2025 -- H 6317
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LC002773
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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 -- BENEFIT DETERMINATION AND UT ILIZATION ACT
Introduced By: Representatives Ackerman, Potter, McNamara, Edwards, Donovan, and
Shallcross Smith
Date Introduced: May 09, 2025
Referred To: House Health & Human Services
(Attorney General)
It is enacted by the General Assembly as follows:
SECTION 1. Section 27-18.9-2 of the General Laws in Chapter 27-18.9 entitled "Benefit 1
Determination and Utilization Review Act" is hereby amended to read as follows: 2
27-18.9-2. Definitions. 3
As used in this chapter, the following terms are defined as follows: 4
(1) “Adverse benefit determination” means a decision not to authorize a healthcare service, 5
including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole 6
or in part, for a benefit. A decision by a utilization-review agent to authorize a healthcare service 7
in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute 8
an adverse determination if the review agent and provider are in agreement regarding the decision. 9
Adverse benefit determinations include: 10
(i) “Administrative adverse benefit determinations,” meaning any adverse benefit 11
determination that does not require the use of medical judgment or clinical criteria such as a 12
determination of an individual’s eligibility to participate in coverage, a determination that a benefit 13
is not a covered benefit, or any rescission of coverage; and 14
(ii) “Non-administrative adverse benefit determinations,” meaning any adverse benefit 15
determination that requires or involves the use of medical judgement or clinical criteria to 16
determine whether the service being reviewed is medically necessary and/or appropriate. This 17
includes the denial of treatments determined to be experimental or investigational, and any denial 18
of coverage of a prescription drug because that drug is not on the healthcare entity’s formulary. 19
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(2) “Appeal” or “internal appeal” means a subsequent review of an adverse benefit 1
determination upon request by a claimant to include the beneficiary or provider to reconsider all or 2
part of the original adverse benefit determination. 3
(3) “Authorization” means a review by a review agent, performed according to this chapter, 4
concluding that the allocation of healthcare services ordered by a provider, given or proposed to be 5
given to a beneficiary, was approved or authorized. 6
(4) “Authorized representative” means an individual acting on behalf of the beneficiary 7
and shall include: the ordering provider; any individual to whom the beneficiary has given express 8
written consent to act on his or her behalf; a person authorized by law to provide substituted consent 9
for the beneficiary; and, when the beneficiary is unable to provide consent, a family member of the 10
beneficiary. 11
(5) “Beneficiary” means a policy-holder subscriber, enrollee, or other individual 12
participating in a health-benefit plan. 13
(6) “Benefit determination” means a decision to approve or deny a request to provide or 14
make payment for a healthcare service or treatment. 15
(7) “Certificate” means a certificate granted by the commissioner to a review agent meeting 16
the requirements of this chapter. 17
(8) “Claim” means a request for plan benefit(s) made by a claimant in accordance with the 18
healthcare entity’s reasonable procedures for filing benefit claims. This shall include pre-service, 19
concurrent, and post-service claims. 20
(9) “Claimant” means a healthcare entity participant, beneficiary, and/or authorized 21
representative who makes a request for plan benefit(s). 22
(10) “Commissioner” means the health insurance commissioner. 23
(11) “Complaint” means an oral or written expression of dissatisfaction by a beneficiary, 24
authorized representative, or a provider. The appeal of an adverse benefit determination is not 25
considered a complaint. 26
(12) “Concurrent assessment” means an assessment of healthcare services conducted 27
during a beneficiary’s hospital stay, course of treatment or services over a period of time, or for the 28
number of treatments. If the medical problem is ongoing, this assessment may include the review 29
of services after they have been rendered and billed. 30
(13) “Concurrent claim” means a request for a plan benefit(s) by a claimant that is for an 31
ongoing course of treatment or services over a period of time or for the number of treatments. 32
(14) “Delegate” means a person or entity authorized pursuant to a delegation of authority 33
or re-delegation of authority, by a healthcare entity or network plan to perform one or more of the 34
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functions and responsibilities of a healthcare entity and/or network plan set forth in this chapter or 1
regulations or guidance promulgated thereunder. 2
(15) “Emergency services” or “emergent services” means those resources provided in the 3
event of the sudden onset of a medical, behavioral health, or other health condition that the absence 4
of immediate medical attention could reasonably be expected, by a prudent layperson, to result in 5
placing the patient’s health in serious jeopardy, serious impairment to bodily or mental functions, 6
