This bill mandates that health plans and issuers publicly report detailed prior authorization denial rates and enhances transparency in health plan comparisons on Exchanges by including prescription drug cost data.
Craig Goldman
Representative
TX-12
The Prior Authorization Accountability Act mandates that group health plans and insurance issuers publicly report detailed data on their prior authorization approval and denial rates, including appeal outcomes and processing times. This transparency requirement aims to give consumers and regulators a clearer view of how prior authorization decisions are made. Furthermore, the bill enhances plan comparisons on health insurance Exchanges by requiring the inclusion of historical prescription drug cost and coverage data for previously offered plans.
Health Insurance Transparency Act Mandates Public Denial Rates and Tech Disclosures by 2027
The Prior Authorization Accountability Act aims to pull back the curtain on the 'black box' of health insurance approvals. Starting January 1, 2027, group health plans and insurance issuers will be legally required to publicly report exactly how often they say 'no' to medical services and drugs. This isn't just a summary; they have to list every specific item or service that requires prior authorization and disclose the percentage of requests they approved versus those they denied. For anyone who has ever had a doctor’s recommendation stalled by an insurance clerk, this bill provides a way to see if your plan is an outlier in rejecting care.
The Digital Decision-Maker Disclosure
One of the most modern shifts in this bill is the focus on technology. Section 2 requires insurers to reveal how many of their approvals or denials were made solely by artificial intelligence, machine learning, or clinical decision-making algorithms. If you are a software engineer or a warehouse manager, you know that automated systems are only as good as their programming. The bill mandates that companies not only report these numbers but also provide a description of the technology they are using to make these life-altering medical calls. This could be a game-changer for transparency, as it forces companies to own up to how much of their 'medical necessity' review is actually being handled by a human versus a computer script.
Receipts for the Appeal Process
We’ve all heard the advice to 'always appeal,' but this legislation will finally show us if that effort pays off. Plans will have to report the percentage of denied requests that were appealed and, more importantly, how many of those appeals actually resulted in an approval. It also tracks the clock: insurers must publish the average and median time it takes to give you an answer. For a small business owner trying to get a knee surgery scheduled or a parent waiting on a specialist, knowing whether a plan takes three days or three weeks to respond is critical information that currently stays hidden behind corporate walls.
Shopping with Better Data
Looking further ahead to 2029, the bill levels up the health insurance Exchange (like Healthcare.gov). When you’re comparing plans during open enrollment, the website will be required to show you the issuer’s historical data on prescription drug costs. This includes trends on the most expensive drugs and how spending has changed year-over-year. Instead of just looking at a monthly premium and guessing what your prescriptions might cost, you’ll have a breakdown of how the plan has handled drug pricing in the past. While the Secretary of HHS has some leeway in how this data is formatted—which could lead to some 'corporate-speak' if not strictly regulated—the goal is to give you the same kind of transparency you expect when checking reviews for a new car or a laptop before you buy.