Life and Health News
June 2025
Welcome to our latest newsletter! As a thought leader in the Insurance Industry for over 50 years we are always excited to share the latest sampling of insurance compliance related bulletins, regulations, and legislative activity. Please feel free to share this newsletter with others that may be interested. Contact Us with any questions on the items in this newsletter or with any other compliance related matter we can assist you with. Enjoy!
AFFORDABLE CARE ACT
Federal Government updated the Transparency in Coverage Final Rules, which regards pricing disclosures, through "FAQs About Affordable Care Act Implementation Part 70" by adopting schema version 2.0 for machine-readable files, enhancing data accessibility and integrity for patients. CMS Notice Dated 5/22/25
AGENT / PRODUCER LICENSING AND APPOINTMENT
Missouri announced that insurance producer licensing exams must now be scheduled at physical testing centers, ending the use of PearsonVue’s OnVue online proctoring system for new reservations. The Department honored existing OnVue appointments through May 18, 2025, but requires all appointments from May 19 onward to be held in person. Bulletin 25-03
ARTIFICIAL INTELLIGENCE
California issued guidance on implementing SB 1120, focusing on the use of AI and decision support tools in utilization management by health insurers and their contracted entities. The guidance requires that determinations of medical necessity be made solely by licensed professionals and prohibits the use of decision support tools to deny, delay, or modify care based on necessity, among other requirements. Insurance Guidance SB 1120:1
Maryland issued a bill requiring carriers, pharmacy benefit managers, and private review agents using artificial intelligence, algorithms, or software tools for utilization reviews to base decisions on an enrollee’s individual medical history and clinical information, ensuring fairness and preventing discrimination. It mandates regular audits, quarterly reviews of these tools’ accuracy, and strict compliance with privacy laws. Insurers must also report to the Commissioner when AI or similar tools contribute to adverse decisions. HB 820
CAPTIVES
Arizona established a framework for certifying dormant captive insurers, allowing eligible insurers to apply for and renew a certificate of dormancy every five years, while prohibiting them from conducting insurance business until reactivated. The bill also revises definitions, reduces capital requirements for protected cell captive insurers, updates licensing procedures, and mandates Arizona residency for at least one board member of LLC-structured captive insurers. HB 2193
CLAIMS / CLAIMS ISSUES
Arizona now requires health care insurers to have a medical director individually review any denial of claims or prior authorizations involving medical necessity. The medical director must exercise independent medical judgment during each review and cannot rely solely on external recommendations. This applies to both claim denials and prior authorization decisions. HB 2175
CONFIDENTIALITY / PRIVACY
Virginia adopted a new law under the Consumer Data Protection Act, requiring social media platforms to use commercially reasonable methods to identify users under 16 and limit their usage to one hour per day. Parents may adjust this limit with verifiable consent. SB 854
DENTAL INSURANCE
Iowa now prohibits dental carriers from denying claims for services approved through prior authorization and requires reimbursement at contracted rates, with certain exceptions. It mandates dental carriers to disclose if a plan is state-regulated, including a “state-regulated” label on ID cards starting July 1, 2025. The act also sets procedures for recovering overpayments, requiring timely written notice, and allowing provider appeals. SF 470
Washington adopted a new law to address unfair and deceptive practices in dental-only insurance plans by prohibiting same-day procedure denials, unless justified by specific factors, like fraud or medical necessity. The law also requires advance notice and fee-free alternatives when reimbursing providers via credit card. SB 5351
DISASTER / CATASTROPHIC EVENT
Kentucky issued an Advisory Opinion regarding the May 2025 storms in Laurel, Pulaski, Russell, and Clay Counties, providing guidance on premium payment extensions, policyholder protections, and mail disruptions for insurers, producers, and adjusters. The Department of Insurance allows insurers to extend payment deadlines until at least June 17, 2025, urges insurers to avoid policy cancellations or rate increases without proper notice, and requires free policy copies upon request. Advisory Opinion 2025-01
