This year, the ACG Board of Governors and the Legislative & Public Policy Council have actively pursued state reforms to expand access to colorectal cancer screening, reign in prior authorization and step therapy requirements, and address other important GI clinical practice priorities.
With many states’ legislative sessions coming to an end, here is a summary of the state-level public policy wins so far in 2023-24. We will continue to update this page as new legislation passes – contact us if we missed legislation in your state. You can also use our Legislative Action Center to get involved! Our simple and user-friendly process only takes a few minutes.
Why are these state actions important? Many commercial health insurance plans (e.g., fully-funded) and coverage determinations are still largely regulated at the state level. ACG continues to advocate for broader, federal reforms through Congressional action and regulations that would impact patients on Medicare, Medicaid, Affordable Care Act marketplace plans, and large group health plans.
ACG continues to be your home for clinical GI and in state houses across the country and in Washington, D.C.
Colorectal Cancer Screening
California: Insurers would be required to cover a “colorectal cancer screening test” that is assigned an A or B grade by the USPSTF or an equivalent recommendation from another certified guideline agency (e.g., ACG guidelines).
- Note: This bill is pending action by the state Senate, but received unanimous support in the Assembly. California members, tell your state senator to support this change!
Kentucky: Effective January 1, 2025, insurers are required to cover “any cancer screening or test” that is consistent with nationally-recognized clinical practice guidelines (e.g., ACG guidelines, USPSTF recommendations). The screenings must be covered without cost-sharing or utilization management requirements.
Illinois: Effective Jan. 1, 2026, insurers are required to cover any “medically necessary” colonoscopy, without patient cost-sharing. Previously, Illinois law only required coverage of a colonoscopy conducted as a follow-up to another, initial screen.
- This bill is awaiting action from the governor, but we expect it to become law after passing the Illinois Senate and House unanimously.
Nebraska: Effective Jan. 1, 2025, insurers are required to cover, without cost sharing, any service that is an “integral part” of a colorectal cancer screening, such as polyp removal, pathology examinations, bowl preparation medications, and anesthesia.
Vermont: Effective Jan. 1, 2025, insurers are required to cover CRC screenings in accordance with USPSTF recommendations for average-risk individuals, without patient cost-sharing. Previously, Vermont only required screenings for those 50 years and older, and now the law does not need to be updated each time new recommendations are issued.
Prior Authorization & Step Therapy
Colorado: A suite of prior authorization reforms passed, including the items below.
- An extended duration of prior authorization approval from 180 days to a full calendar year, effective Jan. 1, 2026.
- For FDA-approved chronic maintenance drugs, insurers or PBMs cannot impose prior authorization more than once every three years if they previously approved a prior authorization request for that patient, effective Jan. 1, 2027.
- Various prior authorization transparency measures that will allow the public to see the number of requests, approvals, appeals, and exemptions. Additionally, the bill establishes the legal framework for a ‘gold card’ program in the state to take effect “no later than” January 1, 2026.
Maryland: Effective January 1, 2025, the new law does the following …
- Requires prior authorization requests for chronic conditions be approved for “as long as necessary to avoid disruptions in care.”
- For patients who change insurance carriers, requires the new insurer to honor previously-approved prior authorizations for 90 days or the length of the course of treatment, whichever is less.
- Requires insurers to provide additional information as to why a utilization management request was denied; and
- Specifically outlines what qualifies as an emergency prior authorization request.
Mississippi: Effective July 1, 2024, the Mississippi Prior Authorization Reform Act …
- Requires insurers to respond to non-urgent prior authorization requests within seven calendar days and urgent requests within 48 hours.
- Requires all adverse determination appeals be conducted by a physician who is board certified in, and has experience treating, the patient’s condition.
- Requires insurers to make available a standard, electronic prior authorization form by January 1, 2025 and then beginning on January 1, 2027, all healthcare providers are required to use those forms.
New Mexico: Effective January 1, 2025, the following reforms to step therapy protocols take effect …
- Insurers are no longer permitted to leverage step therapy requirements or prior authorizations on patients with autoimmune disorders, except when a biosimilar, interchangeable biologic, or generic is available.
- If an insurer grants an exception, it remains in place as long as the drug is therapeutically effective for the patient; previously, the law allowed insurers to revoke the exception at any time.
New York: As of March 21, 2024, insurers have been required to include the clinical rationale and appeals instructions for a step therapy adverse determination.
Oklahoma: Effective January 1, 2025, the new law …
- Requires insurers to respond to non-urgent prior authorization requests within seven days and urgent requests within 72 hours.
- Requires all adverse determination appeals be conducted by a physician who is board certified in, and has experience treating, the patient’s condition.
- Requires insurers to make available a standard, electronic prior authorization API by January 1, 2027 and then beginning on July 1, 2027, all healthcare providers are required to have an EHR compatible with that API.
Vermont: Effective January 1, 2025, the new law …
- Requires insurers to respond to non-urgent prior authorization requests within two business days, and urgent requests within 24 hours.
- Requires a prior authorization approval to remain in place for duration of treatment or one year, whichever is longer. For chronic conditions, insurers may not request additional prior authorization more than once every five years.
- For patients who change insurance carriers, requires the new insurer to honor previously-approved prior authorizations for at least 90 days.
- Allows providers to request an exemption to a step therapy protocol if the patient is “stable on a prescription drug”, as well as expected ineffectiveness.