or serious dysfunction of any bodily organ or part. 7
(16) “External review” means a review of a non-administrative adverse benefit 8
determination (including final internal adverse benefit determination) conducted pursuant to an 9
applicable external review process performed by an independent review organization. 10
(17) “External review decision” means a determination by an independent review 11
organization at the conclusion of the external review. 12
(18) “Final internal adverse benefit determination” means an adverse benefit determination 13
that has been upheld by a plan or issuer at the completion of the internal appeals process or when 14
the internal appeals process has been deemed exhausted as defined in § 27-18.9-7(b)(1). 15
(19) “Health-benefit plan” or “health plan” means a policy, contract, certificate, or 16
agreement entered into, offered, or issued by a healthcare entity to provide, deliver, arrange for, 17
pay for, or reimburse any of the costs of healthcare services. 18
(20) “Healthcare entity” means an insurance company licensed, or required to be licensed, 19
by the state of Rhode Island or other entity subject to the jurisdiction of the commissioner or the 20
jurisdiction of the department of business regulation pursuant to chapter 62 of title 42, that contracts 21
or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or 22
reimburse any of the costs of healthcare services, including, without limitation: a for-profit or 23
nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, 24
a health insurance company, or any other entity providing a plan of health insurance, accident and 25
sickness insurance, health benefits, or healthcare services. 26
(21) “Healthcare services” means and includes, but is not limited to: an admission, 27
diagnostic procedure, therapeutic procedure, treatment, extension of stay, the ordering and/or filling 28
of formulary or non-formulary medications, and any other medical, behavioral, dental, vision care 29
services, activities, or supplies that are covered by the beneficiary’s health-benefit plan. 30
(22) “Independent review organization” or “IRO” means an entity that conducts 31
independent external reviews of adverse benefit determinations or final internal adverse benefit 32
determinations. 33
(23) “Insurer”, for the purposes of § 27-18.9-16, means all insurance companies licensed 34
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to do business in Rhode Island, including those subject to chapter 1 of title 27 ("domestic insurance 1
companies"), a foreign insurance company licensed to do business in Rhode Island and subject to 2
chapter 2 of title 27 ("foreign insurance companies"), a health insurance carrier subject and 3
organized pursuant to chapter 18 of title 27 ("accident and sickness insurance policies"), a nonprofit 4
hospital service corporation subject and organized pursuant to chapter 19 of title 27 ("nonprofit 5
hospital service corporations"), a nonprofit medical services corporation subject and organized 6
pursuant to chapter 20 of title 27 ("nonprofit medical service corporations"), a qualified health 7
maintenance organization subject and organized pursuant to chapter 41 of title 27 ("health 8
maintenance organizations"), and Medicaid Managed Care Organizations. 9
(24) “Network” means the group or groups of participating providers providing healthcare 10
services under a network plan. 11
(24)(25) “Network plan” means a health-benefit plan or health plan that either requires a 12
beneficiary to use, or creates incentives, including financial incentives, for a beneficiary to use the 13
providers managed, owned, under contract with, or employed by the healthcare entity. 14
(25)(26) “Office” means the office of the health insurance commissioner. 15
(26)(27) “Pre-service claim” means the request for a plan benefit(s) by a claimant prior to 16
a service being rendered and is not considered a concurrent claim. 17
(28) "Primary care provider (PCP)", for the purposes of § 27-18.9-16, means internal 18
medicine physicians, family medicine physicians, pediatricians, geriatricians, OB-GYNs, nurse 19
practitioners, certified nurse midwives, and physician’s assistants. 20
(29) "Prior authorization and other utilization review", for the purposes of § 27-18.9-16, 21
means the approval a primary care provider is required by an insurer to obtain from an insurer or 22
pharmacy benefit manager for healthcare to be covered for a patient, in accordance with the 23
definition of utilization review in this section. 24
(27)(30) “Professional provider” means an individual provider or healthcare professional 25
licensed, accredited, or certified to perform specified healthcare services consistent with state law 26
and who provides healthcare services and is not part of a separate facility or institutional contract. 27
(28)(31) “Prospective assessment” or “pre-service assessment” means an assessment of 28
healthcare services prior to services being rendered. 29
(29)(32) “Provider” means a physician, hospital, professional provider, pharmacy, 30
laboratory, dental, medical, or behavioral health provider or other state-licensed or other state-31
recognized provider of health care or behavioral health services or supplies. 32
(30)(33) “Retrospective assessment” or “post-service assessment” means an assessment of 33
healthcare services that have been rendered. This shall not include reviews conducted when the 34
