2025 -- H 5623
========
LC001281
========
S T A T E O F R H O D E I S L A N D
IN GENERAL ASSEMBLY
JANUARY SESSION, A.D. 2025
____________
A N A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES
Introduced By: Representatives McGaw, Potter, Boylan, Speakman, Casimiro,
DeSimone, Tanzi, Donovan, Cotter, and Giraldo
Date Introduced: February 26, 2025
Referred To: House Health & Human Services
It is enacted by the General Assembly as follows:
SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness Insurance 1
Policies" is hereby amended by adding thereto the following section: 2
27-18-95. Prior authorization restrictions for rehabilitative and habilitative services. 3
(a) An individual or group health insurance plan shall not require prior authorization for 4
rehabilitative or habilitative services including, but not limited to, physical therapy or occupational 5
therapy services for the first twelve (12) visits of each new episode of care. After the twelve (12) 6
visits of each new episode of care, an individual or group health insurance plan may not require 7
prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever 8
time period is longer. For purposes of this section, "new episode of care" means treatment for a 9
new or recurring condition for which an insured has not been treated by the provider within the 10
previous ninety (90) days. 11
(b) An individual or group health insurance plan shall not require prior authorization for 12
physical medicine or rehabilitation services provided to patients with chronic pain for the first 13
ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic 14
management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an 15
individual or group health insurance plan may not require prior authorization more frequently than 16
every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this 17
subsection, "chronic pain" means pain that persists or recurs for more than three (3) months. 18
(c) An individual or group health insurance plan shall respond to a prior authorization 19
LC001281 - Page 2 of 8
request for services or visits in an ongoing plan of care for rehabilitative or habilitative services 1
within twenty-four (24) hours. If an individual or group health insurance plan requires more 2
information to render a decision on the prior authorization request, the individual or group health 3
insurance plan shall notify the patient and the provider within twenty-four (24) hours of the initial 4
request with the information that is needed to complete the prior authorization request including, 5
but not limited to, the specific tests and measures needed from the patient and provider. An 6
individual or group health insurance plan shall render a decision on the prior authorization request 7
within twenty-four (24) hours of receiving the requested information. 8
(d) A prior authorization for rehabilitative or habilitative services is deemed to be approved 9
if an individual or group health insurance plan: 10
(1) Fails to timely answer a prior authorization request in accordance with subsection (c) 11
of this section, including due to a failure of the individual or group health insurance plan’s prior 12
authorization platform or process; or 13
(2) Informs a provider that prior authorization is not required orally, via an online platform 14
or program, through the patient's health plan documents or by any other means. 15
(e) An individual or group health insurance plan shall provide a procedure for providers 16
and insureds to obtain retroactive authorization for rehabilitative or habilitative services that are 17
medically necessary covered benefits. An individual or group health insurance plan shall not deny 18
coverage for medically necessary services for failure to obtain a prior authorization, if a medical 19
necessity determination can be made after the rehabilitative or habilitative services have been 20
provided and the services would have been covered benefits if prior authorization had been 21
obtained. 22
(f) An individual or group health insurance plan’s failure to approve a prior authorization 23
for all rehabilitative or habilitative services or visits in a plan of care is subject to the same appeal 24
rights as a denial under the health insurance commissioner’s rule regarding health plan 25
accountability and the provider's network agreement with the carrier, if any. 26
(g) Nothing in this section shall be construed to prohibit an individual or group health 27
insurance plan from performing a retrospective medical necessity review. 28
SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service 29
Corporations" is hereby amended by adding thereto the following section: 30
27-19-87. Prior authorization restrictions for rehabilitative and habilitative services. 31
(a) An individual or group health insurance plan shall not require prior authorization for 32
rehabilitative or habilitative services including, but not limited to, physical therapy or occupational 33
therapy services for the first twelve (12) visits of each new episode of care. After the twelve (12) 34
LC001281 - Page 3 of 8
visits of each new episode of care, an individual or group health insurance plan may not require 1
prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever 2
time period is longer. For purposes of this section, "new episode of care" means treatment for a 3
new or recurring condition for which an insured has not been treated by the provider within the 4
previous ninety (90) days. 5
(b) An individual or group health insurance plan shall not require prior authorization for 6
physical medicine or rehabilitation services provided to patients with chronic pain for the first 7
ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic 8
management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an 9
individual or group health insurance plan may not require prior authorization more frequently than 10
