Rhode Island 2025 Regular Session

Rhode Island House Bill H6317 Compare Versions

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

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5	5	2025 -- H 6317
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7	7	LC002773
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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 -- BENEFIT DETERMINATION AND UT ILIZATION ACT
16	16	Introduced By: Representatives Ackerman, Potter, McNamara, Edwards, Donovan, and
17	17	Shallcross Smith
18	18	Date Introduced: May 09, 2025
19	19	Referred To: House Health & Human Services
20	20	(Attorney General)
21	21
22	22	It is enacted by the General Assembly as follows:
23	23	SECTION 1. Section 27-18.9-2 of the General Laws in Chapter 27-18.9 entitled "Benefit 1
24	24	Determination and Utilization Review Act" is hereby amended to read as follows: 2
25	25	27-18.9-2. Definitions. 3
26	26	As used in this chapter, the following terms are defined as follows: 4
27	27	(1) “Adverse benefit determination” means a decision not to authorize a healthcare service, 5
28	28	including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole 6
29	29	or in part, for a benefit. A decision by a utilization-review agent to authorize a healthcare service 7
30	30	in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute 8
31	31	an adverse determination if the review agent and provider are in agreement regarding the decision. 9
32	32	Adverse benefit determinations include: 10
33	33	(i) “Administrative adverse benefit determinations,” meaning any adverse benefit 11
34	34	determination that does not require the use of medical judgment or clinical criteria such as a 12
35	35	determination of an individual’s eligibility to participate in coverage, a determination that a benefit 13
36	36	is not a covered benefit, or any rescission of coverage; and 14
37	37	(ii) “Non-administrative adverse benefit determinations,” meaning any adverse benefit 15
38	38	determination that requires or involves the use of medical judgement or clinical criteria to 16
39	39	determine whether the service being reviewed is medically necessary and/or appropriate. This 17
40	40	includes the denial of treatments determined to be experimental or investigational, and any denial 18
41	41	of coverage of a prescription drug because that drug is not on the healthcare entity’s formulary. 19
42	42
43	43
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45	45	(2) “Appeal” or “internal appeal” means a subsequent review of an adverse benefit 1
46	46	determination upon request by a claimant to include the beneficiary or provider to reconsider all or 2
47	47	part of the original adverse benefit determination. 3
48	48	(3) “Authorization” means a review by a review agent, performed according to this chapter, 4
49	49	concluding that the allocation of healthcare services ordered by a provider, given or proposed to be 5
50	50	given to a beneficiary, was approved or authorized. 6
51	51	(4) “Authorized representative” means an individual acting on behalf of the beneficiary 7
52	52	and shall include: the ordering provider; any individual to whom the beneficiary has given express 8
53	53	written consent to act on his or her behalf; a person authorized by law to provide substituted consent 9
54	54	for the beneficiary; and, when the beneficiary is unable to provide consent, a family member of the 10
55	55	beneficiary. 11
56	56	(5) “Beneficiary” means a policy-holder subscriber, enrollee, or other individual 12
57	57	participating in a health-benefit plan. 13
58	58	(6) “Benefit determination” means a decision to approve or deny a request to provide or 14
59	59	make payment for a healthcare service or treatment. 15
60	60	(7) “Certificate” means a certificate granted by the commissioner to a review agent meeting 16
61	61	the requirements of this chapter. 17
62	62	(8) “Claim” means a request for plan benefit(s) made by a claimant in accordance with the 18
63	63	healthcare entity’s reasonable procedures for filing benefit claims. This shall include pre-service, 19
64	64	concurrent, and post-service claims. 20
65	65	(9) “Claimant” means a healthcare entity participant, beneficiary, and/or authorized 21
66	66	representative who makes a request for plan benefit(s). 22
67	67	(10) “Commissioner” means the health insurance commissioner. 23
68	68	(11) “Complaint” means an oral or written expression of dissatisfaction by a beneficiary, 24
69	69	authorized representative, or a provider. The appeal of an adverse benefit determination is not 25
70	70	considered a complaint. 26
71	71	(12) “Concurrent assessment” means an assessment of healthcare services conducted 27
72	72	during a beneficiary’s hospital stay, course of treatment or services over a period of time, or for the 28
73	73	number of treatments. If the medical problem is ongoing, this assessment may include the review 29
74	74	of services after they have been rendered and billed. 30
75	75	(13) “Concurrent claim” means a request for a plan benefit(s) by a claimant that is for an 31
76	76	ongoing course of treatment or services over a period of time or for the number of treatments. 32
77	77	(14) “Delegate” means a person or entity authorized pursuant to a delegation of authority 33
78	78	or re-delegation of authority, by a healthcare entity or network plan to perform one or more of the 34
79	79
80	80
81	81	LC002773 - Page 3 of 23
82	82	functions and responsibilities of a healthcare entity and/or network plan set forth in this chapter or 1
83	83	regulations or guidance promulgated thereunder. 2
84	84	(15) “Emergency services” or “emergent services” means those resources provided in the 3
85	85	event of the sudden onset of a medical, behavioral health, or other health condition that the absence 4
86	86	of immediate medical attention could reasonably be expected, by a prudent layperson, to result in 5
87	87	placing the patient’s health in serious jeopardy, serious impairment to bodily or mental functions, 6
88	88	or serious dysfunction of any bodily organ or part. 7
89	89	(16) “External review” means a review of a non-administrative adverse benefit 8
90	90	determination (including final internal adverse benefit determination) conducted pursuant to an 9
91	91	applicable external review process performed by an independent review organization. 10
92	92	(17) “External review decision” means a determination by an independent review 11
93	93	organization at the conclusion of the external review. 12
94	94	(18) “Final internal adverse benefit determination” means an adverse benefit determination 13
95	95	that has been upheld by a plan or issuer at the completion of the internal appeals process or when 14
96	96	the internal appeals process has been deemed exhausted as defined in § 27-18.9-7(b)(1). 15
97	97	(19) “Health-benefit plan” or “health plan” means a policy, contract, certificate, or 16
98	98	agreement entered into, offered, or issued by a healthcare entity to provide, deliver, arrange for, 17
99	99	pay for, or reimburse any of the costs of healthcare services. 18
100	100	(20) “Healthcare entity” means an insurance company licensed, or required to be licensed, 19
101	101	by the state of Rhode Island or other entity subject to the jurisdiction of the commissioner or the 20
102	102	jurisdiction of the department of business regulation pursuant to chapter 62 of title 42, that contracts 21
103	103	or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or 22
104	104	reimburse any of the costs of healthcare services, including, without limitation: a for-profit or 23
105	105	nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, 24
106	106	a health insurance company, or any other entity providing a plan of health insurance, accident and 25
107	107	sickness insurance, health benefits, or healthcare services. 26
108	108	(21) “Healthcare services” means and includes, but is not limited to: an admission, 27
109	109	diagnostic procedure, therapeutic procedure, treatment, extension of stay, the ordering and/or filling 28
110	110	of formulary or non-formulary medications, and any other medical, behavioral, dental, vision care 29
111	111	services, activities, or supplies that are covered by the beneficiary’s health-benefit plan. 30
112	112	(22) “Independent review organization” or “IRO” means an entity that conducts 31