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review agency has been obtaining ongoing information. 1
(31)(34) “Retrospective claim” or “post-service claim” means any claim for a health-plan 2
benefit that is not a pre-service or concurrent claim. 3
(32)(35) “Review agent” means a person or healthcare entity performing benefit 4
determination reviews that is either employed by, affiliated with, under contract with, or acting on 5
behalf of a healthcare entity. 6
(33)(36) “Same or similar specialty” means a practitioner who has the appropriate training 7
and experience that is the same or similar as the attending provider in addition to experience in 8
treating the same problems to include any potential complications as those under review. 9
(34)(37) “Therapeutic interchange” means the interchange or substitution of a drug with a 10
dissimilar chemical structure within the same therapeutic or pharmacological class that can be 11
expected to have similar outcomes and similar adverse reaction profiles when given in equivalent 12
doses, in accordance with protocols approved by the president of the medical staff or medical 13
director and the director of pharmacy. 14
(35)(38) “Tiered network” means a network that identifies and groups some or all types of 15
providers into specific groups to which different provider reimbursement, beneficiary cost-sharing, 16
or provider access requirements, or any combination thereof, apply for the same services. 17
(36)(39) “Urgent healthcare services” includes those resources necessary to treat a 18
symptomatic medical, mental health, substance use, or other healthcare condition that a prudent 19
layperson, acting reasonably, would believe necessitates treatment within a twenty-four hour (24) 20
period of the onset of such a condition in order that the patient’s health status not decline as a 21
consequence. This does not include those conditions considered to be emergent healthcare services 22
as defined in this section. 23
(37)(40) “Utilization review” means the prospective, concurrent, or retrospective 24
assessment of the medical necessity and/or appropriateness of the allocation of healthcare services 25
of a provider, given or proposed to be given, to a beneficiary. Utilization review does not include: 26
(i) The therapeutic interchange of drugs or devices by a pharmacy operating as part of a 27
licensed inpatient healthcare facility; or 28
(ii) The assessment by a pharmacist licensed pursuant to the provisions of chapter 19.1 of 29
title 5, and practicing in a pharmacy operating as part of a licensed inpatient healthcare facility, in 30
the interpretation, evaluation and implementation of medical orders, including assessments and/or 31
comparisons involving formularies and medical orders. 32
(38)(41) “Utilization review plan” means a description of the standards governing 33
utilization review activities performed by a review agent. 34
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SECTION 2. Chapter 27-18.9 of the General Laws entitled "Benefit Determination and 1
Utilization Review Act" is hereby amended by adding thereto the following section: 2
27-18.9-16. Limitations on prior authorization for primary care. 3
(a) Except as provided in subsection (b) of this section, an insurer shall not impose any 4
prior authorization requirement for any admission, item, service, treatment, test, exam, study, 5
procedure, or any generic or brand name prescription drug ordered by a primary care provider. 6
(b) The prohibition set forth in subsection (a) of this section shall not be construed to 7
prohibit prior authorization requirements for controlled substances, or for individual primary care 8
providers after documented cases of fraud, waste or abuse by the Centers of Medicare and Medicaid 9
Services. 10
(c) Notwithstanding any other provision of law to the contrary, in order to establish 11
uniformity in the submission of prior authorization forms, on or after January 1, 2026, any issuer 12
issuing any lawful prior authorization shall use only a single, standardized prior authorization form, 13
in accordance with the following requirements: 14
(1) Except as otherwise allowable by federal law, the form shall not exceed two (2) pages 15
in length, excluding any instructions or guiding documentation; 16
(2) The form shall be made available electronically, and the prescribing provider may 17
submit the completed form electronically to the health benefit plan; 18
(3) In order to lower burden on providers, all insurers must create an online payor portal to 19
allow for online submission of the standardized form. These online portals must contain all relevant 20
prior authorization information, including access to the standardized form, to allow providers to fill 21
out and submit the form online. These portals must be accessible to providers by January 1, 2026; 22
and 23
(4) The issuer must submit its prior authorization form to the office of the health insurance 24
commissioner to be kept on file on January 1, 2026. A copy of any subsequent replacements or 25
modifications of a health insurance issuer's prior authorization form shall be filed with the office 26
of the health insurance commissioner. The office of the health insurance commissioner may 27
promulgate rules and regulations to further standardize and reduce the burden of prior authorization 28
on providers. 29