every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this 11
subsection, "chronic pain" means pain that persists or recurs for more than three (3) months. 12
(c) An individual or group health insurance plan shall respond to a prior authorization 13
request for services or visits in an ongoing plan of care for rehabilitative or habilitative services 14
within twenty-four (24) hours. If an individual or group health insurance plan requires more 15
information to render a decision on the prior authorization request, the individual or group health 16
insurance plan shall notify the patient and the provider within twenty-four (24) hours of the initial 17
request with the information that is needed to complete the prior authorization request including, 18
but not limited to, the specific tests and measures needed from the patient and provider. An 19
individual or group health insurance plan shall render a decision on the prior authorization request 20
within twenty-four (24) hours of receiving the requested information. 21
(d) A prior authorization for rehabilitative or habilitative services is deemed to be approved 22
if an individual or group health insurance plan: 23
(1) Fails to timely answer a prior authorization request in accordance with subsection (c) 24
of this section, including due to a failure of the individual or group health insurance plan’s prior 25
authorization platform or process; or 26
(2) Informs a provider that prior authorization is not required orally, via an online platform 27
or program, through the patient's health plan documents or by any other means. 28
(e) An individual or group health insurance plan shall provide a procedure for providers 29
and insureds to obtain retroactive authorization for rehabilitative or habilitative services that are 30
medically necessary covered benefits. An individual or group health insurance plan shall not deny 31
coverage for medically necessary services for failure to obtain a prior authorization, if a medical 32
necessity determination can be made after the rehabilitative or habilitative services have been 33
provided and the services would have been covered benefits if prior authorization had been 34
LC001281 - Page 4 of 8
obtained. 1
(f) An individual or group health insurance plan’s failure to approve a prior authorization 2
for all rehabilitative or habilitative services or visits in a plan of care is subject to the same appeal 3
rights as a denial under the health insurance commissioner’s rule regarding health plan 4
accountability and the provider's network agreement with the carrier, if any. 5
(g) Nothing in this section shall be construed to prohibit an individual or group health 6
insurance plan from performing a retrospective medical necessity review. 7
SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service 8
Corporations" is hereby amended by adding thereto the following section: 9
27-20-83. Prior authorization restrictions for rehabilitative and habilitative services. 10
(a) An individual or group health insurance plan shall not require prior authorization for 11
rehabilitative or habilitative services including, but not limited to, physical therapy or occupational 12
therapy services for the first twelve (12) visits of each new episode of care. After the twelve (12) 13
visits of each new episode of care, an individual or group health insurance plan may not require 14
prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever 15
time period is longer. For purposes of this section, "new episode of care" means treatment for a 16
new or recurring condition for which an insured has not been treated by the provider within the 17
previous ninety (90) days. 18
(b) An individual or group health insurance plan shall not require prior authorization for 19
physical medicine or rehabilitation services provided to patients with chronic pain for the first 20
ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic 21
management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an 22
individual or group health insurance plan may not require prior authorization more frequently than 23
every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this 24
subsection, "chronic pain" means pain that persists or recurs for more than three (3) months. 25
(c) An individual or group health insurance plan shall respond to a prior authorization 26
request for services or visits in an ongoing plan of care for rehabilitative or habilitative services 27
within twenty-four (24) hours. If an individual or group health insurance plan requires more 28
information to render a decision on the prior authorization request, the individual or group health 29
insurance plan shall notify the patient and the provider within twenty-four (24) hours of the initial 30
request with the information that is needed to complete the prior authorization request including, 31
but not limited to, the specific tests and measures needed from the patient and provider. An 32
individual or group health insurance plan shall render a decision on the prior authorization request 33
within twenty-four (24) hours of receiving the requested information. 34
LC001281 - Page 5 of 8
(d) A prior authorization for rehabilitative or habilitative services is deemed to be approved 1
if an individual or group health insurance plan: 2
(1) Fails to timely answer a prior authorization request in accordance with subsection (c) 3
of this section, including due to a failure of the individual or group health insurance plan’s prior 4
authorization platform or process; or 5
(2) Informs a provider that prior authorization is not required orally, via an online platform 6
or program, through the patient's health plan documents or by any other means. 7
(e) An individual or group health insurance plan shall provide a procedure for providers 8
and insureds to obtain retroactive authorization for rehabilitative or habilitative services that are 9
medically necessary covered benefits. An individual or group health insurance plan shall not deny 10
