Chronic care approvals would last longer for treatment, tests, and prescriptions

A carrier would keep an approved authorization for chronic-condition treatment valid for the treatment period or one year, whichever is longer. This applies when a carrier requires approval for care to treat a diagnosed condition expected to last at least six months that needs ongoing medical attention to manage or prevent harm, or limits daily activities. If treatment is needed for more than one year, the carrier could require renewal no more than once every three years. The carrier would honor the approval through its expiration while the enrollee remains covered by the same plan. Approval would start when the enrollee receives notice and last for the treatment period or one year, whichever is longer.

A carrier would keep approval for a diagnostic procedure or test valid for necessary repeat orders. This covers diagnostic procedures or tests related to treating a chronic condition, as defined in the amendment. For a test or procedure continuing more than one year, the carrier could require renewal no more than once every three years. Approval would start when the enrollee receives notice and last for the diagnosis period or one year, whichever is longer.

If a carrier approves a requested prescription drug, it would cover the drug for the prescription period, including refills, and keep approval valid despite a dosage change. This applies to a prescription when the carrier grants coverage for the requested drug. Approval could be rescinded for doses above limits set by federal or state law, rule, or regulation. For a prescription lasting more than one year, renewal could be required no more than once every three years. Approval would start when the enrollee receives notice and last for the prescription period or one year, whichever is longer.

A carrier would not restrict coverage for certain chronic-condition care approved by an enrollee's previous carrier. This covers care, tests, or prescriptions approved by a previous carrier within 90 days before the enrollee joined the new plan. The enrollee's provider must determine that the care should continue. The carrier must give at least 90 days' notice before restricting coverage under this provision. The prior approval must fall within the 90 days before enrollment; any notice must come at least 90 days before the restriction.