(Boston Orange 編譯) 麻州州長奚莉 (Maura Healey) 今（14 ）日宣佈，保險局 (Division of Insurance, DOI) 已落實更新條例，取消針對癌症掃描、氣喘、糖尿病及心臟病等慢性病例行與必要醫療保健的預先授權 (Prior authorization) 要求。該法規將於 2026 年 6 月 5 日生效。
這項新規定禁止保險公司對多項醫療服務實施預先審查，範疇涵蓋急診、初級照護、預防性服務、癌症診斷後的放射影像檢查、產科護理、門診物質使用障礙治療，以及針對嚴重精神疾病與特定慢性病的藥物治療。
根據條例，若延遲可能嚴重影響患者健康，保險公司必須在 24 小時內回覆緊急授權請求。
針對癌症等慢性病患者，只要病情保持穩定，獲得授權的治療方案將在整個療程中持續有效。此外，新制建立「持續照護」機制，要求保險公司必須承認患者在更換保險計劃前已取得的授權，有效期至少 90 天。保險公司亦被要求公開發布預先授權要求，並在更改政策前提前通知醫療提供者。
奚莉州長指出，若醫師建議治療或用藥，患者應及時獲得，無需經過繁瑣程序。副州長Kim Driscoll 與保險專員Michael Caljouw)表示，此舉旨在減少患者壓力並提高醫療獲取性。丹娜法伯癌症研究所 (Dana-Farber Cancer Institute) 執行長本傑明·艾伯特 (Dr. Benjamin L. Ebert) 指出，新制讓癌症患者能在診斷後立即進行核磁共振 (MRI) 或電腦斷層 (CT) 掃描，無需等待審核，有助於縮短決定治療方案的時間。
根據可負擔醫療品質委員會 (Council for Affordable Quality Healthcare) 數據，醫療產業於 2023 年在預先授權相關的行政成本支出約 13 億美元，較前一年成長 30%。這項改革預計將減少醫療提供者與保險公司的行政負擔。麻州醫學會 (Massachusetts Medical Society) 與麻州健康與醫院協會 (Massachusetts Health & Hospital Association, MHA) 等多個業界團體均表示支持。
Governor Healey Announces Final Regs That Eliminate Prior Authorization Requirements for Routine and Essential Health Care
Updated regulations eliminate prior authorization requirements for cancer scans and medications for chronic conditions like asthma, diabetes and heart disease
BOSTON - Governor Maura Healey today announced that the Division of Insurance (DOI) has finalized updated regulations that eliminate prior authorization requirements for routine and essential health care, including cancer scans and medications for chronic conditions like asthma, diabetes and heart disease.
The regulations will reduce delays and eliminate barriers that too often prevent patients from getting timely health care. Prior authorization requires patients and providers to obtain approval from insurance companies before certain treatments, services or medications can be provided, which can add unnecessary delays, stress and costs.
During the public comment period additional provisions were added to eliminate prior authorization for radiology imaging used after a cancer diagnosis to determine the stage of the cancer or determine the best treatment method, as well as to ensure that prior authorization approval for chronic conditions, like cancer, continue throughout the entire course of treatment.
“We’re making it easier, faster and cheaper for Massachusetts residents to get the care that they need,” said Governor Healey. “If your doctor says you need a treatment or medication, you deserve to get it in a timely manner without jumping through hoops. These new regulations will help people with cancer, diabetes, asthma, heart conditions, mental health concerns and more. I’m grateful for the leadership of Commissioner Caljouw and the team at DOI, and all of the patients, providers, hospitals, insurers and advocates who partnered with us to make this possible. We’re going to continue to work together to lower health care costs for everyone.”
“Health care access and affordability remain top concerns for people across Massachusetts,” said Lieutenant Governor Kim Driscoll. “These new rules will cut down on unnecessary delays, stress and costs by making it easier for patients and families to access essential care.”
“These reforms will ensure Massachusetts residents get the care they need when they need it,” said Insurance Commissioner Michael Caljouw. “We would not be here without the collaborative approach of stakeholders towards the crafting of these meaningful changes.”
“Health care access is essential to strong communities and a competitive economy,” said Economic Development Secretary Eric Paley. “By reducing delays and eliminating unnecessary barriers to treatment, these reforms will help patients get care faster and make the health care system more reliable for residents and providers across Massachusetts.”
“We applaud the Healey Administration for prioritizing much-needed reforms to the prior authorization process, which will help Massachusetts residents get the timely health care they need and deserve,” said Dr. Benjamin L. Ebert, president and CEO of Dana-Farber Cancer Institute. “The reforms announced today will allow patients and families to focus on treatment and healing while also giving doctors and nurses more time to care for their patients. We look forward to continuing our collaboration with the Administration and our healthcare partners to enhance the progress made today, ensuring that prior authorization works better for everyone.”
The reforms are the result of months of review and feedback from patients, providers, hospitals, insurers, and advocates across Massachusetts. The new regulations prohibit the use of prior authorization requirements for a wide range of health care services, including emergency and urgent care, primary care, preventive services, radiology imaging after a cancer diagnosis, maternity care, outpatient substance use disorder treatment, physical and occupational therapy and medications for serious mental illness and certain chronic conditions.
The regulations also establish new patient protections, including requiring insurers to respond to urgent requests within 24 hours when delays could seriously impact a patient’s health. Patients with chronic conditions, including cancer, who receive authorization for treatment will also have approvals honored for the duration of their treatment as long as they remain stable.
Additional reforms will help ensure continuity of care for patients who switch insurance plans by requiring insurers to honor existing authorizations for at least 90 days. Insurers will also be required to publicly post prior authorization requirements and notify providers in advance before making changes to their policies.
The regulations will reduce administrative burdens on providers and insurers alike, reducing costs while helping patients receive care more quickly and consistently. According to the Council for Affordable Quality Healthcare, the health care industry spent approximately $1.3 billion on administrative costs related to prior authorization in 2023. That is a 30 percent increase over the previous year and can be largely attributed to the rise in the volume of prior authorizations.
Examples of how these reforms will help patients include:
• A patient with a chronic condition like diabetes, asthma or heart disease, or who has a serious persistent mental illness, will no longer have to obtain prior authorization for their medication.
• A cancer patient receiving treatment will maintain approval throughout the course of treatment if their condition remains stable.
• A patient who was recently diagnosed with cancer will not have to wait for prior authorization before getting the MRI or CT scan needed to determine what stage their cancer is or what treatment is required.
• A patient with rheumatoid arthritis who has an existing authorization for his treatment but recently switched to a new insurer will have that prior authorization honored for at least three months.
• An insurer will be required to respond to a prior authorization request from a multiple sclerosis patient experiencing a relapse and needing steroid injections to prevent permanent nerve damage within 24 hours.
• A provider who recently diagnosed their patient with a new condition will more easily be able to identify if a prior authorization is required for a particular course of treatment.
• Patients facing urgent medical situations will receive faster responses from insurers when time-sensitive care is needed.
The regulations will take effect on June 5, 2026, with patients expected to begin benefiting from these changes later this year.
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