Rhode Island 2025 Regular Session

Rhode Island House Bill H5623 Compare Versions

Only one version of the bill is available at this time.

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5	5	2025 -- H 5623
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7	7	LC001281
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9	9	S T A T E O F R H O D E I S L A N D
10	10	IN GENERAL ASSEMBLY
11	11	JANUARY SESSION, A.D. 2025
12	12	____________
13	13
14	14	A N A C T
15	15	RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES
16	16	Introduced By: Representatives McGaw, Potter, Boylan, Speakman, Casimiro,
17	17	DeSimone, Tanzi, Donovan, Cotter, and Giraldo
18	18	Date Introduced: February 26, 2025
19	19	Referred To: House Health & Human Services
20	20
21	21
22	22	It is enacted by the General Assembly as follows:
23	23	SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness Insurance 1
24	24	Policies" is hereby amended by adding thereto the following section: 2
25	25	27-18-95. Prior authorization restrictions for rehabilitative and habilitative services. 3
26	26	(a) An individual or group health insurance plan shall not require prior authorization for 4
27	27	rehabilitative or habilitative services including, but not limited to, physical therapy or occupational 5
28	28	therapy services for the first twelve (12) visits of each new episode of care. After the twelve (12) 6
29	29	visits of each new episode of care, an individual or group health insurance plan may not require 7
30	30	prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever 8
31	31	time period is longer. For purposes of this section, "new episode of care" means treatment for a 9
32	32	new or recurring condition for which an insured has not been treated by the provider within the 10
33	33	previous ninety (90) days. 11
34	34	(b) An individual or group health insurance plan shall not require prior authorization for 12
35	35	physical medicine or rehabilitation services provided to patients with chronic pain for the first 13
36	36	ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic 14
37	37	management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an 15
38	38	individual or group health insurance plan may not require prior authorization more frequently than 16
39	39	every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this 17
40	40	subsection, "chronic pain" means pain that persists or recurs for more than three (3) months. 18
41	41	(c) An individual or group health insurance plan shall respond to a prior authorization 19
42	42
43	43
44	44	LC001281 - Page 2 of 8
45	45	request for services or visits in an ongoing plan of care for rehabilitative or habilitative services 1
46	46	within twenty-four (24) hours. If an individual or group health insurance plan requires more 2
47	47	information to render a decision on the prior authorization request, the individual or group health 3
48	48	insurance plan shall notify the patient and the provider within twenty-four (24) hours of the initial 4
49	49	request with the information that is needed to complete the prior authorization request including, 5
50	50	but not limited to, the specific tests and measures needed from the patient and provider. An 6
51	51	individual or group health insurance plan shall render a decision on the prior authorization request 7
52	52	within twenty-four (24) hours of receiving the requested information. 8
53	53	(d) A prior authorization for rehabilitative or habilitative services is deemed to be approved 9
54	54	if an individual or group health insurance plan: 10
55	55	(1) Fails to timely answer a prior authorization request in accordance with subsection (c) 11
56	56	of this section, including due to a failure of the individual or group health insurance plan’s prior 12
57	57	authorization platform or process; or 13
58	58	(2) Informs a provider that prior authorization is not required orally, via an online platform 14
59	59	or program, through the patient's health plan documents or by any other means. 15
60	60	(e) An individual or group health insurance plan shall provide a procedure for providers 16
61	61	and insureds to obtain retroactive authorization for rehabilitative or habilitative services that are 17
62	62	medically necessary covered benefits. An individual or group health insurance plan shall not deny 18
63	63	coverage for medically necessary services for failure to obtain a prior authorization, if a medical 19
64	64	necessity determination can be made after the rehabilitative or habilitative services have been 20
65	65	provided and the services would have been covered benefits if prior authorization had been 21
66	66	obtained. 22
67	67	(f) An individual or group health insurance plan’s failure to approve a prior authorization 23
68	68	for all rehabilitative or habilitative services or visits in a plan of care is subject to the same appeal 24
69	69	rights as a denial under the health insurance commissioner’s rule regarding health plan 25