Kentucky issued guidance requiring insurers to allow prescription drug refills, with provider or pharmacist approval, to ensure medication access after the May 2025 storms, especially in Laurel, Pulaski, Russell, and Clay Counties. Advisory Opinion 2025-02
Maryland issued emergency regulations requiring health carriers to waive time restrictions on prescription refills and replacements of durable medical equipment, eyeglasses, and dentures for residents of Allegany and Garrett Counties during the declared State of Emergency starting May 15, 2025. Bulletin 25-7 (Revised)
Maryland requires all property, casualty, life, and health insurers to provide a 60-day grace period for premium payments to policyholders and businesses in Allegany and Garrett Counties following the May 15, 2025 State of Emergency. Bulletin 25-8
Missouri issued a bulletin urging health carriers and pharmacy benefit managers to ensure continued access to prescription medications for individuals affected by the May 2025 tornado and storms. The order permits temporary waivers of certain rules to support medication refills and replacements, even when prescriptions were recently filled or prescribing physicians are unavailable. Health carriers are encouraged to work with enrollees to prevent disruptions in care. Bulletin 25-04
DISCRIMINATION
Maryland adopted a law prohibiting life and disability insurance carriers from unfairly discriminating based on medical information, including genetic test results, unless the information is actuarially relevant to the insurance risk. It also forbids insurers from accessing sensitive medical data without written consent or requiring genetic testing or full genome sequencing as a condition for coverage eligibility. HB 1007
FILING REQUIREMENTS / PROCEDURES
Colorado revised its rules governing the filing, certification, and reporting of limited benefit health plans, including updates for Paid Family and Medical Leave Insurance (FAMLI) policies. The regulation expands applicability, adds filing requirements for FAMLI, mandates clear disclosures for fixed indemnity products, and requires separate annual certifications for FAMLI policies, while adopting new forms and notices to support compliance. 3 CCR 702 Reg. 4-2-40
Oregon requires insurers to submit complete rate and policy form filings electronically through SERFF, including all supporting documents and clear explanations of changes. Insurers must keep approval records for at least five years and get prior approval before withdrawing or discontinuing products. Filings that don’t meet requirements may be rejected, and all communications must go through SERFF, except certain “wrap-up” filings sent by email. Bulletin 2025-5
FRAUD / ANTI-FRAUD
Nevada issued its 2025 Fraud Assessment Notification requiring all insurers with a Certificate of Authority to pay an annual fraud assessment fee by July 15, 2025. The Division of Insurance will email invoices on May 30 and requires companies to update fraud contact details by May 23 to avoid penalties. Notice Dated 5/6/25
Oklahoma requires regulated entities to pay a $750 annual Anti-Fraud Assessment fee electronically through OPTins by July 1, 2025. Paper payments are no longer accepted, and entities must register on OPTins to submit forms and pay the fee. Special Notice 2025 Anti-Fraud Assessment
HEALTH CARE EXCHANGE / MARKETPLACE
Arkansas updated its health insurance rate filing requirements in response to new CMS directives, mandating two rate filings for Plan Year 2026 with new assumptions for the second-rate filing. Insurers must include clearly labeled alternative rate documentation in SERFF and are required to offer off-Exchange-only plans without CSR load to protect unsubsidized enrollees from inflated premiums. Bulletin 4A-2025
Colorado amended its rules for calculating premium rate reductions for Colorado Option standardized bronze, silver, and gold health plans effective January 1, 2026, and beyond. The regulation limits annual premium increases to no more than medical inflation and introduces adjustments based on cost-sharing changes and federal AV calculator updates. 3 CCR 702 Reg. 4-2-85
Illinois issued a bulletin to guide issuers through certification and recertification of individual, small group, dental, and student health plans for Plan Year 2026 on and off the ACA Marketplace. The bulletin outlines federal and state compliance requirements, deadlines, rate filing instructions, and network adequacy standards. Company Bulletin 2025-
North Carolina issued an advisory memorandum detailing submission procedures for 2026 Plan Year Single Risk Pool Rate Filings for non-grandfathered ACA-compliant individual and small group health plans. The memo outlines documentation requirements, deadlines, confidentiality rules, and amendment limitations to ensure state and federal compliance. Memorandum Dated 4/25/25
HEALTH INSURANCE - COMPREHENSIVE