113	113	independent external reviews of adverse benefit determinations or final internal adverse benefit 32
114	114	determinations. 33
115	115	(23) “Insurer”, for the purposes of § 27-18.9-16, means all insurance companies licensed 34
116	116
117	117
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119	119	to do business in Rhode Island, including those subject to chapter 1 of title 27 ("domestic insurance 1
120	120	companies"), a foreign insurance company licensed to do business in Rhode Island and subject to 2
121	121	chapter 2 of title 27 ("foreign insurance companies"), a health insurance carrier subject and 3
122	122	organized pursuant to chapter 18 of title 27 ("accident and sickness insurance policies"), a nonprofit 4
123	123	hospital service corporation subject and organized pursuant to chapter 19 of title 27 ("nonprofit 5
124	124	hospital service corporations"), a nonprofit medical services corporation subject and organized 6
125	125	pursuant to chapter 20 of title 27 ("nonprofit medical service corporations"), a qualified health 7
126	126	maintenance organization subject and organized pursuant to chapter 41 of title 27 ("health 8
127	127	maintenance organizations"), and Medicaid Managed Care Organizations. 9
128	128	(24) “Network” means the group or groups of participating providers providing healthcare 10
129	129	services under a network plan. 11
130	130	(24)(25) “Network plan” means a health-benefit plan or health plan that either requires a 12
131	131	beneficiary to use, or creates incentives, including financial incentives, for a beneficiary to use the 13
132	132	providers managed, owned, under contract with, or employed by the healthcare entity. 14
133	133	(25)(26) “Office” means the office of the health insurance commissioner. 15
134	134	(26)(27) “Pre-service claim” means the request for a plan benefit(s) by a claimant prior to 16
135	135	a service being rendered and is not considered a concurrent claim. 17
136	136	(28) "Primary care provider (PCP)", for the purposes of § 27-18.9-16, means internal 18
137	137	medicine physicians, family medicine physicians, pediatricians, geriatricians, OB-GYNs, nurse 19
138	138	practitioners, certified nurse midwives, and physician’s assistants. 20
139	139	(29) "Prior authorization and other utilization review", for the purposes of § 27-18.9-16, 21
140	140	means the approval a primary care provider is required by an insurer to obtain from an insurer or 22
141	141	pharmacy benefit manager for healthcare to be covered for a patient, in accordance with the 23
142	142	definition of utilization review in this section. 24
143	143	(27)(30) “Professional provider” means an individual provider or healthcare professional 25
144	144	licensed, accredited, or certified to perform specified healthcare services consistent with state law 26
145	145	and who provides healthcare services and is not part of a separate facility or institutional contract. 27
146	146	(28)(31) “Prospective assessment” or “pre-service assessment” means an assessment of 28
147	147	healthcare services prior to services being rendered. 29
148	148	(29)(32) “Provider” means a physician, hospital, professional provider, pharmacy, 30
149	149	laboratory, dental, medical, or behavioral health provider or other state-licensed or other state-31
150	150	recognized provider of health care or behavioral health services or supplies. 32
151	151	(30)(33) “Retrospective assessment” or “post-service assessment” means an assessment of 33
152	152	healthcare services that have been rendered. This shall not include reviews conducted when the 34
153	153
154	154
155	155	LC002773 - Page 5 of 23
156	156	review agency has been obtaining ongoing information. 1
157	157	(31)(34) “Retrospective claim” or “post-service claim” means any claim for a health-plan 2
158	158	benefit that is not a pre-service or concurrent claim. 3
159	159	(32)(35) “Review agent” means a person or healthcare entity performing benefit 4
160	160	determination reviews that is either employed by, affiliated with, under contract with, or acting on 5
161	161	behalf of a healthcare entity. 6
162	162	(33)(36) “Same or similar specialty” means a practitioner who has the appropriate training 7
163	163	and experience that is the same or similar as the attending provider in addition to experience in 8
164	164	treating the same problems to include any potential complications as those under review. 9
165	165	(34)(37) “Therapeutic interchange” means the interchange or substitution of a drug with a 10
166	166	dissimilar chemical structure within the same therapeutic or pharmacological class that can be 11
167	167	expected to have similar outcomes and similar adverse reaction profiles when given in equivalent 12
168	168	doses, in accordance with protocols approved by the president of the medical staff or medical 13
169	169	director and the director of pharmacy. 14
170	170	(35)(38) “Tiered network” means a network that identifies and groups some or all types of 15
171	171	providers into specific groups to which different provider reimbursement, beneficiary cost-sharing, 16
172	172	or provider access requirements, or any combination thereof, apply for the same services. 17
173	173	(36)(39) “Urgent healthcare services” includes those resources necessary to treat a 18
174	174	symptomatic medical, mental health, substance use, or other healthcare condition that a prudent 19
175	175	layperson, acting reasonably, would believe necessitates treatment within a twenty-four hour (24) 20
176	176	period of the onset of such a condition in order that the patient’s health status not decline as a 21
177	177	consequence. This does not include those conditions considered to be emergent healthcare services 22
178	178	as defined in this section. 23
179	179	(37)(40) “Utilization review” means the prospective, concurrent, or retrospective 24
180	180	assessment of the medical necessity and/or appropriateness of the allocation of healthcare services 25
181	181	of a provider, given or proposed to be given, to a beneficiary. Utilization review does not include: 26
182	182	(i) The therapeutic interchange of drugs or devices by a pharmacy operating as part of a 27
183	183	licensed inpatient healthcare facility; or 28
184	184	(ii) The assessment by a pharmacist licensed pursuant to the provisions of chapter 19.1 of 29
185	185	title 5, and practicing in a pharmacy operating as part of a licensed inpatient healthcare facility, in 30
186	186	the interpretation, evaluation and implementation of medical orders, including assessments and/or 31
187	187	comparisons involving formularies and medical orders. 32
188	188	(38)(41) “Utilization review plan” means a description of the standards governing 33
189	189	utilization review activities performed by a review agent. 34
190	190
191	191
192	192	LC002773 - Page 6 of 23
193	193	SECTION 2. Chapter 27-18.9 of the General Laws entitled "Benefit Determination and 1
194	194	Utilization Review Act" is hereby amended by adding thereto the following section: 2
195	195	27-18.9-16. Limitations on prior authorization for primary care. 3
196	196	(a) Except as provided in subsection (b) of this section, an insurer shall not impose any 4
197	197	prior authorization requirement for any admission, item, service, treatment, test, exam, study, 5
198	198	procedure, or any generic or brand name prescription drug ordered by a primary care provider. 6
199	199	(b) The prohibition set forth in subsection (a) of this section shall not be construed to 7
200	200	prohibit prior authorization requirements for controlled substances, or for individual primary care 8
201	201	providers after documented cases of fraud, waste or abuse by the Centers of Medicare and Medicaid 9
202	202	Services. 10
203	203	(c) Notwithstanding any other provision of law to the contrary, in order to establish 11
204	204	uniformity in the submission of prior authorization forms, on or after January 1, 2026, any issuer 12
205	205	issuing any lawful prior authorization shall use only a single, standardized prior authorization form, 13
206	206	in accordance with the following requirements: 14
207	207	(1) Except as otherwise allowable by federal law, the form shall not exceed two (2) pages 15
208	208	in length, excluding any instructions or guiding documentation; 16
209	209	(2) The form shall be made available electronically, and the prescribing provider may 17