70	70	accountability and the provider's network agreement with the carrier, if any. 26
71	71	(g) Nothing in this section shall be construed to prohibit an individual or group health 27
72	72	insurance plan from performing a retrospective medical necessity review. 28
73	73	SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service 29
74	74	Corporations" is hereby amended by adding thereto the following section: 30
75	75	27-19-87. Prior authorization restrictions for rehabilitative and habilitative services. 31
76	76	(a) An individual or group health insurance plan shall not require prior authorization for 32
77	77	rehabilitative or habilitative services including, but not limited to, physical therapy or occupational 33
78	78	therapy services for the first twelve (12) visits of each new episode of care. After the twelve (12) 34
79	79
80	80
81	81	LC001281 - Page 3 of 8
82	82	visits of each new episode of care, an individual or group health insurance plan may not require 1
83	83	prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever 2
84	84	time period is longer. For purposes of this section, "new episode of care" means treatment for a 3
85	85	new or recurring condition for which an insured has not been treated by the provider within the 4
86	86	previous ninety (90) days. 5
87	87	(b) An individual or group health insurance plan shall not require prior authorization for 6
88	88	physical medicine or rehabilitation services provided to patients with chronic pain for the first 7
89	89	ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic 8
90	90	management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an 9
91	91	individual or group health insurance plan may not require prior authorization more frequently than 10
92	92	every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this 11
93	93	subsection, "chronic pain" means pain that persists or recurs for more than three (3) months. 12
94	94	(c) An individual or group health insurance plan shall respond to a prior authorization 13
95	95	request for services or visits in an ongoing plan of care for rehabilitative or habilitative services 14
96	96	within twenty-four (24) hours. If an individual or group health insurance plan requires more 15
97	97	information to render a decision on the prior authorization request, the individual or group health 16
98	98	insurance plan shall notify the patient and the provider within twenty-four (24) hours of the initial 17
99	99	request with the information that is needed to complete the prior authorization request including, 18
100	100	but not limited to, the specific tests and measures needed from the patient and provider. An 19
101	101	individual or group health insurance plan shall render a decision on the prior authorization request 20
102	102	within twenty-four (24) hours of receiving the requested information. 21
103	103	(d) A prior authorization for rehabilitative or habilitative services is deemed to be approved 22
104	104	if an individual or group health insurance plan: 23
105	105	(1) Fails to timely answer a prior authorization request in accordance with subsection (c) 24
106	106	of this section, including due to a failure of the individual or group health insurance plan’s prior 25
107	107	authorization platform or process; or 26
108	108	(2) Informs a provider that prior authorization is not required orally, via an online platform 27
109	109	or program, through the patient's health plan documents or by any other means. 28
110	110	(e) An individual or group health insurance plan shall provide a procedure for providers 29
111	111	and insureds to obtain retroactive authorization for rehabilitative or habilitative services that are 30
112	112	medically necessary covered benefits. An individual or group health insurance plan shall not deny 31
113	113	coverage for medically necessary services for failure to obtain a prior authorization, if a medical 32
114	114	necessity determination can be made after the rehabilitative or habilitative services have been 33
115	115	provided and the services would have been covered benefits if prior authorization had been 34
116	116
117	117
118	118	LC001281 - Page 4 of 8
119	119	obtained. 1
120	120	(f) An individual or group health insurance plan’s failure to approve a prior authorization 2
121	121	for all rehabilitative or habilitative services or visits in a plan of care is subject to the same appeal 3
122	122	rights as a denial under the health insurance commissioner’s rule regarding health plan 4
123	123	accountability and the provider's network agreement with the carrier, if any. 5
124	124	(g) Nothing in this section shall be construed to prohibit an individual or group health 6
125	125	insurance plan from performing a retrospective medical necessity review. 7
126	126	SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service 8
127	127	Corporations" is hereby amended by adding thereto the following section: 9
128	128	27-20-83. Prior authorization restrictions for rehabilitative and habilitative services. 10
