Provides an insurer would not impose prior authorization requirements for any service ordered by an in-network primary care provider.
Impact
The enactment of H5120 would have profound implications for state laws governing healthcare delivery and insurance practices in Rhode Island. By restricting insurers from imposing prior authorization for primary care orders, the bill is expected to alter existing insurance regulations, shifting responsibilities and accountability toward insurance providers. This reform is likely to empower primary care providers, enabling them to make more autonomous decisions in patient care without needing to secure prior approvals, which can often hinder the treatment process and affect patient outcomes.
Summary
House Bill H5120, known as the Rhode Island Prior Authorization Reform Act of 2025, seeks to eliminate prior authorization requirements imposed by insurers for any services ordered by in-network primary care providers, which would significantly streamline the process for patients accessing medical services. Proponents argue that removing these barriers can lead to improved patient care by reducing delays caused by authorization processes and ensuring that patients receive timely medical attention. The bill emphasizes a focus on making healthcare more accessible and efficient, aligning with broader healthcare reform efforts.
Sentiment
The sentiment around H5120 appears to be largely positive among advocates of healthcare reform, who view it as a necessary step toward enhancing patient access to care and reducing administrative complexities. However, some concerns have been raised by insurance companies and certain stakeholders regarding the potential for increased costs and the risk of overutilization of healthcare services. This tension reflects broader debates in healthcare reform about balancing patient needs with cost containment and operational efficiency.
Contention
Notable points of contention include challenges related to the potential financial impact on insurers, particularly if the removal of prior authorization leads to higher rates of service usage without corresponding oversight. Insurance companies might argue that prior authorizations serve as necessary checks to prevent unnecessary procedures and manage healthcare costs effectively. The ongoing dialogue around this bill highlights the important considerations of patient safety, cost management, and the roles and responsibilities of insurance companies in the healthcare landscape.
Limits the use by insurers of step therapy, a protocol that establishes a specific sequence in which prescription drugs for a specified medical condition are covered by an insurer, by allowing medical providers to request step therapy exceptions.
Limits the use by insurers of step therapy, a protocol that establishes a specific sequence in which prescription drugs for a specified medical condition are covered by an insurer, by allowing medical providers to request step therapy exceptions.
Includes the definition of "primary care services" and requires that all biennial reports shall include a review and recommendation of rates for primary care services on and after September 1, 2025.
Provides that any insurer refusing to honor a "direction to pay" executed by an insured for payment on a property damage benefit would constitute an unfair claims practice.
Provides that any insurer refusing to honor a "direction to pay" executed by an insured for payment on a property damage benefit would constitute an unfair claims practice.
All Medicaid programs operated by EOHHS would not reimburse home care providers less than fee-for-service rates adopted by rate review recommendations of the office of health insurance commissioners.
Prohibits an insurer from imposing a requirement of prior authorization for any admission, item, service, treatment, test, exam, study, procedure, or any generic or brand name prescription drug ordered by a primary care provider.
Limits the use by insurers of step therapy, a protocol that establishes a specific sequence in which prescription drugs for a specified medical condition are covered by an insurer, by allowing medical providers to request step therapy exceptions.
Limits the use by insurers of step therapy, a protocol that establishes a specific sequence in which prescription drugs for a specified medical condition are covered by an insurer, by allowing medical providers to request step therapy exceptions.
Limits the use by insurers of step therapy, a protocol that establishes a specific sequence in which prescription drugs for a specified medical condition are covered by an insurer, by allowing medical providers to request step therapy exceptions.