210	210	submit the completed form electronically to the health benefit plan; 18
211	211	(3) In order to lower burden on providers, all insurers must create an online payor portal to 19
212	212	allow for online submission of the standardized form. These online portals must contain all relevant 20
213	213	prior authorization information, including access to the standardized form, to allow providers to fill 21
214	214	out and submit the form online. These portals must be accessible to providers by January 1, 2026; 22
215	215	and 23
216	216	(4) The issuer must submit its prior authorization form to the office of the health insurance 24
217	217	commissioner to be kept on file on January 1, 2026. A copy of any subsequent replacements or 25
218	218	modifications of a health insurance issuer's prior authorization form shall be filed with the office 26
219	219	of the health insurance commissioner. The office of the health insurance commissioner may 27
220	220	promulgate rules and regulations to further standardize and reduce the burden of prior authorization 28
221	221	on providers. 29
222	222	SECTION 3. Section 42-7.2-5 of the General Laws in Chapter 42-7.2 entitled "Office of 30
223	223	Health and Human Services" is hereby amended to read as follows: 31
224	224	42-7.2-5. Duties of the secretary. 32
225	225	The secretary shall be subject to the direction and supervision of the governor for the 33
226	226	oversight, coordination, and cohesive direction of state-administered health and human services 34
227	227
228	228
229	229	LC002773 - Page 7 of 23
230	230	and in ensuring the laws are faithfully executed, notwithstanding any law to the contrary. In this 1
231	231	capacity, the secretary of the executive office of health and human services (EOHHS) shall be 2
232	232	authorized to: 3
233	233	(1) Coordinate the administration and financing of healthcare benefits, human services, and 4
234	234	programs including those authorized by the state’s Medicaid section 1115 demonstration waiver 5
235	235	and, as applicable, the Medicaid state plan under Title XIX of the U.S. Social Security Act. 6
236	236	However, nothing in this section shall be construed as transferring to the secretary the powers, 7
237	237	duties, or functions conferred upon the departments by Rhode Island public and general laws for 8
238	238	the administration of federal/state programs financed in whole or in part with Medicaid funds or 9
239	239	the administrative responsibility for the preparation and submission of any state plans, state plan 10
240	240	amendments, or authorized federal waiver applications, once approved by the secretary. 11
241	241	(2) Serve as the governor’s chief advisor and liaison to federal policymakers on Medicaid 12
242	242	reform issues as well as the principal point of contact in the state on any such related matters. 13
243	243	(3)(i) Review and ensure the coordination of the state’s Medicaid section 1115 14
244	244	demonstration waiver requests and renewals as well as any initiatives and proposals requiring 15
245	245	amendments to the Medicaid state plan or formal amendment changes, as described in the special 16
246	246	terms and conditions of the state’s Medicaid section 1115 demonstration waiver with the potential 17
247	247	to affect the scope, amount, or duration of publicly funded healthcare services, provider payments 18
248	248	or reimbursements, or access to or the availability of benefits and services as provided by Rhode 19
249	249	Island general and public laws. The secretary shall consider whether any such changes are legally 20
250	250	and fiscally sound and consistent with the state’s policy and budget priorities. The secretary shall 21
251	251	also assess whether a proposed change is capable of obtaining the necessary approvals from federal 22
252	252	officials and achieving the expected positive consumer outcomes. Department directors shall, 23
253	253	within the timelines specified, provide any information and resources the secretary deems necessary 24
254	254	in order to perform the reviews authorized in this section. 25
255	255	(ii) Direct the development and implementation of any Medicaid policies, procedures, or 26
256	256	systems that may be required to assure successful operation of the state’s health and human services 27
257	257	integrated eligibility system and coordination with HealthSource RI, the state’s health insurance 28
258	258	marketplace. 29
259	259	(iii) Beginning in 2015, conduct on a biennial basis a comprehensive review of the 30
260	260	Medicaid eligibility criteria for one or more of the populations covered under the state plan or a 31
261	261	waiver to ensure consistency with federal and state laws and policies, coordinate and align systems, 32
262	262	and identify areas for improving quality assurance, fair and equitable access to services, and 33
263	263	opportunities for additional financial participation. 34
264	264
265	265
266	266	LC002773 - Page 8 of 23
267	267	(iv) Implement service organization and delivery reforms that facilitate service integration, 1
268	268	increase value, and improve quality and health outcomes. 2
269	269	(4) Beginning in 2020, prepare and submit to the governor, the chairpersons of the house 3
270	270	and senate finance committees, the caseload estimating conference, and to the joint legislative 4
271	271	committee for health-care oversight, by no later than September 15 of each year, a comprehensive 5
272	272	overview of all Medicaid expenditures outcomes, administrative costs, and utilization rates. The 6
273	273	overview shall include, but not be limited to, the following information: 7
274	274	(i) Expenditures under Titles XIX and XXI of the Social Security Act, as amended; 8
275	275	(ii) Expenditures, outcomes, and utilization rates by population and sub-population served 9
276	276	(e.g., families with children, persons with disabilities, children in foster care, children receiving 10
277	277	adoption assistance, adults ages nineteen (19) to sixty-four (64), and elders); 11
278	278	(iii) Expenditures, outcomes, and utilization rates by each state department or other 12
279	279	municipal or public entity receiving federal reimbursement under Titles XIX and XXI of the Social 13
280	280	Security Act, as amended; 14
281	281	(iv) Expenditures, outcomes, and utilization rates by type of service and/or service 15
282	282	provider; 16
283	283	(v) Expenditures by mandatory population receiving mandatory services and, reported 17
284	284	separately, optional services, as well as optional populations receiving mandatory services and, 18
285	285	reported separately, optional services for each state agency receiving Title XIX and XXI funds; and 19
286	286	(vi) Information submitted to the Centers for Medicare & Medicaid Services for the 20
287	287	mandatory annual state reporting of the Core Set of Children’s Health Care Quality Measures for 21
288	288	Medicaid and Children’s Health Insurance Program, behavioral health measures on the Core Set of 22
289	289	Adult Health Care Quality Measures for Medicaid and the Core Sets of Health Home Quality 23
290	290	Measures for Medicaid to ensure compliance with the Bipartisan Budget Act of 2018, Pub. L. No. 24
291	291	115-123. 25
292	292	The directors of the departments, as well as local governments and school departments, 26
293	293	shall assist and cooperate with the secretary in fulfilling this responsibility by providing whatever 27
294	294	resources, information and support shall be necessary. 28
295	295	(5) Resolve administrative, jurisdictional, operational, program, or policy conflicts among 29
296	296	departments and their executive staffs and make necessary recommendations to the governor. 30
297	297	(6) Ensure continued progress toward improving the quality, the economy, the 31
298	298	accountability, and the efficiency of state-administered health and human services. In this capacity, 32
299	299	the secretary shall: 33
300	300	(i) Direct implementation of reforms in the human resources practices of the executive 34
301	301
302	302
303	303	LC002773 - Page 9 of 23
304	304	office and the departments that streamline and upgrade services, achieve greater economies of scale 1
305	305	and establish the coordinated system of the staff education, cross-training, and career development 2