SECTION 3. Section 42-7.2-5 of the General Laws in Chapter 42-7.2 entitled "Office of 30
Health and Human Services" is hereby amended to read as follows: 31
42-7.2-5. Duties of the secretary. 32
The secretary shall be subject to the direction and supervision of the governor for the 33
oversight, coordination, and cohesive direction of state-administered health and human services 34
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and in ensuring the laws are faithfully executed, notwithstanding any law to the contrary. In this 1
capacity, the secretary of the executive office of health and human services (EOHHS) shall be 2
authorized to: 3
(1) Coordinate the administration and financing of healthcare benefits, human services, and 4
programs including those authorized by the state’s Medicaid section 1115 demonstration waiver 5
and, as applicable, the Medicaid state plan under Title XIX of the U.S. Social Security Act. 6
However, nothing in this section shall be construed as transferring to the secretary the powers, 7
duties, or functions conferred upon the departments by Rhode Island public and general laws for 8
the administration of federal/state programs financed in whole or in part with Medicaid funds or 9
the administrative responsibility for the preparation and submission of any state plans, state plan 10
amendments, or authorized federal waiver applications, once approved by the secretary. 11
(2) Serve as the governor’s chief advisor and liaison to federal policymakers on Medicaid 12
reform issues as well as the principal point of contact in the state on any such related matters. 13
(3)(i) Review and ensure the coordination of the state’s Medicaid section 1115 14
demonstration waiver requests and renewals as well as any initiatives and proposals requiring 15
amendments to the Medicaid state plan or formal amendment changes, as described in the special 16
terms and conditions of the state’s Medicaid section 1115 demonstration waiver with the potential 17
to affect the scope, amount, or duration of publicly funded healthcare services, provider payments 18
or reimbursements, or access to or the availability of benefits and services as provided by Rhode 19
Island general and public laws. The secretary shall consider whether any such changes are legally 20
and fiscally sound and consistent with the state’s policy and budget priorities. The secretary shall 21
also assess whether a proposed change is capable of obtaining the necessary approvals from federal 22
officials and achieving the expected positive consumer outcomes. Department directors shall, 23
within the timelines specified, provide any information and resources the secretary deems necessary 24
in order to perform the reviews authorized in this section. 25
(ii) Direct the development and implementation of any Medicaid policies, procedures, or 26
systems that may be required to assure successful operation of the state’s health and human services 27
integrated eligibility system and coordination with HealthSource RI, the state’s health insurance 28
marketplace. 29
(iii) Beginning in 2015, conduct on a biennial basis a comprehensive review of the 30
Medicaid eligibility criteria for one or more of the populations covered under the state plan or a 31
waiver to ensure consistency with federal and state laws and policies, coordinate and align systems, 32
and identify areas for improving quality assurance, fair and equitable access to services, and 33
opportunities for additional financial participation. 34
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(iv) Implement service organization and delivery reforms that facilitate service integration, 1
increase value, and improve quality and health outcomes. 2
(4) Beginning in 2020, prepare and submit to the governor, the chairpersons of the house 3
and senate finance committees, the caseload estimating conference, and to the joint legislative 4
committee for health-care oversight, by no later than September 15 of each year, a comprehensive 5
overview of all Medicaid expenditures outcomes, administrative costs, and utilization rates. The 6
overview shall include, but not be limited to, the following information: 7
(i) Expenditures under Titles XIX and XXI of the Social Security Act, as amended; 8
(ii) Expenditures, outcomes, and utilization rates by population and sub-population served 9
(e.g., families with children, persons with disabilities, children in foster care, children receiving 10
adoption assistance, adults ages nineteen (19) to sixty-four (64), and elders); 11
(iii) Expenditures, outcomes, and utilization rates by each state department or other 12
municipal or public entity receiving federal reimbursement under Titles XIX and XXI of the Social 13
Security Act, as amended; 14
(iv) Expenditures, outcomes, and utilization rates by type of service and/or service 15
provider; 16
(v) Expenditures by mandatory population receiving mandatory services and, reported 17
separately, optional services, as well as optional populations receiving mandatory services and, 18
reported separately, optional services for each state agency receiving Title XIX and XXI funds; and 19
(vi) Information submitted to the Centers for Medicare & Medicaid Services for the 20
mandatory annual state reporting of the Core Set of Children’s Health Care Quality Measures for 21
Medicaid and Children’s Health Insurance Program, behavioral health measures on the Core Set of 22
