马萨诸塞州对保险公司备受诟病的预先授权程序出台了新的限制措施

【中美创新时报2026年6月6日讯】（记者温友平编译）上周五，马萨诸塞州希利政府颁布了相关规定，限制保险公司何时可以要求事先授权开处方药、进行检查以及就诊某些医疗服务提供者。《波士顿环球报》记者马林·沃尔夫对此作了下述报道。

德布拉·夏皮罗医生和她的员工每周都要在剑桥的诊所花费数小时向保险公司申请许可，以便为他们的初级保健患者开具某些药物和进行某些治疗。

繁琐的审批流程，即事先授权，耗费了他们的时间，延误了沙皮罗医生患有胸痛、肠道感染甚至癌症等紧急疾病的患者的治疗。

但上周五，希利政府采取措施缓解这些难题，颁布了相关规定，限制保险公司何时可以要求事先授权开 处方药、进行检查以及就诊某些医疗服务提供者。

这些法规旨在简化某些慢性病（包括糖尿病和哮喘）治疗所需基本服务和药物的繁文缛节。它们还 为更换保险公司的患者提供保护。此外，它们还禁止对物理治疗、职业治疗、语言治疗、产科服务以及治疗严重精神疾病的药物进行事先审批，以及其他一些变更。

哪些服务和药物可以免除事先授权的决定是在与利益相关者举行听证会后做出的。就连将事先授权视为控制医疗支出关键工具的健康保险公司也签署了这些规定。

州长莫拉·希利和支持者表示，这些改革将使人们更快、更便宜地获得医疗服务，同时减轻医疗服务提供者的部分文书工作负担。

“这些改变将使医疗保健系统更好地服务于患者和医护人员，同时帮助人们在正确的时间获得正确的护理，”希利在一份声明中说。

州保险专员迈克尔·卡尔乔表示，患者可能要到年底才能感受到新规带来的变化。在正式实施这些措施之前，州政府将与保险公司和医疗服务提供商举办一系列教育培训。

专家表示，更难预测的是，这些规定究竟会对患者和医生产生多大的影响。

卡尔尤表示，该州的监管机构仅涵盖商业保险市场中约一半的投保人所投保的保险计划。这些人的雇主都“全额投保”，这意味着他们的保险公司承担支付医疗费用的全部责任。

这些规定不适用于直接支付医疗保健费用的“自保型”雇主——而这类雇主占大多数。这意味着，大型雇主仍然可以选择在希利限制的领域要求事先获得授权。

其他不受该规定约束的保险计划包括政府为低收入居民和老年人提供的保险计划，例如 MassHealth 和 Medicare，以及涵盖公共雇员、退休人员及其家属的团体保险委员会。

宾夕法尼亚大学佩雷​​尔曼医学院卫生政策助理教授亚伦·施瓦茨博士表示：“对于医疗服务提供者来说，由于不同保险类型的规则不同，事先授权方面仍然存在大量的不确定性和行政负担。”

包括施瓦茨在内的专家表示，还需要时间来观察这些改变是否能帮助患者更快地获得治疗。

麻萨诸塞州最大的商业保险公司蓝十字蓝盾（Blue Cross Blue Shield of Massachusetts）既提供受保险部门监管的保险计划，也提供不受监管的保险计划。该公司尚未决定是否对其不受监管的保险计划实施新规。

保险公司正在寻求有关某些条款的更多细节，包括取消治疗严重精神疾病的药物和门诊药物滥用障碍服务的事先授权。

“在这些领域，如果没有事先授权，我们可能根本看不到欺诈行为，”蓝十字发言人表示。

蓝十字首席医疗官桑迪亚·拉奥博士补充说，该机构已经遵守了许多新规定。她说，蓝十字只有不到2%的保险索赔需要事先授权。

多年来，马萨诸塞州的医疗保健行业一直饱受成本飙升和支出失控的困扰。随着联邦政府削减对中低收入居民的保险补贴，以及即将对马萨诸塞州医疗补助计划（MassHealth）参保人员实施工作要求，该州领导人正竭尽全力寻找各种方法来加强这个摇摇欲坠的体系。

周五出台的规定代表了一种妥协。

根据改革措施，受影响的保险公司不得要求患者在接受紧急护理、周末或节假日提供的康复护理服务以及用于确定癌症分期的影像检查时，事先获得授权。慢性病管理的授权必须在患者整个治疗期间保持有效，只要患者病情稳定即可。此外，当患者生命受到威胁时，保险公司必须在24小时内做出回应。

与此同时，这些规定也允许健康保险公司在注意到使用率上升导致多个季度支出增加时提出担忧。

代表包括Point32Health和麻省总医院布莱根健康计划在内的多家保险公司的马萨诸塞州健康计划协会支持这些改革。首席执行官洛拉·佩莱格里尼表示，该协会的成员致力于与医疗服务提供商和监管机构合作，落实这些改革措施。

佩莱格​​里尼在一份声明中表示：“但仅靠行政改革无法降低保费或使医疗保健更实惠。这些努力必须与切实有效的行动相结合，以解决成本增长的根本原因——包括不断上涨的医院价格、门诊设施成本和处方药支出。”

保险专员卡尔乔承认，这些规定不会让每个人，甚至任何人，都感到完全满意。

卡尔尤说：“每个人想要的都不一样，有的想要多一点，有的想要少一点。这让我相信，我们已经制定了一套全面而平衡的改革方案。”

题图：州长莫拉·希利一直大力宣传她限制事先授权的努力，这种做法长期以来一直激怒着因保险公司拒赔而感到愤怒的消费者。丹妮尔·帕尔希兹卡兰/《波士顿环球报》记者

附原英文报道：

Mass. has new limits on insurers’ much-hated prior authorizations. Here’s what to know.