306	306	services necessary to recruit and retain a highly-skilled, responsive, and engaged health and human 3
307	307	services workforce; 4
308	308	(ii) Encourage EOHHS-wide consumer-centered approaches to service design and delivery 5
309	309	that expand their capacity to respond efficiently and responsibly to the diverse and changing needs 6
310	310	of the people and communities they serve; 7
311	311	(iii) Develop all opportunities to maximize resources by leveraging the state’s purchasing 8
312	312	power, centralizing fiscal service functions related to budget, finance, and procurement, 9
313	313	centralizing communication, policy analysis and planning, and information systems and data 10
314	314	management, pursuing alternative funding sources through grants, awards, and partnerships and 11
315	315	securing all available federal financial participation for programs and services provided EOHHS-12
316	316	wide; 13
317	317	(iv) Improve the coordination and efficiency of health and human services legal functions 14
318	318	by centralizing adjudicative and legal services and overseeing their timely and judicious 15
319	319	administration; 16
320	320	(v) Facilitate the rebalancing of the long-term system by creating an assessment and 17
321	321	coordination organization or unit for the expressed purpose of developing and implementing 18
322	322	procedures EOHHS-wide that ensure that the appropriate publicly funded health services are 19
323	323	provided at the right time and in the most appropriate and least restrictive setting; 20
324	324	(vi) Strengthen health and human services program integrity, quality control and 21
325	325	collections, and recovery activities by consolidating functions within the office in a single unit that 22
326	326	ensures all affected parties pay their fair share of the cost of services and are aware of alternative 23
327	327	financing; 24
328	328	(vii) Assure protective services are available to vulnerable elders and adults with 25
329	329	developmental and other disabilities by reorganizing existing services, establishing new services 26
330	330	where gaps exist, and centralizing administrative responsibility for oversight of all related 27
331	331	initiatives and programs. 28
332	332	(7) Prepare and integrate comprehensive budgets for the health and human services 29
333	333	departments and any other functions and duties assigned to the office. The budgets shall be 30
334	334	submitted to the state budget office by the secretary, for consideration by the governor, on behalf 31
335	335	of the state’s health and human services agencies in accordance with the provisions set forth in § 32
336	336	35-3-4. 33
337	337	(8) Utilize objective data to evaluate health and human services policy goals, resource use 34
338	338
339	339
340	340	LC002773 - Page 10 of 23
341	341	and outcome evaluation and to perform short and long-term policy planning and development. 1
342	342	(9) Establishment of an integrated approach to interdepartmental information and data 2
343	343	management that complements and furthers the goals of the unified health infrastructure project 3
344	344	initiative and that will facilitate the transition to a consumer-centered integrated system of state-4
345	345	administered health and human services. 5
346	346	(10) At the direction of the governor or the general assembly, conduct independent reviews 6
347	347	of state-administered health and human services programs, policies and related agency actions and 7
348	348	activities and assist the department directors in identifying strategies to address any issues or areas 8
349	349	of concern that may emerge thereof. The department directors shall provide any information and 9
350	350	assistance deemed necessary by the secretary when undertaking such independent reviews. 10
351	351	(11) Provide regular and timely reports to the governor and make recommendations with 11
352	352	respect to the state’s health and human services agenda. 12
353	353	(12) Employ such personnel and contract for such consulting services as may be required 13
354	354	to perform the powers and duties lawfully conferred upon the secretary. 14
355	355	(13) Assume responsibility for complying with the provisions of any general or public law 15
356	356	or regulation related to the disclosure, confidentiality, and privacy of any information or records, 16
357	357	in the possession or under the control of the executive office or the departments assigned to the 17
358	358	executive office, that may be developed or acquired or transferred at the direction of the governor 18
359	359	or the secretary for purposes directly connected with the secretary’s duties set forth herein. 19
360	360	(14) Hold the director of each health and human services department accountable for their 20
361	361	administrative, fiscal, and program actions in the conduct of the respective powers and duties of 21
362	362	their agencies. 22
363	363	(15) Identify opportunities for inclusion with the EOHHS’ October 1, 2023 budget 23
364	364	submission, to remove fixed eligibility thresholds for programs under its purview by establishing 24
365	365	sliding scale decreases in benefits commensurate with income increases up to four hundred fifty 25
366	366	percent (450%) of the federal poverty level. These shall include but not be limited to, medical 26
367	367	assistance, childcare assistance, and food assistance. 27
368	368	(16) Ensure that insurers minimize administrative burdens on providers that may delay 28
369	369	medically necessary care, including requiring that insurers do not impose a prior authorization or 29
370	370	other utilization management review requirement for any admission, item, service, treatment, test, 30
371	371	exam, study procedure, or any generic or brand name prescription drug ordered by an in-network 31
372	372	primary care provider; provided, however, the prohibition shall not be construed to prohibit prior 32
373	373	authorization requirements for controlled substances. Provided further, that as used in this section, 33
374	374	the terms "insurer," "primary care provider," and "prior authorization and other utilization 34
375	375
376	376
377	377	LC002773 - Page 11 of 23
378	378	management" means the same as those terms are defined in § 27-18.9-2. 1
379	379	SECTION 4. Section 42-14.5-3 of the General Laws in Chapter 42-14.5 entitled "The 2
380	380	Rhode Island Health Care Reform Act of 2004 — Health Insurance Oversight" is hereby amended 3
381	381	to read as follows: 4
382	382	42-14.5-3. Powers and duties. 5
383	383	The health insurance commissioner shall have the following powers and duties: 6
384	384	(a) To conduct quarterly public meetings throughout the state, separate and distinct from 7
385	385	rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers 8
386	386	licensed to provide health insurance in the state; the effects of such rates, services, and operations 9
387	387	on consumers, medical care providers, patients, and the market environment in which the insurers 10
388	388	operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less 11
389	389	than ten (10) days of the hearing(s) shall go to the general assembly, the governor, the Rhode Island 12
390	390	Medical Society, the Hospital Association of Rhode Island, the director of health, the attorney 13
391	391	general, and the chambers of commerce. Public notice shall be posted on the department’s website 14
392	392	and given in the newspaper of general circulation, and to any entity in writing requesting notice. 15
393	393	(b) To make recommendations to the governor and the house of representatives and senate 16
394	394	finance committees regarding healthcare insurance and the regulations, rates, services, 17
395	395	administrative expenses, reserve requirements, and operations of insurers providing health 18
396	396	insurance in the state, and to prepare or comment on, upon the request of the governor or 19
397	397	chairpersons of the house or senate finance committees, draft legislation to improve the regulation 20
398	398	of health insurance. In making the recommendations, the commissioner shall recognize that it is 21
399	399	the intent of the legislature that the maximum disclosure be provided regarding the reasonableness 22
400	400	of individual administrative expenditures as well as total administrative costs. The commissioner 23