Adult Health Care Quality Measures for Medicaid and the Core Sets of Health Home Quality 23
Measures for Medicaid to ensure compliance with the Bipartisan Budget Act of 2018, Pub. L. No. 24
115-123. 25
The directors of the departments, as well as local governments and school departments, 26
shall assist and cooperate with the secretary in fulfilling this responsibility by providing whatever 27
resources, information and support shall be necessary. 28
(5) Resolve administrative, jurisdictional, operational, program, or policy conflicts among 29
departments and their executive staffs and make necessary recommendations to the governor. 30
(6) Ensure continued progress toward improving the quality, the economy, the 31
accountability, and the efficiency of state-administered health and human services. In this capacity, 32
the secretary shall: 33
(i) Direct implementation of reforms in the human resources practices of the executive 34
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office and the departments that streamline and upgrade services, achieve greater economies of scale 1
and establish the coordinated system of the staff education, cross-training, and career development 2
services necessary to recruit and retain a highly-skilled, responsive, and engaged health and human 3
services workforce; 4
(ii) Encourage EOHHS-wide consumer-centered approaches to service design and delivery 5
that expand their capacity to respond efficiently and responsibly to the diverse and changing needs 6
of the people and communities they serve; 7
(iii) Develop all opportunities to maximize resources by leveraging the state’s purchasing 8
power, centralizing fiscal service functions related to budget, finance, and procurement, 9
centralizing communication, policy analysis and planning, and information systems and data 10
management, pursuing alternative funding sources through grants, awards, and partnerships and 11
securing all available federal financial participation for programs and services provided EOHHS-12
wide; 13
(iv) Improve the coordination and efficiency of health and human services legal functions 14
by centralizing adjudicative and legal services and overseeing their timely and judicious 15
administration; 16
(v) Facilitate the rebalancing of the long-term system by creating an assessment and 17
coordination organization or unit for the expressed purpose of developing and implementing 18
procedures EOHHS-wide that ensure that the appropriate publicly funded health services are 19
provided at the right time and in the most appropriate and least restrictive setting; 20
(vi) Strengthen health and human services program integrity, quality control and 21
collections, and recovery activities by consolidating functions within the office in a single unit that 22
ensures all affected parties pay their fair share of the cost of services and are aware of alternative 23
financing; 24
(vii) Assure protective services are available to vulnerable elders and adults with 25
developmental and other disabilities by reorganizing existing services, establishing new services 26
where gaps exist, and centralizing administrative responsibility for oversight of all related 27
initiatives and programs. 28
(7) Prepare and integrate comprehensive budgets for the health and human services 29
departments and any other functions and duties assigned to the office. The budgets shall be 30
submitted to the state budget office by the secretary, for consideration by the governor, on behalf 31
of the state’s health and human services agencies in accordance with the provisions set forth in § 32
35-3-4. 33
(8) Utilize objective data to evaluate health and human services policy goals, resource use 34
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and outcome evaluation and to perform short and long-term policy planning and development. 1
(9) Establishment of an integrated approach to interdepartmental information and data 2
management that complements and furthers the goals of the unified health infrastructure project 3
initiative and that will facilitate the transition to a consumer-centered integrated system of state-4
administered health and human services. 5
(10) At the direction of the governor or the general assembly, conduct independent reviews 6
of state-administered health and human services programs, policies and related agency actions and 7
activities and assist the department directors in identifying strategies to address any issues or areas 8
of concern that may emerge thereof. The department directors shall provide any information and 9
assistance deemed necessary by the secretary when undertaking such independent reviews. 10
(11) Provide regular and timely reports to the governor and make recommendations with 11
respect to the state’s health and human services agenda. 12
(12) Employ such personnel and contract for such consulting services as may be required 13
to perform the powers and duties lawfully conferred upon the secretary. 14
(13) Assume responsibility for complying with the provisions of any general or public law 15
or regulation related to the disclosure, confidentiality, and privacy of any information or records, 16
in the possession or under the control of the executive office or the departments assigned to the 17
executive office, that may be developed or acquired or transferred at the direction of the governor 18