Oregon issued a bulletin requiring health insurers to cover medically necessary gender-affirming treatments without denial or blanket exclusions. Insurers must ensure provider network adequacy and allow out-of-network access without extra costs if needed. Additionally, reviews denying coverage must be done by qualified providers trained in gender-affirming care. Bulletin 2025-4
HOLDING COMPANIES
Oklahoma revised its insurer subsidiary laws to align with NAIC standards by updating definitions, expanding registration and reporting requirements for insurers within holding company systems, and mandating enterprise risk reports, group capital calculations, and Liquidity Stress Test results. HB 1497
LIFE INSURANCE / LIFE CONTRACTS
Georgia amended its group life insurance law to prohibit policies from excluding or limiting coverage for service members' deaths, except when the death results directly or indirectly from war or related hazards. SB 109
LIFE INSURANCE AND ANNUITY SOLICITATION
Arizona enacted a new law to ensure transparency in the marketing and sale of life insurance policies. The law mandates formatting, content, and disclosure requirements for illustrations, requires annual reporting to policyowners, and imposes penalties for violations. It also defines key terms and outlines the role of illustration actuaries. HB 2076
LONG-TERM CARE INSURANCE
Oklahoma updated its long-term care laws by revising the nursing facilities quality of care fee, including transferring employment of fifteen ombudsmen from the Department of Human Services to the Office of the Attorney General. SB 947
MEDICARE SUPPLEMENT INSURANCE
Louisiana directs all health insurance issuers and HMOs authorized for Medicare Supplement policies to use the "Refund Filing Template" for annual refund filings, effective for filings submitted after April 30, 2025. Issuers must submit all required information through SERFF. Directive 227
Maryland now requires carriers to pay insurance producers the same commission rates for certain Medicare supplement policies regardless of whether the policies are sold during open enrollment, as underwritten policies, or under specific legal provisions. This applies to Medicare policies issued within 30 days after an individual’s birthday or to individuals aged 65 and older. SB 956
Utah implemented a new law to establish an annual election period for existing Medigap enrollees, beginning May 7, 2025. During the 60-day window starting on their birthday, enrollees may switch to a Medigap plan of equal or lesser value from their current insurer without re-rating or re-underwriting. Bulletin 2025-5
MISCELLANEOUS
Arizona revised the health care provider credentialing process by setting strict timelines for insurers to acknowledge, process, and load credentialing applications, including a 60-day limit to complete credentialing and a 30-day limit to update billing systems. The law mandates insurer communication at each stage, limits delays, protects providers' claims from denial due to timing, and requires patient disclosures when non-credentialed providers deliver care. SB 1291
Arizona authorized health insurers and Medicaid to limit coverage for organ transplants or post-transplant care involving procedures or organ procurement connected to the People's Republic of China or Hong Kong. The law applies to various insurance types, including disability, group, and subscription plans, and permits denials of coverage for valid reasons. It does not mandate transplant coverage, and requires federal approval for Medicaid implementation. HB 2109
Iowa now requires health insurers to respond to credentialing requests from physicians, advanced registered nurse practitioners, or physician assistants within 56 calendar days and to provide written reasons if the request is denied. HF 875
Maryland revised its Family and Medical Leave Insurance Program by refining definitions, updating self-employed participation rules, adjusting reporting timelines, and modifying contribution rates and benefit calculations to enhance program administration. The bill defines "anchor date" for wage calculations, establishes optional self-employed enrollment regulations by 2028, sets claim submission windows from 2027 to 2028, and ties maximum weekly benefit amounts to the Consumer Price Index starting in 2029. HB 102
NONFORFEITURE
Arkansas amended its Standard Nonforfeiture Law for Life Insurance to allow insurers to defer payment of a cash surrender value for up to six months, provided the policy’s death benefit remains in force during that time. If the payment is delayed more than 45 days after the surrender request, insurers must pay interest on the amount due. SB 519
NOTICE TO INSUREDS