401	401	shall make recommendations on the levels of reserves, including consideration of: targeted reserve 24
402	402	levels; trends in the increase or decrease of reserve levels; and insurer plans for distributing excess 25
403	403	reserves. 26
404	404	(c) To establish a consumer/business/labor/medical advisory council to obtain information 27
405	405	and present concerns of consumers, business, and medical providers affected by health insurance 28
406	406	decisions. The council shall develop proposals to allow the market for small business health 29
407	407	insurance to be affordable and fairer. The council shall be involved in the planning and conduct of 30
408	408	the quarterly public meetings in accordance with subsection (a). The advisory council shall develop 31
409	409	measures to inform small businesses of an insurance complaint process to ensure that small 32
410	410	businesses that experience rate increases in a given year may request and receive a formal review 33
411	411	by the department. The advisory council shall assess views of the health provider community 34
412	412
413	413
414	414	LC002773 - Page 12 of 23
415	415	relative to insurance rates of reimbursement, billing, and reimbursement procedures, and the 1
416	416	insurers’ role in promoting efficient and high-quality health care. The advisory council shall issue 2
417	417	an annual report of findings and recommendations to the governor and the general assembly and 3
418	418	present its findings at hearings before the house and senate finance committees. The advisory 4
419	419	council is to be diverse in interests and shall include representatives of community consumer 5
420	420	organizations; small businesses, other than those involved in the sale of insurance products; and 6
421	421	hospital, medical, and other health provider organizations. Such representatives shall be nominated 7
422	422	by their respective organizations. The advisory council shall be co-chaired by the health insurance 8
423	423	commissioner and a community consumer organization or small business member to be elected by 9
424	424	the full advisory council. 10
425	425	(d) To establish and provide guidance and assistance to a subcommittee (“the professional-11
426	426	provider-health-plan work group”) of the advisory council created pursuant to subsection (c), 12
427	427	composed of healthcare providers and Rhode Island licensed health plans. This subcommittee shall 13
428	428	include in its annual report and presentation before the house and senate finance committees the 14
429	429	following information: 15
430	430	(1) A method whereby health plans shall disclose to contracted providers the fee schedules 16
431	431	used to provide payment to those providers for services rendered to covered patients; 17
432	432	(2) A standardized provider application and credentials verification process, for the 18
433	433	purpose of verifying professional qualifications of participating healthcare providers; 19
434	434	(3) The uniform health plan claim form utilized by participating providers; 20
435	435	(4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit 21
436	436	hospital or medical service corporations, as defined by chapters 19 and 20 of title 27, to make 22
437	437	facility-specific data and other medical service-specific data available in reasonably consistent 23
438	438	formats to patients regarding quality and costs. This information would help consumers make 24
439	439	informed choices regarding the facilities and clinicians or physician practices at which to seek care. 25
440	440	Among the items considered would be the unique health services and other public goods provided 26
441	441	by facilities and clinicians or physician practices in establishing the most appropriate cost 27
442	442	comparisons; 28
443	443	(5) All activities related to contractual disclosure to participating providers of the 29
444	444	mechanisms for resolving health plan/provider disputes; 30
445	445	(6) The uniform process being utilized for confirming, in real time, patient insurance 31
446	446	enrollment status, benefits coverage, including copays and deductibles; 32
447	447	(7) Information related to temporary credentialing of providers seeking to participate in the 33
448	448	plan’s network and the impact of the activity on health plan accreditation; 34
449	449
450	450
451	451	LC002773 - Page 13 of 23
452	452	(8) The feasibility of regular contract renegotiations between plans and the providers in 1
453	453	their networks; and 2
454	454	(9) Efforts conducted related to reviewing impact of silent PPOs on physician practices. 3
455	455	(e) To enforce the provisions of title 27 and title 42 as set forth in § 42-14-5(d). 4
456	456	(f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The 5
457	457	fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17. 6
458	458	(g) To analyze the impact of changing the rating guidelines and/or merging the individual 7
459	459	health insurance market, as defined in chapter 18.5 of title 27, and the small-employer health 8
460	460	insurance market, as defined in chapter 50 of title 27, in accordance with the following: 9
461	461	(1) The analysis shall forecast the likely rate increases required to effect the changes 10
462	462	recommended pursuant to the preceding subsection (g) in the direct-pay market and small-employer 11
463	463	health insurance market over the next five (5) years, based on the current rating structure and 12
464	464	current products. 13
465	465	(2) The analysis shall include examining the impact of merging the individual and small-14
466	466	employer markets on premiums charged to individuals and small-employer groups. 15
467	467	(3) The analysis shall include examining the impact on rates in each of the individual and 16
468	468	small-employer health insurance markets and the number of insureds in the context of possible 17
469	469	changes to the rating guidelines used for small-employer groups, including: community rating 18
470	470	principles; expanding small-employer rate bonds beyond the current range; increasing the employer 19
471	471	group size in the small-group market; and/or adding rating factors for broker and/or tobacco use. 20
472	472	(4) The analysis shall include examining the adequacy of current statutory and regulatory 21
473	473	oversight of the rating process and factors employed by the participants in the proposed, new 22
474	474	merged market. 23
475	475	(5) The analysis shall include assessment of possible reinsurance mechanisms and/or 24
476	476	federal high-risk pool structures and funding to support the health insurance market in Rhode Island 25
477	477	by reducing the risk of adverse selection and the incremental insurance premiums charged for this 26
478	478	risk, and/or by making health insurance affordable for a selected at-risk population. 27
479	479	(6) The health insurance commissioner shall work with an insurance market merger task 28
480	480	force to assist with the analysis. The task force shall be chaired by the health insurance 29
481	481	commissioner and shall include, but not be limited to, representatives of the general assembly, the 30
482	482	business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage in 31
483	483	the individual market in Rhode Island, health insurance brokers, and members of the general public. 32
484	484	(7) For the purposes of conducting this analysis, the commissioner may contract with an 33
485	485	outside organization with expertise in fiscal analysis of the private insurance market. In conducting 34
486	486
487	487
488	488	LC002773 - Page 14 of 23
489	489	its study, the organization shall, to the extent possible, obtain and use actual health plan data. Said 1
490	490	data shall be subject to state and federal laws and regulations governing confidentiality of health 2
491	491	care and proprietary information. 3
492	492	(8) The task force shall meet as necessary and include its findings in the annual report, and 4
493	493	the commissioner shall include the information in the annual presentation before the house and 5
494	494	senate finance committees. 6
495	495	(h) To establish and convene a workgroup representing healthcare providers and health 7
496	496	insurers for the purpose of coordinating the development of processes, guidelines, and standards to 8