or the secretary for purposes directly connected with the secretary’s duties set forth herein. 19
(14) Hold the director of each health and human services department accountable for their 20
administrative, fiscal, and program actions in the conduct of the respective powers and duties of 21
their agencies. 22
(15) Identify opportunities for inclusion with the EOHHS’ October 1, 2023 budget 23
submission, to remove fixed eligibility thresholds for programs under its purview by establishing 24
sliding scale decreases in benefits commensurate with income increases up to four hundred fifty 25
percent (450%) of the federal poverty level. These shall include but not be limited to, medical 26
assistance, childcare assistance, and food assistance. 27
(16) Ensure that insurers minimize administrative burdens on providers that may delay 28
medically necessary care, including requiring that insurers do not impose a prior authorization or 29
other utilization management review requirement for any admission, item, service, treatment, test, 30
exam, study procedure, or any generic or brand name prescription drug ordered by an in-network 31
primary care provider; provided, however, the prohibition shall not be construed to prohibit prior 32
authorization requirements for controlled substances. Provided further, that as used in this section, 33
the terms "insurer," "primary care provider," and "prior authorization and other utilization 34
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management" means the same as those terms are defined in § 27-18.9-2. 1
SECTION 4. Section 42-14.5-3 of the General Laws in Chapter 42-14.5 entitled "The 2
Rhode Island Health Care Reform Act of 2004 — Health Insurance Oversight" is hereby amended 3
to read as follows: 4
42-14.5-3. Powers and duties. 5
The health insurance commissioner shall have the following powers and duties: 6
(a) To conduct quarterly public meetings throughout the state, separate and distinct from 7
rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers 8
licensed to provide health insurance in the state; the effects of such rates, services, and operations 9
on consumers, medical care providers, patients, and the market environment in which the insurers 10
operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less 11
than ten (10) days of the hearing(s) shall go to the general assembly, the governor, the Rhode Island 12
Medical Society, the Hospital Association of Rhode Island, the director of health, the attorney 13
general, and the chambers of commerce. Public notice shall be posted on the department’s website 14
and given in the newspaper of general circulation, and to any entity in writing requesting notice. 15
(b) To make recommendations to the governor and the house of representatives and senate 16
finance committees regarding healthcare insurance and the regulations, rates, services, 17
administrative expenses, reserve requirements, and operations of insurers providing health 18
insurance in the state, and to prepare or comment on, upon the request of the governor or 19
chairpersons of the house or senate finance committees, draft legislation to improve the regulation 20
of health insurance. In making the recommendations, the commissioner shall recognize that it is 21
the intent of the legislature that the maximum disclosure be provided regarding the reasonableness 22
of individual administrative expenditures as well as total administrative costs. The commissioner 23
shall make recommendations on the levels of reserves, including consideration of: targeted reserve 24
levels; trends in the increase or decrease of reserve levels; and insurer plans for distributing excess 25
reserves. 26
(c) To establish a consumer/business/labor/medical advisory council to obtain information 27
and present concerns of consumers, business, and medical providers affected by health insurance 28
decisions. The council shall develop proposals to allow the market for small business health 29
insurance to be affordable and fairer. The council shall be involved in the planning and conduct of 30
the quarterly public meetings in accordance with subsection (a). The advisory council shall develop 31
measures to inform small businesses of an insurance complaint process to ensure that small 32
businesses that experience rate increases in a given year may request and receive a formal review 33
by the department. The advisory council shall assess views of the health provider community 34
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relative to insurance rates of reimbursement, billing, and reimbursement procedures, and the 1
insurers’ role in promoting efficient and high-quality health care. The advisory council shall issue 2
an annual report of findings and recommendations to the governor and the general assembly and 3
present its findings at hearings before the house and senate finance committees. The advisory 4
council is to be diverse in interests and shall include representatives of community consumer 5
organizations; small businesses, other than those involved in the sale of insurance products; and 6
hospital, medical, and other health provider organizations. Such representatives shall be nominated 7
by their respective organizations. The advisory council shall be co-chaired by the health insurance 8
commissioner and a community consumer organization or small business member to be elected by 9
the full advisory council. 10