129	129	(a) An individual or group health insurance plan shall not require prior authorization for 11
130	130	rehabilitative or habilitative services including, but not limited to, physical therapy or occupational 12
131	131	therapy services for the first twelve (12) visits of each new episode of care. After the twelve (12) 13
132	132	visits of each new episode of care, an individual or group health insurance plan may not require 14
133	133	prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever 15
134	134	time period is longer. For purposes of this section, "new episode of care" means treatment for a 16
135	135	new or recurring condition for which an insured has not been treated by the provider within the 17
136	136	previous ninety (90) days. 18
137	137	(b) An individual or group health insurance plan shall not require prior authorization for 19
138	138	physical medicine or rehabilitation services provided to patients with chronic pain for the first 20
139	139	ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic 21
140	140	management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an 22
141	141	individual or group health insurance plan may not require prior authorization more frequently than 23
142	142	every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this 24
143	143	subsection, "chronic pain" means pain that persists or recurs for more than three (3) months. 25
144	144	(c) An individual or group health insurance plan shall respond to a prior authorization 26
145	145	request for services or visits in an ongoing plan of care for rehabilitative or habilitative services 27
146	146	within twenty-four (24) hours. If an individual or group health insurance plan requires more 28
147	147	information to render a decision on the prior authorization request, the individual or group health 29
148	148	insurance plan shall notify the patient and the provider within twenty-four (24) hours of the initial 30
149	149	request with the information that is needed to complete the prior authorization request including, 31
150	150	but not limited to, the specific tests and measures needed from the patient and provider. An 32
151	151	individual or group health insurance plan shall render a decision on the prior authorization request 33
152	152	within twenty-four (24) hours of receiving the requested information. 34
153	153
154	154
155	155	LC001281 - Page 5 of 8
156	156	(d) A prior authorization for rehabilitative or habilitative services is deemed to be approved 1
157	157	if an individual or group health insurance plan: 2
158	158	(1) Fails to timely answer a prior authorization request in accordance with subsection (c) 3
159	159	of this section, including due to a failure of the individual or group health insurance plan’s prior 4
160	160	authorization platform or process; or 5
161	161	(2) Informs a provider that prior authorization is not required orally, via an online platform 6
162	162	or program, through the patient's health plan documents or by any other means. 7
163	163	(e) An individual or group health insurance plan shall provide a procedure for providers 8
164	164	and insureds to obtain retroactive authorization for rehabilitative or habilitative services that are 9
165	165	medically necessary covered benefits. An individual or group health insurance plan shall not deny 10
166	166	coverage for medically necessary services for failure to obtain a prior authorization, if a medical 11
167	167	necessity determination can be made after the rehabilitative or habilitative services have been 12
168	168	provided and the services would have been covered benefits if prior authorization had been 13
169	169	obtained. 14
170	170	(f) An individual or group health insurance plan’s failure to approve a prior authorization 15
171	171	for all rehabilitative or habilitative services or visits in a plan of care is subject to the same appeal 16
172	172	rights as a denial under the health insurance commissioner’s rule regarding health plan 17
173	173	accountability and the provider's network agreement with the carrier, if any. 18
174	174	(g) Nothing in this section shall be construed to prohibit an individual or group health 19
175	175	insurance plan from performing a retrospective medical necessity review. 20
176	176	SECTION 4. Chapter 27-41 of the General Laws entitled "Health Maintenance 21
177	177	Organizations" is hereby amended by adding thereto the following section: 22
178	178	27-41-100. Prior authorization restrictions for rehabilitative and habilitative services. 23
179	179	(a) An individual or group health insurance plan shall not require prior authorization for 24
180	180	rehabilitative or habilitative services including, but not limited to, physical therapy or occupational 25
181	181	therapy services for the first twelve (12) visits of each new episode of care. After the twelve (12) 26
182	182	visits of each new episode of care, an individual or group health insurance plan may not require 27
183	183	prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever 28
