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Bill would tighten prior-authorization rules, set time limits and continuity protections
Summary
Senate Bill 434, introduced Sept. 29, 2025, would require faster prior-authorization decisions, minimum one-year authorizations, and 90-day continuity of prior approvals when enrollees switch plans. The bill also limits retroactive payment denials except for provider misrepresentation or enrollee ineligibility.
Senate Bill 434, introduced Sept. 29, 2025, would impose new timing, documentation and transparency requirements for prior authorization under Wisconsin health plans, including insurer-administered and certain limited network products. The bill was introduced by Senators Cabral-Guevara, Jacque and Nass and cosponsored by Representatives Dittrich, Behnke, Goeben, Kreibich, Maxey, Mursau and Palmeri; it was referred to the Committee on Insurance, Housing, Rural Issues and Forestry.
The measure defines "prior authorization" as the process by which utilization review entities determine medical necessity or appropriateness of otherwise covered services before they are provided. It requires that adverse determinations — decisions that a proposed service is not medically necessary, experimental or investigational and therefore denied, reduced or terminated — be made by a physician, physician assistant, or advanced practice registered nurse who may issue prescription orders, and that those determinations be made under the clinical direction of a utilization-review medical director licensed in Wisconsin.
Under the bill, utilization review entities must issue an authorization or an adverse determination within 72 hours after receiving all necessary information in nonurgent cases. For services that meet the bill's definition of "urgent health care service," the deadline is 24 hours after receipt of all necessary information. The bill specifies that necessary information may include results of required face-to-face clinical evaluations or second opinions.
Authorizations would be valid for at least one year from the date the provider receives the authorization and must remain effective despite changes in a drug's form, dosage or method of administration or changes in frequency, extent or duration of a health care service. An authorization for treatment of a chronic or long-term care condition — defined in the bill as a condition that has persisted for at least one year despite reasonable efforts to relieve or cure it — remains valid for the duration of treatment and may not be reauthorized repeatedly.
The bill also addresses continuity of care when enrollees change coverage. A utilization review entity for a new health benefit plan or self-insured plan must accept documentation of a prior authorization rendered by the prior utilization review entity for at least 90 days of the enrollee's coverage under the new plan; during that 90-day period the new entity may perform its own prior authorization. If coverage or utilization-review criteria change, those changes may not affect an enrollee who received an authorization before the effective date of the change for the remainder of that plan year. The bill further requires a health insurer to continue to accept an authorization it previously rendered when an enrollee changes coverage offered by the same insurer.
On payments, the bill bars retroactive denial of payment for a service for which an authorization was rendered, except in two circumstances: (1) the provider knowingly and materially misrepresented the service to the utilization review entity with intent to deceive and obtain unlawful payment; or (2) the enrollee was not eligible for coverage on the day the service was performed.
The bill creates statutes numbered 609.815 and 632.848 and amends multiple cross-referenced provisions in existing law to subject specified plan types (including limited service health organizations, preferred provider plans and defined network plans) to the new requirements. It sets the effective date as Sept. 1, 2026, or the first day of the seventh month after publication, whichever is later.
The text does not record floor or committee debate, votes, fiscal estimates beyond a statutory note that the proposal "may contain a health insurance mandate" requiring a social and financial impact report, or implementation details such as enforcement mechanisms or administrative penalties beyond the statutory standards themselves.