(d) To establish and provide guidance and assistance to a subcommittee (“the professional-11
provider-health-plan work group”) of the advisory council created pursuant to subsection (c), 12
composed of healthcare providers and Rhode Island licensed health plans. This subcommittee shall 13
include in its annual report and presentation before the house and senate finance committees the 14
following information: 15
(1) A method whereby health plans shall disclose to contracted providers the fee schedules 16
used to provide payment to those providers for services rendered to covered patients; 17
(2) A standardized provider application and credentials verification process, for the 18
purpose of verifying professional qualifications of participating healthcare providers; 19
(3) The uniform health plan claim form utilized by participating providers; 20
(4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit 21
hospital or medical service corporations, as defined by chapters 19 and 20 of title 27, to make 22
facility-specific data and other medical service-specific data available in reasonably consistent 23
formats to patients regarding quality and costs. This information would help consumers make 24
informed choices regarding the facilities and clinicians or physician practices at which to seek care. 25
Among the items considered would be the unique health services and other public goods provided 26
by facilities and clinicians or physician practices in establishing the most appropriate cost 27
comparisons; 28
(5) All activities related to contractual disclosure to participating providers of the 29
mechanisms for resolving health plan/provider disputes; 30
(6) The uniform process being utilized for confirming, in real time, patient insurance 31
enrollment status, benefits coverage, including copays and deductibles; 32
(7) Information related to temporary credentialing of providers seeking to participate in the 33
plan’s network and the impact of the activity on health plan accreditation; 34
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(8) The feasibility of regular contract renegotiations between plans and the providers in 1
their networks; and 2
(9) Efforts conducted related to reviewing impact of silent PPOs on physician practices. 3
(e) To enforce the provisions of title 27 and title 42 as set forth in § 42-14-5(d). 4
(f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The 5
fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17. 6
(g) To analyze the impact of changing the rating guidelines and/or merging the individual 7
health insurance market, as defined in chapter 18.5 of title 27, and the small-employer health 8
insurance market, as defined in chapter 50 of title 27, in accordance with the following: 9
(1) The analysis shall forecast the likely rate increases required to effect the changes 10
recommended pursuant to the preceding subsection (g) in the direct-pay market and small-employer 11
health insurance market over the next five (5) years, based on the current rating structure and 12
current products. 13
(2) The analysis shall include examining the impact of merging the individual and small-14
employer markets on premiums charged to individuals and small-employer groups. 15
(3) The analysis shall include examining the impact on rates in each of the individual and 16
small-employer health insurance markets and the number of insureds in the context of possible 17
changes to the rating guidelines used for small-employer groups, including: community rating 18
principles; expanding small-employer rate bonds beyond the current range; increasing the employer 19
group size in the small-group market; and/or adding rating factors for broker and/or tobacco use. 20
(4) The analysis shall include examining the adequacy of current statutory and regulatory 21
oversight of the rating process and factors employed by the participants in the proposed, new 22
merged market. 23
(5) The analysis shall include assessment of possible reinsurance mechanisms and/or 24
federal high-risk pool structures and funding to support the health insurance market in Rhode Island 25
by reducing the risk of adverse selection and the incremental insurance premiums charged for this 26
risk, and/or by making health insurance affordable for a selected at-risk population. 27
(6) The health insurance commissioner shall work with an insurance market merger task 28
force to assist with the analysis. The task force shall be chaired by the health insurance 29
commissioner and shall include, but not be limited to, representatives of the general assembly, the 30
business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage in 31
the individual market in Rhode Island, health insurance brokers, and members of the general public. 32
(7) For the purposes of conducting this analysis, the commissioner may contract with an 33
outside organization with expertise in fiscal analysis of the private insurance market. In conducting 34
LC002773 - Page 14 of 23
its study, the organization shall, to the extent possible, obtain and use actual health plan data. Said 1
data shall be subject to state and federal laws and regulations governing confidentiality of health 2
care and proprietary information. 3
(8) The task force shall meet as necessary and include its findings in the annual report, and 4
the commissioner shall include the information in the annual presentation before the house and 5
senate finance committees. 6
