular conditions. Lastly, the regulations include a process for carriers to request DOI approved exceptions where utilization patterns support the need for additional management.