By Amy Killelea and Christine Monahan
Prior authorization reform continues to be a high well being care precedence in state legislatures as states work by means of 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 therapy. Insurers, alternatively, argue that utilization administration—a spread of strategies, together with prior authorization, designed to make sure sufferers are receiving acceptable care—are vital to scale back pointless care and to manage prices.
Which view is appropriate? The reply is probably going a mixture of each. Utilization administration may also help be certain that providers lined by a well being plan are protected 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 mistaken, leading to denials of protection which might be the truth is medically vital.
A current report printed by Georgetown College McCourt College of Public Coverage’s Middle on Well being Insurance coverage Reforms (CHIR) provides to this proof, utilizing steady glucose screens (CGMs) as a case examine. CHIR’s evaluation discovered vast variability in protection of CGMs throughout absolutely insured plans and plenty of examples of plan protection standards that don’t align with broadly 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 providers to make sure it isn’t used to disclaim entry to clinically acceptable care.
The Fantastic Print Of Plan Protection Standards
CHIR’s evaluation targeted on protection insurance policies for CGMs, units that enable people to observe their blood glucose ranges each couple of minutes. CGMs make it simpler for folks with diabetes to observe glucose ranges, modify insulin, and stop harmful issues 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 gadget varieties. These standards are sometimes buried inside a plan’s medical necessity or utilization administration coverage paperwork, separate from plan formulary paperwork that always embrace solely whether or not a CGM is roofed and never the tremendous print detailing the precise necessities for protection. Nonetheless, these hard-to-find protection standards embrace crucial 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 fascinating case examine to evaluate whether or not prior authorization insurance policies are aligned with evidence-based requirements of care. In contrast to different providers 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 evaluate of current proof for CGMs, and primarily based on this evaluate strongly recommends early entry to CGMs for folks with insulin-requiring diabetes. But, for privately insured people, entry to CGMs stays uneven, probably partially as a consequence of plan protection boundaries. CHIR’s report discovered widespread use of prior authorization for many lined 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 which may have prevented these harmful swings within the first place presents a irritating and dangerous catch-22. Equally, utilizing totally different medical standards for various gadget varieties when there aren’t any medical variations throughout CGM varieties that may justify differing standards is complicated for sufferers and suppliers; it additionally suggests arbitrary insurance policies which may be extra targeted on value 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 current report from psychological and behavioral well being specialists, for instance, discovered that plan utilization administration and medical necessity insurance policies usually failed to supply entry to typically accepted requirements of look after psychological well being and behavioral well being situations, doubtlessly working afoul of state and federal psychological and behavioral well being protection legal guidelines. One other examine analyzing prescription drug protection insurance policies discovered “weak alignment” between plan protection insurance policies and printed medical tips for explicit medicines; plan insurance policies usually imposed further limitations on prescription drug protection not advisable by medical tips.
Value Issues On Each Sides Of Prior Authorization
Payers might 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 obtainable that will have comparable security and efficacy profiles however totally 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 usually include excessive worth tags that insurance policy go on to shoppers within the type of larger premiums, however failing to successfully handle a continual situation additionally comes with a price ticket due to larger well being care use. Early entry to CGMs, for instance, can cut back emergency division and hospitalization prices for sufferers with diabetes.
The value of insufficient entry to vital care and therapy is commonly quite a bit tougher to quantify and will play out over a time horizon that doesn’t match the typical time shoppers spend on a personal 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 Beneficial Care?
We now have beforehand characterised prior authorization reform as falling into two classes. The primary class consists of course of reforms that search to ease the executive burden of prior authorization, together with reforms that pace up plan protection determination timelines, create uniform prior authorization operational insurance policies, and guarantee prior authorization data is extra transparently obtainable to sufferers and suppliers. Transparency necessities would go a good distance to assist sufferers and suppliers higher perceive each what limitations plans place on explicit providers and the standards sufferers should meet for sure providers to be lined. As CHIR’s analysis discovered, data on CGM protection insurance policies was usually troublesome to seek out, complicated, or incomplete.
The second class consists of extra substantive reforms to prior authorization standards that goal to extra intently 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 important 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 methods to reform prior authorization of their 2026 classes. To make sure, there aren’t any simple options. As well being care prices proceed to rise—significantly for prescribed drugs—prior authorization is a vital value containment mechanism that many coverage makers are detest to eradicate utterly. Nonetheless, they can 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 therapy.
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 Folks-to-Folks Well being Basis, Inc.