By Amy Killelea and Christine Monahan
Prior authorization reform continues to be a high well being care precedence in state legislatures as states work via the 2026 legislative session. State actions have been pushed by rising frustration from sufferers and suppliers alike who argue that arbitrary prior authorization insurance policies are getting in the best way of entry to clinically acceptable care and remedy. Insurers, alternatively, argue that utilization administration—a variety of strategies, together with prior authorization, designed to make sure sufferers are receiving acceptable care—are mandatory to cut back pointless care and to manage prices.
Which view is appropriate? The reply is probably going a mixture of each. Utilization administration will help be certain that companies coated by a well being plan are secure and efficient for the person affected person and may incentivize use of probably the most cost-effective choices. Nonetheless, a rising physique of proof factors to prior authorization insurance policies getting this calculus fallacious, leading to denials of protection which can be in actual fact medically mandatory.
A latest report revealed by Georgetown College McCourt College of Public Coverage’s Heart on Well being Insurance coverage Reforms (CHIR) provides to this proof, utilizing steady glucose displays (CGMs) as a case research. CHIR’s evaluation discovered extensive variability in protection of CGMs throughout absolutely insured plans and plenty of examples of plan protection standards that don’t align with extensively accepted medical requirements of look after diabetes. These findings might assist inform efforts to place guardrails on prior authorization throughout a broad vary of situations and companies to make sure it isn’t used to disclaim entry to clinically acceptable care.
The Fantastic Print Of Plan Protection Standards
CHIR’s evaluation centered on protection insurance policies for CGMs, units that permit people to observe their blood glucose ranges each couple of minutes. CGMs make it simpler for individuals with diabetes to observe glucose ranges, regulate insulin, and stop harmful problems from drops in blood sugar. Our evaluation checked out whether or not CGMs are subjected to prior authorization (most are), and the medical standards that plans require sufferers to satisfy to get entry to CGMs writ massive or to particular CGM system varieties. These standards are sometimes buried inside a plan’s medical necessity or utilization administration coverage paperwork, separate from plan formulary paperwork that usually embody solely whether or not a CGM is roofed and never the effective print detailing the particular necessities for protection. Nonetheless, these hard-to-find protection standards embody essential data for sufferers and suppliers on whether or not a plan will cowl a selected CGM primarily based on the affected person’s particular person want.
CGM protection presents an attention-grabbing case research to evaluate whether or not prior authorization insurance policies are aligned with evidence-based requirements of care. In contrast to different companies the place there might not be a definitive proof base demonstrating security, efficacy, and medical consensus, the American Diabetes Affiliation (ADA) Requirements of Care features a sturdy assessment of latest proof for CGMs, and primarily based on this assessment strongly recommends early entry to CGMs for individuals with insulin-requiring diabetes. But, for privately insured people, entry to CGMs stays uneven, doubtless partially resulting from plan protection limitations. CHIR’s report discovered widespread use of prior authorization for many coated CGMs in addition to medical standards for CGM protection that aren’t aligned with contemporaneous ADA suggestions.
These discrepancies between a plan’s protection standards and evidence-based medical requirements of care can have profound implications for entry to look after sufferers. For instance, requiring somebody with insulin-requiring diabetes to show cases of blood glucose highs and lows earlier than permitting that affected person to entry the CGM that may have prevented these harmful swings within the first place presents a irritating and dangerous catch-22. Equally, utilizing completely different medical standards for various system varieties when there aren’t any medical variations throughout CGM varieties that will justify differing standards is complicated for sufferers and suppliers; it additionally suggests arbitrary insurance policies that could be extra centered on price management than medical outcomes.
Research have recognized this disconnect between plan prior authorization insurance policies and up-to-date evidence-based requirements of look after different situations exterior of diabetes. A latest report from psychological and behavioral well being specialists, for instance, discovered that plan utilization administration and medical necessity insurance policies typically failed to supply entry to usually accepted requirements of look after psychological well being and behavioral well being situations, probably working afoul of state and federal psychological and behavioral well being protection legal guidelines. One other research analyzing prescription drug protection insurance policies discovered “weak alignment” between plan protection insurance policies and revealed medical pointers for explicit medicines; plan insurance policies typically imposed extra limitations on prescription drug protection not advisable by medical pointers.
Value Issues On Each Sides Of Prior Authorization
Payers could argue that the constraints they place on use are essential to maintain prices down, particularly in areas the place there are a number of therapies accessible that will have related security and efficacy profiles however completely different negotiated costs. And whereas there may be some logic thus far, researchers and economists are fast to level out that there are two sides to the fee ledger. Sure, new medicines and units typically include excessive value tags that insurance coverage move on to shoppers within the type of greater premiums, however failing to successfully handle a continual situation additionally comes with a price ticket due to greater well being care use. Early entry to CGMs, for instance, can scale back emergency division and hospitalization prices for sufferers with diabetes.
The worth of insufficient entry to mandatory care and remedy is usually lots tougher to quantify and will play out over a time horizon that doesn’t match the typical time shoppers spend on a non-public insurance coverage plan. Nonetheless, it’s an necessary consideration as payers and coverage makers weigh the fee implications of prior authorization reforms.
How Are Coverage Makers Reforming Prior Authorization To Guarantee Sufferers Have Entry To Clinically Advisable Care?
We now have beforehand characterised prior authorization reform as falling into two classes. The primary class contains course of reforms that search to ease the executive burden of prior authorization, together with reforms that velocity up plan protection determination timelines, create uniform prior authorization operational insurance policies, and guarantee prior authorization data is extra transparently accessible to sufferers and suppliers. Transparency necessities would go a great distance to assist sufferers and suppliers higher perceive each what limitations plans place on explicit companies and the standards sufferers should meet for sure companies to be coated. As CHIR’s analysis discovered, data on CGM protection insurance policies was typically tough to search out, complicated, or incomplete.
The second class contains extra substantive reforms to prior authorization standards that intention to extra carefully tether prior authorization to medical requirements of care. Pursuing substantive reforms is extra immediately related to addressing the disconnect between plan protection insurance policies and entry to clinically acceptable care. Substantive prior authorization reforms have included requiring plans to quote peer-reviewed proof to justify prior authorization choices (for instance, Alaska), prohibiting prior authorization for sure interventions the place the proof base signifies vital advantages from entry and harms from delays or inappropriate denials (for instance, Colorado and Nebraska), and requiring prior authorization appeals to be reviewed by a supplier with requisite experience within the medical space at situation (for instance, Delaware).
Prior authorization has emerged as a legislative precedence over the previous a number of years, and states are persevering with to grapple with the way to reform prior authorization of their 2026 classes. To make sure, there aren’t any straightforward options. As well being care prices proceed to rise—significantly for prescribed drugs—prior authorization is a crucial price containment mechanism that many coverage makers are detest to remove utterly. Nonetheless, they are able to discover center floor in insurance policies that put in place guardrails for prior authorization use to make sure sufferers nonetheless have entry to clinically advisable care and remedy.
Christine H. Monahan and Amy Killelea “Steady Glucose Monitor Protection Standards And The Want For Prior Authorization Reform” Might 7, 2026, https://www.healthaffairs.org/content material/forefront/continuous-glucose-monitor-coverage-criteria-and-need-prior-authorization-reform. Copyright © 2026 Well being Affairs by Venture HOPE – The Individuals-to-Individuals Well being Basis, Inc.
