State legislatures and regulators are moving fast, and for payers, third-party administrators (TPAs), and pharmacy benefit managers (PBMs), the business impact is real. Starting this fall and continuing into early 2026, multiple states will enact new utilization management laws that reshape prior authorization (PA), peer-to-peer (P2P) reviews, and oversight of utilization review processes.
If your organization isn’t prepared, the risks are clear: fines, compliance penalties, reputational harm, and provider dissatisfaction.
At MRIoA, our mission is to give health plans clarity and confidence in navigating these complex changes. Here’s a closer look at four states where new regulations are going into effect and what they mean for your business.
Georgia – H.B. 197 (Effective Jan 1, 2026)
What’s changing: Georgia requires insurers to make a good-faith effort for a pre-denial peer-to-peer review. That effort must include either a callback system, a telecommunications platform, or a public website to schedule callbacks. In addition, insurers must implement and maintain a program to reduce prior authorization requirements, with the first filing due July 1, 2026.
- Georgia General Assembly – HB 197: https://www.legis.ga.gov/legislation/64277
Why it matters: These requirements add new operational and reporting burdens. Failure to comply risks fines, member delays, and strained provider relationships.
Takeaway: Don’t wait until the deadline. Begin building callback workflows now and assess how your PA program can be reduced without compromising compliance.
New Jersey – A.B. 1825 (Effective Jan 1, 2026)
What’s changing: New Jersey requires Medicaid and state employee health plans to implement evidence-based step therapy protocols and establish a clear exception process. Exceptions must be granted under defined clinical circumstances, with turnaround times of 24 hours (urgent) and 72 hours (non-urgent).
- New Jersey Legislature – A1825: https://www.njleg.state.nj.us/bill-search/2024/A1825
Why it matters: Plans must build exception workflows, publish criteria, and ensure timely responses. Missing a deadline or mishandling exceptions could trigger penalties and disrupt member care.
Takeaway: Review your step therapy protocols now and prepare your teams to meet New Jersey’s new requirements.
Illinois – H.B. 4055 (Effective Jan 1, 2026)
What’s changing: Illinois will restrict plans from requiring prior authorization for FDA-approved therapies for hereditary bleeding disorders more frequently than every six months, or for the length of the prescription, whichever is shorter.
- Illinois General Assembly – HB4055: https://www.ilga.gov/legislation/billstatus.asp?DocNum=4055&GAID=19&GA=103&DocTypeID=HB&LegID=152792&SessionID=112
Why it matters: This is not a full PA ban, but it requires significant adjustments to authorization logic and systems. Failure to comply risks penalties, reputational harm, and potential patient impact.
Takeaway: Update your PA rules and test your systems now to avoid costly mistakes.
Texas – H.B. 3812 & S.B. 815 (Effective Sept 1, 2025)
What’s changing: H.B. 3812 requires that certain determinations be made by a Texas-licensed physician, who may not hold an administrative medicine license.
- Texas Legislature – HB 3812: https://capitol.texas.gov/BillLookup/History.aspx?LegSess=88R&Bill=HB3812
S.B. 815 prohibits utilization review agents from using automated decision systems to make adverse determinations. The law also grants the commissioner authority to audit UR agents’ practices.
- Texas Legislature – SB 815: https://capitol.texas.gov/BillLookup/History.aspx?LegSess=88R&Bill=SB815
Why it matters: Health plans must align physician oversight models with licensing requirements and ensure compliance processes can withstand audits.
Takeaway: Evaluate your current utilization review oversight and ensure your staffing and governance models meet Texas’ new requirements.
The Bottom Line
These are not minor updates. They are business-impacting regulatory changes with real financial, operational, and reputational stakes.
MRIoA provides the clinical expertise, regulatory guidance, and actionable insights that health plans, TPAs, and PBMs need to adapt quickly and with confidence.
Join us for the Regulatory & Compliance Roundtable on October 2, 2025 to hear from experts, understand what these laws mean for your organization, and walk away with strategies to reduce risk and ensure compliance.
Register for the Roundtable Here