497	497	streamline healthcare administration that are to be adopted by payors and providers of healthcare 9
498	498	services operating in the state. This workgroup shall include representatives with expertise who 10
499	499	would contribute to the streamlining of healthcare administration and who are selected from 11
500	500	hospitals, physician practices, community behavioral health organizations, each health insurer, and 12
501	501	other affected entities. The workgroup shall also include at least one designee each from the Rhode 13
502	502	Island Medical Society, Rhode Island Council of Community Mental Health Organizations, the 14
503	503	Rhode Island Health Center Association, and the Hospital Association of Rhode Island. In any year 15
504	504	that the workgroup meets and submits recommendations to the office of the health insurance 16
505	505	commissioner, the office of the health insurance commissioner shall submit such recommendations 17
506	506	to the health and human services committees of the Rhode Island house of representatives and the 18
507	507	Rhode Island senate prior to the implementation of any such recommendations and subsequently 19
508	508	shall submit a report to the general assembly by June 30, 2024. The report shall include the 20
509	509	recommendations the commissioner may implement, with supporting rationale. The workgroup 21
510	510	shall consider and make recommendations for: 22
511	511	(1) Establishing a consistent standard for electronic eligibility and coverage verification. 23
512	512	Such standard shall: 24
513	513	(i) Include standards for eligibility inquiry and response and, wherever possible, be 25
514	514	consistent with the standards adopted by nationally recognized organizations, such as the Centers 26
515	515	for Medicare & Medicaid Services; 27
516	516	(ii) Enable providers and payors to exchange eligibility requests and responses on a system-28
517	517	to-system basis or using a payor-supported web browser; 29
518	518	(iii) Provide reasonably detailed information on a consumer’s eligibility for healthcare 30
519	519	coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing 31
520	520	requirements for specific services at the specific time of the inquiry; current deductible amounts; 32
521	521	accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and 33
522	522	other information required for the provider to collect the patient’s portion of the bill; 34
523	523
524	524
525	525	LC002773 - Page 15 of 23
526	526	(iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility 1
527	527	and benefits information; 2
528	528	(v) Recommend a standard or common process to protect all providers from the costs of 3
529	529	services to patients who are ineligible for insurance coverage in circumstances where a payor 4
530	530	provides eligibility verification based on best information available to the payor at the date of the 5
531	531	request of eligibility. 6
532	532	(2) Developing implementation guidelines and promoting adoption of the guidelines for: 7
533	533	(i) The use of the National Correct Coding Initiative code-edit policy by payors and 8
534	534	providers in the state; 9
535	535	(ii) Publishing any variations from codes and mutually exclusive codes by payors in a 10
536	536	manner that makes for simple retrieval and implementation by providers; 11
537	537	(iii) Use of Health Insurance Portability and Accountability Act standard group codes, 12
538	538	reason codes, and remark codes by payors in electronic remittances sent to providers; 13
539	539	(iv) Uniformity in the processing of claims by payors; and the processing of corrections to 14
540	540	claims by providers and payors; 15
541	541	(v) A standard payor-denial review process for providers when they request a 16
542	542	reconsideration of a denial of a claim that results from differences in clinical edits where no single, 17
543	543	common-standards body or process exists and multiple conflicting sources are in use by payors and 18
544	544	providers. 19
545	545	(vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual 20
546	546	payor’s ability to employ, and not disclose to providers, temporary code edits for the purpose of 21
547	547	detecting and deterring fraudulent billing activities. The guidelines shall require that each payor 22
548	548	disclose to the provider its adjudication decision on a claim that was denied or adjusted based on 23
549	549	the application of such edits and that the provider have access to the payor’s review and appeal 24
550	550	process to challenge the payor’s adjudication decision. 25
551	551	(vii) Nothing in this subsection shall be construed to modify the rights or obligations of 26
552	552	payors or providers with respect to procedures relating to the investigation, reporting, appeal, or 27
553	553	prosecution under applicable law of potentially fraudulent billing activities. 28
554	554	(3) Developing and promoting widespread adoption by payors and providers of guidelines 29
555	555	to: 30
556	556	(i) Ensure payors do not automatically deny claims for services when extenuating 31
557	557	circumstances make it impossible for the provider to obtain a preauthorization before services are 32
558	558	performed or notify a payor within an appropriate standardized timeline of a patient’s admission; 33
559	559	(ii) Require payors to use common and consistent processes and time frames when 34
560	560
561	561
562	562	LC002773 - Page 16 of 23
563	563	responding to provider requests for medical management approvals. Whenever possible, such time 1
564	564	frames shall be consistent with those established by leading national organizations and be based 2
565	565	upon the acuity of the patient’s need for care or treatment. For the purposes of this section, medical 3
566	566	management includes prior authorization of services, preauthorization of services, precertification 4
567	567	of services, post-service review, medical-necessity review, and benefits advisory; 5
568	568	(iii) Develop, maintain, and promote widespread adoption of a single, common website 6
569	569	where providers can obtain payors’ preauthorization, benefits advisory, and preadmission 7
570	570	requirements; 8
571	571	(iv) Establish guidelines for payors to develop and maintain a website that providers can 9
572	572	use to request a preauthorization, including a prospective clinical necessity review; receive an 10
573	573	authorization number; and transmit an admission notification; 11
574	574	(v) Develop and implement the use of programs that implement selective prior 12
575	575	authorization requirements, based on stratification of healthcare providers’ performance and 13
576	576	adherence to evidence-based medicine with the input of contracted healthcare providers and/or 14
577	577	provider organizations. Such criteria shall be transparent and easily accessible to contracted 15
578	578	providers. Such selective prior authorization programs shall be available when healthcare providers 16
579	579	participate directly with the insurer in risk-based payment contracts and may be available to 17
580	580	providers who do not participate in risk-based contracts; 18
581	581	(vi) Require the review of medical services, including behavioral health services, and 19
582	582	prescription drugs, subject to prior authorization on at least an annual basis, with the input of 20
583	583	contracted healthcare providers and/or provider organizations. Any changes to the list of medical 21
584	584	services, including behavioral health services, and prescription drugs requiring prior authorization, 22
585	585	shall be shared via provider-accessible websites; 23
586	586	(vii) Improve communication channels between health plans, healthcare providers, and 24
587	587	patients by: 25
588	588	(A) Requiring transparency and easy accessibility of prior authorization requirements, 26
589	589	criteria, rationale, and program changes to contracted healthcare providers and patients/health plan 27
590	590	enrollees which may be satisfied by posting to provider-accessible and member-accessible 28
591	591	websites; and 29
592	592	(B) Supporting: 30
593	593	(I) Timely submission by healthcare providers of the complete information necessary to 31
594	594	make a prior authorization determination, as early in the process as possible; and 32
595	595	(II) Timely notification of prior authorization determinations by health plans to impacted 33