Maryland now requires health insurers to include a unique identifier for decision-makers in adverse decision notices starting June 1, 2025, and to clearly inform members of denial rights with contact info starting October 1, 2025. It also mandates quarterly reporting on significant increases in adverse decisions and requires private review agents to publicly post utilization review criteria. SB 474
PHARMACY BENEFIT MANAGERS
Montana updated its laws governing pharmacies and pharmacy benefit managers (PBMs), enhancing transparency, reimbursement fairness, and pharmacy protections from October 1, 2025, through June 30, 2029. The law prohibits recoupment based on drug purchase timing, mandates minimum reimbursement rates for independent pharmacies, bans various PBM-imposed fees, and bars the use of effective rate contracting. HB 740
South Dakota issued a bulletin clarifying that Pharmacy Benefit Managers (PBMs) using Discount Medical Plan Organizations in prescription drug claims must comply with Insurance Code Chapter 58-29E. PBMs linked to insured health plans are responsible for ensuring all reimbursement and fee rules under this code are followed. Bulletin 25-03
Tennessee enacted a new law requiring pharmacy benefits managers (PBMs) to follow the same prompt pay standards as health insurers for timely reimbursement of claims to pharmacists. It also removes penalty caps for PBM violations and aligns PBM sanctions with broader insurance law penalties for late payments. SB 881
PREMIUM TAX
Kentucky updated the Local Government Premium Tax rates, reporting requirements, and procedures for authorized insurers and surplus lines brokers for premiums collected through June 30, 2026. The issued bulletin mandates use of a Verified Risk Location system for large insurers, specifies tax disclosure and exemption rules, and sets penalties for late payments while allowing exemptions for due diligence. It also requires mandatory electronic filing of annual reconciliation reports and provides guidance on forms, refunds, and credits. Bulletin 2025-01
PRE-NEED CONTRACTS
Oklahoma tightened regulation of prepaid funeral benefit providers by requiring permits, electronic filings, and prior approval for ownership transfers and name changes. It also mandates funding disclosures, annual reporting, and increases penalties for violations. HB 1498
THIRD PARTY ADMINISTRATORS
Texas removed the requirement that insurers conduct on-site audits of third-party administrators. The state still mandates that insurers review and audit administrators biennially when managing benefits for over 100 individuals. SB 1151
TRADE PRACTICES
Montana revised its insurance laws to restrict who may present themselves as financial advisors or charge for financial planning services. The law bars insurance producers from using financial planner titles without proper credentials and mandates written, signed agreements for any planning fees. It also expands unfair trade practice rules for insurers and lead generators, and strengthens advertising and disclosure requirements. HB 114
UTILIZATION REVIEW - HEALTH CARE
Georgia enacted new requirements for insurers using prior authorization to establish programs that reduce requirements for high-performing providers who follow evidence-based care. Insurers must annually report program details to the Department of Insurance starting July 1, 2026. The law also strengthens compliance rules for private review agents, requiring them to attempt direct communication with treating providers before issuing adverse determinations. HB 197
Indiana updated its insurance code to tighten oversight of prior authorization by shifting authority to utilization review entities, prohibiting prior authorization for the first 12 physical therapy or chiropractic visits per care episode, and enhancing transparency and patient protections. The law mandates electronic submission options, preserves granted authorizations for up to a year, and requires automatic approval if entities miss response deadlines. SB 480
Montana adopted a new law governing health utilization reviews and prior authorization, requiring that only in-state licensed physicians make or review adverse determinations and grievances. The law prohibits those physicians from having prior involvement in or financial interest in the grievance outcome. It also bans prior authorization for FDA-approved substance use disorder medications when prescribed within labeled dosages. SB 446
Montana now requires health plans to honor existing prior authorizations for 90 days when enrollees switch plans and to approve discharge prescriptions for at least three days without prior authorization. The new law prohibits retroactive denial of approved services and mandates electronic acceptance and response to prior authorization requests, while also easing step therapy requirements for patients with prior use history. SB449