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| 5 | 5 | | 2025 -- H 5024 |
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| 7 | 7 | | LC000318 |
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| 8 | 8 | | ======== |
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| 9 | 9 | | S T A T E O F R H O D E I S L A N D |
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| 10 | 10 | | IN GENERAL ASSEMBLY |
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| 11 | 11 | | JANUARY SESSION, A.D. 2025 |
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| 12 | 12 | | ____________ |
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| 13 | 13 | | |
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| 14 | 14 | | A N A C T |
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| 15 | 15 | | RELATING TO INSURANCE -- BENEFIT DETERMINATION AND UT ILIZATION |
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| 16 | 16 | | REVIEW ACT |
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| 17 | 17 | | Introduced By: Representatives Edwards, Kislak, Bennett, Kennedy, Potter, and Cruz |
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| 18 | 18 | | Date Introduced: January 10, 2025 |
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| 19 | 19 | | Referred To: House Health & Human Services |
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| 20 | 20 | | |
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| 21 | 21 | | |
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| 22 | 22 | | It is enacted by the General Assembly as follows: |
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| 23 | 23 | | SECTION 1. Chapter 27-18.9 of the General Laws entitled "Benefit Determination and 1 |
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| 24 | 24 | | Utilization Review Act" is hereby amended by adding thereto the following section: 2 |
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| 25 | 25 | | 27-18.9-16. Utilization review decisions. 3 |
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| 26 | 26 | | (a) A utilization review decision shall not retrospectively deny coverage for healthcare 4 |
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| 27 | 27 | | services provided to a covered person, when prior approval has been obtained from the insurer or 5 |
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| 28 | 28 | | its designee for those services, unless the approval was based upon fraudulent, materially 6 |
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| 29 | 29 | | inaccurate, or misrepresented information submitted by the covered person, authorized person, or 7 |
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| 30 | 30 | | the provider. 8 |
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| 31 | 31 | | (b) For health benefit plans issued or renewed on or after the effective date of this section, 9 |
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| 32 | 32 | | an insurer shall not require or conduct a prospective or concurrent review for a prescription 10 |
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| 33 | 33 | | medicine: 11 |
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| 34 | 34 | | (1) That is used in the treatment of alcohol or opioid use disorder; 12 |
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| 35 | 35 | | (2) That contains Methadone, Buprenorphine or Naltrexone; or 13 |
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| 36 | 36 | | (3) That was approved before the effective date of this section by the United States Food 14 |
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| 37 | 37 | | and Drug Administration for the mitigation of opioid withdrawal symptoms. 15 |
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| 38 | 38 | | (c) In conducting utilization reviews for Medicaid benefits, each Medicaid managed care 16 |
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| 39 | 39 | | organization shall use the medical necessity criteria selected by the Rhode Island division of 17 |
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| 40 | 40 | | insurance for making determinations of medical necessity and clinical appropriateness pursuant to 18 |
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| 41 | 41 | | |
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| 42 | 42 | | |
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| 43 | 43 | | LC000318 - Page 2 of 3 |
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| 44 | 44 | | the utilization review plan. 1 |
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| 45 | 45 | | SECTION 2. This act shall take effect upon passage. 2 |
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| 46 | 46 | | ======== |
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| 47 | 47 | | LC000318 |
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| 48 | 48 | | ======== |
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| 49 | 49 | | |
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| 50 | 50 | | |
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| 51 | 51 | | LC000318 - Page 3 of 3 |
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| 52 | 52 | | EXPLANATION |
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| 53 | 53 | | BY THE LEGISLATIVE COUNCIL |
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| 54 | 54 | | OF |
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| 55 | 55 | | A N A C T |
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| 56 | 56 | | RELATING TO INSURANCE -- BENEFIT DETERMINATION AND UT ILIZATION |
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| 57 | 57 | | REVIEW ACT |
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| 58 | 58 | | *** |
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| 59 | 59 | | This act would prohibit healthcare insurers from requiring or conducting a review for 1 |
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| 60 | 60 | | prescription medicine that is used in the treatment of alcohol or opioid use disorder, that contains 2 |
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| 61 | 61 | | Methadone, Burenorphine, or Naltrexone or that was approved for the mitigation of opioid 3 |
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| 62 | 62 | | withdrawal symptoms. 4 |
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| 63 | 63 | | This act would take effect upon passage. 5 |
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| 64 | 64 | | ======== |
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| 65 | 65 | | LC000318 |
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| 66 | 66 | | ======== |
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