596	596	health plan enrollees, and healthcare providers, including, but not limited to, ordering providers, 34
597	597
598	598
599	599	LC002773 - Page 17 of 23
600	600	and/or rendering providers, and dispensing pharmacists which may be satisfied by posting to 1
601	601	provider-accessible websites or similar electronic portals or services; 2
602	602	(viii) Increase and strengthen continuity of patient care by: 3
603	603	(A) Defining protections for continuity of care during a transition period for patients 4
604	604	undergoing an active course of treatment, when there is a formulary or treatment coverage change 5
605	605	or change of health plan that may disrupt their current course of treatment and when the treating 6
606	606	physician determines that a transition may place the patient at risk; and for prescription medication 7
607	607	by allowing a grace period of coverage to allow consideration of referred health plan options or 8
608	608	establishment of medical necessity of the current course of treatment; 9
609	609	(B) Requiring continuity of care for medical services, including behavioral health services, 10
610	610	and prescription medications for patients on appropriate, chronic, stable therapy through 11
611	611	minimizing repetitive prior authorization requirements; and which for prescription medication shall 12
612	612	be allowed only on an annual review, with exception for labeled limitation, to establish continued 13
613	613	benefit of treatment; and 14
614	614	(C) Requiring communication between healthcare providers, health plans, and patients to 15
615	615	facilitate continuity of care and minimize disruptions in needed treatment which may be satisfied 16
616	616	by posting to provider-accessible websites or similar electronic portals or services; 17
617	617	(D) Continuity of care for formulary or drug coverage shall distinguish between FDA 18
618	618	designated interchangeable products and proprietary or marketed versions of a medication; 19
619	619	(ix) Encourage healthcare providers and/or provider organizations and health plans to 20
620	620	accelerate use of electronic prior authorization technology, including adoption of national standards 21
621	621	where applicable; and 22
622	622	(x) For the purposes of subsections (h)(3)(v) through (h)(3)(x) of this section, the 23
623	623	workgroup meeting may be conducted in part or whole through electronic methods. 24
624	624	(4) To provide a report to the house and senate, on or before January 1, 2017, with 25
625	625	recommendations for establishing guidelines and regulations for systems that give patients 26
626	626	electronic access to their claims information, particularly to information regarding their obligations 27
627	627	to pay for received medical services, pursuant to 45 C.F.R. § 164.524. 28
628	628	(5) No provision of this subsection (h) shall preclude the ongoing work of the office of 29
629	629	health insurance commissioner’s administrative simplification task force, which includes meetings 30
630	630	with key stakeholders in order to improve, and provide recommendations regarding, the prior 31
631	631	authorization process. 32
632	632	(i) To issue an anti-cancer medication report. Not later than June 30, 2014, and annually 33
633	633	thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate 34
634	634
635	635
636	636	LC002773 - Page 18 of 23
637	637	committee on health and human services, and the house committee on corporations, with: (1) 1
638	638	Information on the availability in the commercial market of coverage for anti-cancer medication 2
639	639	options; (2) For the state employee’s health benefit plan, the costs of various cancer-treatment 3
640	640	options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member 4
641	641	utilization and cost-sharing expense. 5
642	642	(j) To monitor the adequacy of each health plan’s compliance with the provisions of the 6
643	643	federal Mental Health Parity Act, including a review of related claims processing and 7
644	644	reimbursement procedures. Findings, recommendations, and assessments shall be made available 8
645	645	to the public. 9
646	646	(k) To monitor the transition from fee-for-service and toward global and other alternative 10
647	647	payment methodologies for the payment for healthcare services. Alternative payment 11
648	648	methodologies should be assessed for their likelihood to promote access to affordable health 12
649	649	insurance, health outcomes, and performance. 13
650	650	(l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital 14
651	651	payment variation, including findings and recommendations, subject to available resources. 15
652	652	(m) Notwithstanding any provision of the general or public laws or regulation to the 16
653	653	contrary, provide a report with findings and recommendations to the president of the senate and the 17
654	654	speaker of the house, on or before April 1, 2014, including, but not limited to, the following 18
655	655	information: 19
656	656	(1) The impact of the current, mandated healthcare benefits as defined in §§ 27-18-48.1, 20
657	657	27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41 of title 27, and §§ 27-21
658	658	18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health 22
659	659	insurance for fully insured employers, subject to available resources; 23
660	660	(2) Current provider and insurer mandates that are unnecessary and/or duplicative due to 24
661	661	the existing standards of care and/or delivery of services in the healthcare system; 25
662	662	(3) A state-by-state comparison of health insurance mandates and the extent to which 26
663	663	Rhode Island mandates exceed other states benefits; and 27
664	664	(4) Recommendations for amendments to existing mandated benefits based on the findings 28
665	665	in (m)(1), (m)(2), and (m)(3) above. 29
666	666	(n) On or before July 1, 2014, the office of the health insurance commissioner, in 30
667	667	collaboration with the director of health and lieutenant governor’s office, shall submit a report to 31
668	668	the general assembly and the governor to inform the design of accountable care organizations 32
669	669	(ACOs) in Rhode Island as unique structures for comprehensive healthcare delivery and value-33
670	670	based payment arrangements, that shall include, but not be limited to: 34
671	671
672	672
673	673	LC002773 - Page 19 of 23
674	674	(1) Utilization review; 1
675	675	(2) Contracting; and 2
676	676	(3) Licensing and regulation. 3
677	677	(o) On or before February 3, 2015, the office of the health insurance commissioner shall 4
678	678	submit a report to the general assembly and the governor that describes, analyzes, and proposes 5
679	679	recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard 6
680	680	to patients with mental health and substance use disorders. 7
681	681	(p) To work to ensure the health insurance coverage of behavioral health care under the 8
682	682	same terms and conditions as other health care, and to integrate behavioral health parity 9
683	683	requirements into the office of the health insurance commissioner insurance oversight and 10
684	684	healthcare transformation efforts. 11
685	685	(q) To work with other state agencies to seek delivery system improvements that enhance 12
686	686	access to a continuum of mental health and substance use disorder treatment in the state; and 13
687	687	integrate that treatment with primary and other medical care to the fullest extent possible. 14
688	688	(r) To direct insurers toward policies and practices that address the behavioral health needs 15
689	689	of the public and greater integration of physical and behavioral healthcare delivery. 16
690	690	(s) The office of the health insurance commissioner shall conduct an analysis of the impact 17
691	691	of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and 18
692	692	submit a report of its findings to the general assembly on or before June 1, 2023. 19
693	693	(t) To undertake the analyses, reports, and studies contained in this section: 20
694	694	(1) The office shall hire the necessary staff and prepare a request for proposal for a qualified 21
695	695	and competent firm or firms to undertake the following analyses, reports, and studies: 22
696	696	(i) The firm shall undertake a comprehensive review of all social and human service 23