coverage for medically necessary services for failure to obtain a prior authorization, if a medical 11
necessity determination can be made after the rehabilitative or habilitative services have been 12
provided and the services would have been covered benefits if prior authorization had been 13
obtained. 14
(f) An individual or group health insurance plan’s failure to approve a prior authorization 15
for all rehabilitative or habilitative services or visits in a plan of care is subject to the same appeal 16
rights as a denial under the health insurance commissioner’s rule regarding health plan 17
accountability and the provider's network agreement with the carrier, if any. 18
(g) Nothing in this section shall be construed to prohibit an individual or group health 19
insurance plan from performing a retrospective medical necessity review. 20
SECTION 4. Chapter 27-41 of the General Laws entitled "Health Maintenance 21
Organizations" is hereby amended by adding thereto the following section: 22
27-41-100. Prior authorization restrictions for rehabilitative and habilitative services. 23
(a) An individual or group health insurance plan shall not require prior authorization for 24
rehabilitative or habilitative services including, but not limited to, physical therapy or occupational 25
therapy services for the first twelve (12) visits of each new episode of care. After the twelve (12) 26
visits of each new episode of care, an individual or group health insurance plan may not require 27
prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever 28
time period is longer. For purposes of this section, "new episode of care" means treatment for a 29
new or recurring condition for which an insured has not been treated by the provider within the 30
previous ninety (90) days. 31
(b) An individual or group health insurance plan shall not require prior authorization for 32
physical medicine or rehabilitation services provided to patients with chronic pain for the first 33
ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic 34
LC001281 - Page 6 of 8
management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an 1
individual or group health insurance plan may not require prior authorization more frequently than 2
every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this 3
subsection, "chronic pain" means pain that persists or recurs for more than three (3) months. 4
(c) An individual or group health insurance plan shall respond to a prior authorization 5
request for services or visits in an ongoing plan of care for rehabilitative or habilitative services 6
within twenty-four (24) hours. If an individual or group health insurance plan requires more 7
information to render a decision on the prior authorization request, the individual or group health 8
insurance plan shall notify the patient and the provider within twenty-four (24) hours of the initial 9
request with the information that is needed to complete the prior authorization request including, 10
but not limited to, the specific tests and measures needed from the patient and provider. An 11
individual or group health insurance plan shall render a decision on the prior authorization request 12
within twenty-four (24) hours of receiving the requested information. 13
(d) A prior authorization for rehabilitative or habilitative services is deemed to be approved 14
if an individual or group health insurance plan: 15
(1) Fails to timely answer a prior authorization request in accordance with subsection (c) 16
of this section, including due to a failure of the individual or group health insurance plan’s prior 17
authorization platform or process; or 18
(2) Informs a provider that prior authorization is not required orally, via an online platform 19
or program, through the patient's health plan documents or by any other means. 20
(e) An individual or group health insurance plan shall provide a procedure for providers 21
and insureds to obtain retroactive authorization for rehabilitative or habilitative services that are 22
medically necessary covered benefits. An individual or group health insurance plan shall not deny 23
coverage for medically necessary services for failure to obtain a prior authorization, if a medical 24
necessity determination can be made after the rehabilitative or habilitative services have been 25
provided and the services would have been covered benefits if prior authorization had been 26
obtained. 27
(f) An individual or group health insurance plan’s failure to approve a prior authorization 28
for all rehabilitative or habilitative services or visits in a plan of care is subject to the same appeal 29
rights as a denial under the health insurance commissioner’s rule regarding health plan 30
accountability and the provider's network agreement with the carrier, if any. 31
(g) Nothing in this section shall be construed to prohibit an individual or group health 32
insurance plan from performing a retrospective medical necessity review. 33
LC001281 - Page 7 of 8
SECTION 5. This act shall take effect on January 1, 2026 1
========
LC001281
========
LC001281 - Page 8 of 8
EXPLANATION
BY THE LEGISLATIVE COUNCIL
OF
A N A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES
***
This act would prohibit health insurance plans from requiring prior authorization for a new 1
episode of rehabilitative care for twelve (12) visits, or from requiring prior authorization for 2
rehabilitative care for chronic pain for ninety (90) days. This act would further mandate that where 3
prior authorization is required, the health insurance plan would respond within twenty-four (24) 4
hours. In addition, this act would require health insurance plans to provide a procedure for providers 5
and insureds to obtain retroactive authorization for services that are medically necessary covered 6
benefits. 7
This act would take effect on January 1, 2026 8
========
LC001281
========