184	184	time period is longer. For purposes of this section, "new episode of care" means treatment for a 29
185	185	new or recurring condition for which an insured has not been treated by the provider within the 30
186	186	previous ninety (90) days. 31
187	187	(b) An individual or group health insurance plan shall not require prior authorization for 32
188	188	physical medicine or rehabilitation services provided to patients with chronic pain for the first 33
189	189	ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic 34
190	190
191	191
192	192	LC001281 - Page 6 of 8
193	193	management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an 1
194	194	individual or group health insurance plan may not require prior authorization more frequently than 2
195	195	every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this 3
196	196	subsection, "chronic pain" means pain that persists or recurs for more than three (3) months. 4
197	197	(c) An individual or group health insurance plan shall respond to a prior authorization 5
198	198	request for services or visits in an ongoing plan of care for rehabilitative or habilitative services 6
199	199	within twenty-four (24) hours. If an individual or group health insurance plan requires more 7
200	200	information to render a decision on the prior authorization request, the individual or group health 8
201	201	insurance plan shall notify the patient and the provider within twenty-four (24) hours of the initial 9
202	202	request with the information that is needed to complete the prior authorization request including, 10
203	203	but not limited to, the specific tests and measures needed from the patient and provider. An 11
204	204	individual or group health insurance plan shall render a decision on the prior authorization request 12
205	205	within twenty-four (24) hours of receiving the requested information. 13
206	206	(d) A prior authorization for rehabilitative or habilitative services is deemed to be approved 14
207	207	if an individual or group health insurance plan: 15
208	208	(1) Fails to timely answer a prior authorization request in accordance with subsection (c) 16
209	209	of this section, including due to a failure of the individual or group health insurance plan’s prior 17
210	210	authorization platform or process; or 18
211	211	(2) Informs a provider that prior authorization is not required orally, via an online platform 19
212	212	or program, through the patient's health plan documents or by any other means. 20
213	213	(e) An individual or group health insurance plan shall provide a procedure for providers 21
214	214	and insureds to obtain retroactive authorization for rehabilitative or habilitative services that are 22
215	215	medically necessary covered benefits. An individual or group health insurance plan shall not deny 23
216	216	coverage for medically necessary services for failure to obtain a prior authorization, if a medical 24
217	217	necessity determination can be made after the rehabilitative or habilitative services have been 25
218	218	provided and the services would have been covered benefits if prior authorization had been 26
219	219	obtained. 27
220	220	(f) An individual or group health insurance plan’s failure to approve a prior authorization 28
221	221	for all rehabilitative or habilitative services or visits in a plan of care is subject to the same appeal 29
222	222	rights as a denial under the health insurance commissioner’s rule regarding health plan 30
223	223	accountability and the provider's network agreement with the carrier, if any. 31
224	224	(g) Nothing in this section shall be construed to prohibit an individual or group health 32
225	225	insurance plan from performing a retrospective medical necessity review. 33
226	226
227	227
228	228	LC001281 - Page 7 of 8
229	229	SECTION 5. This act shall take effect on January 1, 2026 1
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231	231	LC001281
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234	234
235	235	LC001281 - Page 8 of 8
236	236	EXPLANATION
237	237	BY THE LEGISLATIVE COUNCIL
238	238	OF
239	239	A N A C T
240	240	RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES
241	241	***
242	242	This act would prohibit health insurance plans from requiring prior authorization for a new 1
243	243	episode of rehabilitative care for twelve (12) visits, or from requiring prior authorization for 2
244	244	rehabilitative care for chronic pain for ninety (90) days. This act would further mandate that where 3
245	245	prior authorization is required, the health insurance plan would respond within twenty-four (24) 4
246	246	hours. In addition, this act would require health insurance plans to provide a procedure for providers 5
247	247	and insureds to obtain retroactive authorization for services that are medically necessary covered 6
248	248	benefits. 7
249	249	This act would take effect on January 1, 2026 8
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