By Marin Wolf Globe Staff,Updated June 5, 2026 

Governor Maura Healey has touted her efforts to restrict prior authorizations, a practice that has long drawn the ire of consumers outraged about insurance denials. Danielle Parhizkaran/Globe Staff

Dr. Debra Shapiro and her staff spend hours in their Cambridge practice each week asking permission from insurers to prescribe their primary care patients certain medications and procedures.

The arduous process, known as prior authorization, eats up their time and delays care for Shaprio’s patients experiencing pressing ailments like chest pain, intestinal infections, and even cancer.

But on Friday, the Healey administration took steps to ease those headaches, issuing rules that limit when insurers can require prior authorization for prescriptions and tests, along with visits to certain providers.

The regulations are meant to restrict the red tape surrounding some essential services and medications for managing chronic diseases, including diabetes and asthma. They also establish protections for patients who switch insurance providers. And they ban prior authorizations for physical, occupational, and speech therapies, maternity services, and medications for serious mental illness, among other changes.

The decision over which services and medications to exempt from prior authorizations were determined following hearings with stakeholders. Even health insurers, which view prior authorization as a critical tool for controlling health care spending, have signed onto the regulations.

Governor Maura Healey and supporters say the reforms will make accessing care faster and cheaper while lessening some of the paperwork burden for providers.

“These changes will make the health care system work better for patients and providers while helping people get the right care at the right time,” Healey said in a statement.

State Insurance Commissioner Michael Caljouw said it will likely take until the end of the year for patients to see any changes from the regulations. The state will hold a series of education sessions with insurers and providers before starting to enforce the measures.

What is harder to predict, experts say, is just how much of an impact these rules will actually have for patients and doctors.

The state’s regulatory authority only covers plans that account for about half of the people who purchase insurance in the commercial market, Caljouw said. Those are people whose employers are “fully insured,” meaning their insurer takes on the financial responsibility for paying out medical claims.

The regulations will not apply to “self-insured” employers that pay health care claims directly — the majority of employers. That means large employers could still choose to require prior authorizations in the areas Healey has restricted.

Other insurance plans that are exempt from the regulations include government insurance programs for low-income residents and seniors including MassHealth and Medicare, as well as the Group Insurance Commission that covers public employees, retirees, and their families.

“For providers, there will still be a substantial amount of uncertainty and administrative burden related to prior authorization” because of the differing rules based on insurance type, said Dr. Aaron Schwartz, assistant professor of health policy at the University of Pennsylvania’s Perelman School of Medicine.

Experts, including Schwartz, said it will take time to see whether the changes help patients get care sooner.

Blue Cross Blue Shield of Massachusetts, the state’s largest commercial insurer, offers both plans that are regulated by the Division of Insurance and plans that are not. The organization has not decided whether it will implement the new regulations for the plans not overseen by the division.

The insurer is seeking more details on certain provisions, including the elimination of prior authorizations for medications treating serious mental illness and outpatient substance use disorder services.

“These are some areas we see fraud that, without any prior authorization, we’d be blind to,” a Blue Cross spokesperson said.

Blue Cross Chief Medical Officer Dr. Sandhya Rao added that the organization already follows many of the new regulations. Less than 2 percent of insurance claims at Blue Cross are subject to prior authorization, she said.

For years, Massachusetts’ health care industry has been weighed down by skyrocketing costs and uncontrolled spending. As the state wades through the rubble of reduced federal insurance subsidies for low- and middle-income residents, and stares down impending work requirements for MassHealth enrollees, leaders are scrambling to find any way to bolster a shaky system.

Friday’s regulations represent a sort of compromise.

Under the reforms, affected insurers cannot require prior authorizations on services, supplies, and medications related to urgent care, post-acute care services on weekends or holidays, and imaging to determine the stage of a diagnosed cancer. Approvals for chronic disease management must remain valid for the patient’s entire treatment, as long as the patient remains in stable condition. Insurers must also respond to requests within 24 hours when a patient’s life is in danger.

At the same time, the regulations include a way for health insurers to raise concerns if they notice higher rates of usage driving greater spending over multiple quarters.

The Massachusetts Association of Health Plans, which represents insurers including Point32Health and the Mass General Brigham Health Plan, supported the reforms. CEO Lora Pellegrini said the organization’s members are committed to working with providers and regulators to put the changes in place.

“But administrative reforms alone will not lower premiums or make health care more affordable,” Pellegrini said in a statement. “Those efforts must be paired with meaningful action to address the underlying drivers of cost growth — including rising hospital prices, outpatient facility costs, and prescription drug spending.”

Caljouw, the insurance commissioner, admitted the regulations aren’t going to make everyone — or even anyone — perfectly happy.

“Everybody wants a little bit more, a little bit less, depending on their perspective,” Caljouw said. “That makes me confident that we’ve landed a comprehensive and balanced set of reforms.”