697	697	programs having a contract with or licensed by the state or any subdivision of the department of 24
698	698	children, youth and families (DCYF), the department of behavioral healthcare, developmental 25
699	699	disabilities and hospitals (BHDDH), the department of human services (DHS), the department of 26
700	700	health (DOH), and Medicaid for the purposes of: 27
701	701	(A) Establishing a baseline of the eligibility factors for receiving services; 28
702	702	(B) Establishing a baseline of the service offering through each agency for those 29
703	703	determined eligible; 30
704	704	(C) Establishing a baseline understanding of reimbursement rates for all social and human 31
705	705	service programs including rates currently being paid, the date of the last increase, and a proposed 32
706	706	model that the state may use to conduct future studies and analyses; 33
707	707	(D) Ensuring accurate and adequate reimbursement to social and human service providers 34
708	708
709	709
710	710	LC002773 - Page 20 of 23
711	711	that facilitate the availability of high-quality services to individuals receiving home and 1
712	712	community-based long-term services and supports provided by social and human service providers; 2
713	713	(E) Ensuring the general assembly is provided accurate financial projections on social and 3
714	714	human service program costs, demand for services, and workforce needs to ensure access to entitled 4
715	715	beneficiaries and services; 5
716	716	(F) Establishing a baseline and determining the relationship between state government and 6
717	717	the provider network including functions, responsibilities, and duties; 7
718	718	(G) Determining a set of measures and accountability standards to be used by EOHHS and 8
719	719	the general assembly to measure the outcomes of the provision of services including budgetary 9
720	720	reporting requirements, transparency portals, and other methods; and 10
721	721	(H) Reporting the findings of human services analyses and reports to the speaker of the 11
722	722	house, senate president, chairs of the house and senate finance committees, chairs of the house and 12
723	723	senate health and human services committees, and the governor. 13
724	724	(2) The analyses, reports, and studies required pursuant to this section shall be 14
725	725	accomplished and published as follows and shall provide: 15
726	726	(i) An assessment and detailed reporting on all social and human service program rates to 16
727	727	be completed by January 1, 2023, including rates currently being paid and the date of the last 17
728	728	increase; 18
729	729	(ii) An assessment and detailed reporting on eligibility standards and processes of all 19
730	730	mandatory and discretionary social and human service programs to be completed by January 1, 20
731	731	2023; 21
732	732	(iii) An assessment and detailed reporting on utilization trends from the period of January 22
733	733	1, 2017, through December 31, 2021, for social and human service programs to be completed by 23
734	734	January 1, 2023; 24
735	735	(iv) An assessment and detailed reporting on the structure of the state government as it 25
736	736	relates to the provision of services by social and human service providers including eligibility and 26
737	737	functions of the provider network to be completed by January 1, 2023; 27
738	738	(v) An assessment and detailed reporting on accountability standards for services for social 28
739	739	and human service programs to be completed by January 1, 2023; 29
740	740	(vi) An assessment and detailed reporting by April 1, 2023, on all professional licensed 30
741	741	and unlicensed personnel requirements for established rates for social and human service programs 31
742	742	pursuant to a contract or established fee schedule; 32
743	743	(vii) An assessment and reporting on access to social and human service programs, to 33
744	744	include any wait lists and length of time on wait lists, in each service category by April 1, 2023; 34
745	745
746	746
747	747	LC002773 - Page 21 of 23
748	748	(viii) An assessment and reporting of national and regional Medicaid rates in comparison 1
749	749	to Rhode Island social and human service provider rates by April 1, 2023; 2
750	750	(ix) An assessment and reporting on usual and customary rates paid by private insurers and 3
751	751	private pay for similar social and human service providers, both nationally and regionally, by April 4
752	752	1, 2023; and 5
753	753	(x) Completion of the development of an assessment and review process that includes the 6
754	754	following components: eligibility; scope of services; relationship of social and human service 7
755	755	provider and the state; national and regional rate comparisons and accountability standards that 8
756	756	result in recommended rate adjustments; and this process shall be completed by September 1, 2023, 9
757	757	and conducted biennially hereafter. The biennial rate setting shall be consistent with payment 10
758	758	requirements established in § 1902(a)(30)(A) of the Social Security Act, 42 U.S.C. § 11
759	759	1396a(a)(30)(A), and all federal and state law, regulations, and quality and safety standards. The 12
760	760	results and findings of this process shall be transparent, and public meetings shall be conducted to 13
761	761	allow providers, recipients, and other interested parties an opportunity to ask questions and provide 14
762	762	comment beginning in September 2023 and biennially thereafter. 15
763	763	(3) In fulfillment of the responsibilities defined in subsection (t), the office of the health 16
764	764	insurance commissioner shall consult with the Executive Office of Health and Human Services. 17
765	765	(u) Annually, each department (namely, EOHHS, DCYF, DOH, DHS, and BHDDH) shall 18
766	766	include the corresponding components of the assessment and review (i.e., eligibility; scope of 19
767	767	services; relationship of social and human service provider and the state; and national and regional 20
768	768	rate comparisons and accountability standards including any changes or substantive issues between 21
769	769	biennial reviews) including the recommended rates from the most recent assessment and review 22
770	770	with their annual budget submission to the office of management and budget and provide a detailed 23
771	771	explanation and impact statement if any rate variances exist between submitted recommended 24
772	772	budget and the corresponding recommended rate from the most recent assessment and review 25
773	773	process starting October 1, 2023, and biennially thereafter. 26
774	774	(v) The general assembly shall appropriate adequate funding as it deems necessary to 27
775	775	undertake the analyses, reports, and studies contained in this section relating to the powers and 28
776	776	duties of the office of the health insurance commissioner. 29
777	777	(w) Ensure that insurers minimize administrative burdens that may delay medically 30
778	778	necessary care, including by promulgating rules and regulations and taking enforcement actions to 31
779	779	implement § 27-18.9-16. 32
780	780
781	781
782	782	LC002773 - Page 22 of 23
783	783	SECTION 5. This act shall take effect on January 1, 2026. 1
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785	785	LC002773
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787	787
788	788
789	789	LC002773 - Page 23 of 23
790	790	EXPLANATION
791	791	BY THE LEGISLATIVE COUNCIL
792	792	OF
793	793	A N A C T
794	794	RELATING TO INSURANCE -- BENEFIT DETERMINATION AND UTILIZATION ACT
795	795	***
796	796	This act would prohibit an insurer from imposing a requirement of prior authorization for 1
797	797	any admission, item, service, treatment, test, exam, study, procedure, or any generic or brand name 2
798	798	prescription drug ordered by a primary care provider unless it was a requirement for controlled 3
799	799	substances, or individual primary care providers with documented cases of fraud, waste or abuse. 4
800	800	The act would also require any issuer issuing any lawful prior authorization to use a single, 5
801	801	standardized prior authorization form. 6
802	802	This act would take effect on January 1, 2026. 7
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804	804	LC002773
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