BY JEFFREY PERKINS, MMS LEGISLATIVE & REGULATORY AFFAIRS COUNSEL
For physicians, prior authorization is not an abstract policy issue. It is the phone call that delays chemotherapy, the January scramble to reapprove a stable patient’s medication, or the hours spent navigating insurer portals instead of caring
for patients in the exam room.
In January 2026, the Massachusetts Division of Insurance (DOI) released draft prior authorization (PA) regulations designed to address long-standing concerns about delays in care and excessive administrative burden. The proposal follows the DOI’s
Examination Report reviewing PA practices across Massachusetts insurers. The report concluded that PA frequently delays medically necessary treatment and places a disproportionate burden on physician practices, hospitals, and patients.
At its February 2026 draft regulations listening session, the DOI opened by acknowledging the Massachusetts Medical Society’s (MMS) sustained and strategic leadership on PA reform. Most notably, the MMS launched the Prior Authorization Reform
Coalition — bringing together MMS, the Massachusetts Health and Hospital Association, and Health Care for All — to advocate for comprehensive legislative reform through An Act relative to reducing administrative burden (S.1403/H.4616).
The Coalition’s goal is clear: ensure timely access to medically necessary care for patients while reducing the administrative burdens that undermine physicians’ ability to deliver it. The DOI’s proposed regulatory reforms reflect the impact
of that advocacy.
What the Draft Regulations Would Change
The DOI draft regulations, which apply to fully funded commercial plans, introduce several important reforms.
Most notably, they would eliminate prior authorization for emergency and urgent care, primary care, maternity care, occupational and physical therapy, substance use disorder treatment, certain prescription drugs used for chronic disease management,
inpatient acute care services, and post-acute services delivered on weekends and holidays.
The regulations would also enforce strict deadlines for insurer decisions for urgently needed care, building upon existing statutory timeframes. Specifically, where a delay could seriously jeopardize a patient’s health, insurers would be required
to respond within 24 hours. If an insurer fails to issue a decision within the required timeframes, the request would be deemed approved.
To improve continuity of care for patients, when an insured moves to a new plan, an existing PA must be honored by the new carrier for at least 90 days after enrollment, provided that the original requesting provider is in-network and the service is a covered benefit under the new health benefit plan.
Taken together, these reforms represent a meaningful first step toward improving patient access to care and reducing administrative waste, but they need to be codified through legislation and strengthened if they are to fully achieve their intent.
Physician Voices Shape the Next Phase
During the DOI’s February 2026 hearing, MMS organized physicians from across the state to share firsthand experiences and recommendations for strengthening the proposal.
Dr. Kate Atkinson, a primary care physician in Northampton, emphasized the strain repeated authorizations place on both patients and physicians. “It takes months of our time racing around trying to get drugs approved that somebody’s been on for
a chronic disease for years — it makes no sense,” she said. Requiring repeated approvals for stable, long-term treatment wastes clinical time and needlessly disrupts patient care.
Dr. Chris Garofalo, a family physician in North Attleboro, echoed this concern. “Chronic conditions do not respect a calendar, and physicians dread January 1 for reasons other than the weather,” he noted. “The hassle associated with renewing prior
authorization year after year, when there has not been a change in clinical condition, exacerbates patient access issues.” Annual resets that ignore clinical stability create preventable barriers for patients and providers alike.
He also urged the DOI to clarify how the prohibitions on PA for primary care services will work in practice. “Right now, patients do not need permission to see a primary care physician and receive office care,” he said. “It’s the care flowing
from the visit — the labs, imaging, and medications prescribed by the physician — that are the real challenge for physicians and patients. And it’s not clear from the regulations whether that care would be covered under the prohibition on
prior authorizations for primary care services. We ask you to consider that care ordered by a primary care physician specifically not be subject to PA.”
Their testimony underscored an essential point: reform must work in real-world clinical settings.
The Work Ahead
While the draft regulations represent important progress, regulatory reform alone is not enough. MMS has formally submitted detailed recommendations to clarify and strengthen the proposed regulations, ensuring they deliver tangible improvements for patients and physicians.
At the same time, MMS continues to advocate for comprehensive legislation that would codify these changes and go further in protecting access to high-quality care and reducing administrative burden. At the March 25, 2026, Doctors’ Day at the State
House, physicians across the Commonwealth reinforced a shared message: regulatory progress must be paired with legislative action to drive lasting, impactful change.
After much effort, prior authorization reform is underway. With continued physician engagement and advocacy, these reforms can fulfill their promise: timely care for patients, reduced administrative burden, and a health care system that supports
physicians rather than standing in their way.