(h) To establish and convene a workgroup representing healthcare providers and health 7
insurers for the purpose of coordinating the development of processes, guidelines, and standards to 8
streamline healthcare administration that are to be adopted by payors and providers of healthcare 9
services operating in the state. This workgroup shall include representatives with expertise who 10
would contribute to the streamlining of healthcare administration and who are selected from 11
hospitals, physician practices, community behavioral health organizations, each health insurer, and 12
other affected entities. The workgroup shall also include at least one designee each from the Rhode 13
Island Medical Society, Rhode Island Council of Community Mental Health Organizations, the 14
Rhode Island Health Center Association, and the Hospital Association of Rhode Island. In any year 15
that the workgroup meets and submits recommendations to the office of the health insurance 16
commissioner, the office of the health insurance commissioner shall submit such recommendations 17
to the health and human services committees of the Rhode Island house of representatives and the 18
Rhode Island senate prior to the implementation of any such recommendations and subsequently 19
shall submit a report to the general assembly by June 30, 2024. The report shall include the 20
recommendations the commissioner may implement, with supporting rationale. The workgroup 21
shall consider and make recommendations for: 22
(1) Establishing a consistent standard for electronic eligibility and coverage verification. 23
Such standard shall: 24
(i) Include standards for eligibility inquiry and response and, wherever possible, be 25
consistent with the standards adopted by nationally recognized organizations, such as the Centers 26
for Medicare & Medicaid Services; 27
(ii) Enable providers and payors to exchange eligibility requests and responses on a system-28
to-system basis or using a payor-supported web browser; 29
(iii) Provide reasonably detailed information on a consumer’s eligibility for healthcare 30
coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing 31
requirements for specific services at the specific time of the inquiry; current deductible amounts; 32
accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and 33
other information required for the provider to collect the patient’s portion of the bill; 34
LC002773 - Page 15 of 23
(iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility 1
and benefits information; 2
(v) Recommend a standard or common process to protect all providers from the costs of 3
services to patients who are ineligible for insurance coverage in circumstances where a payor 4
provides eligibility verification based on best information available to the payor at the date of the 5
request of eligibility. 6
(2) Developing implementation guidelines and promoting adoption of the guidelines for: 7
(i) The use of the National Correct Coding Initiative code-edit policy by payors and 8
providers in the state; 9
(ii) Publishing any variations from codes and mutually exclusive codes by payors in a 10
manner that makes for simple retrieval and implementation by providers; 11
(iii) Use of Health Insurance Portability and Accountability Act standard group codes, 12
reason codes, and remark codes by payors in electronic remittances sent to providers; 13
(iv) Uniformity in the processing of claims by payors; and the processing of corrections to 14
claims by providers and payors; 15
(v) A standard payor-denial review process for providers when they request a 16
reconsideration of a denial of a claim that results from differences in clinical edits where no single, 17
common-standards body or process exists and multiple conflicting sources are in use by payors and 18
providers. 19
(vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual 20
payor’s ability to employ, and not disclose to providers, temporary code edits for the purpose of 21
detecting and deterring fraudulent billing activities. The guidelines shall require that each payor 22
disclose to the provider its adjudication decision on a claim that was denied or adjusted based on 23
the application of such edits and that the provider have access to the payor’s review and appeal 24
process to challenge the payor’s adjudication decision. 25
(vii) Nothing in this subsection shall be construed to modify the rights or obligations of 26
payors or providers with respect to procedures relating to the investigation, reporting, appeal, or 27
prosecution under applicable law of potentially fraudulent billing activities. 28
(3) Developing and promoting widespread adoption by payors and providers of guidelines 29
to: 30
(i) Ensure payors do not automatically deny claims for services when extenuating 31
circumstances make it impossible for the provider to obtain a preauthorization before services are 32
performed or notify a payor within an appropriate standardized timeline of a patient’s admission; 33
(ii) Require payors to use common and consistent processes and time frames when 34
LC002773 - Page 16 of 23
responding to provider requests for medical management approvals. Whenever possible, such time 1
frames shall be consistent with those established by leading national organizations and be based 2
upon the acuity of the patient’s need for care or treatment. For the purposes of this section, medical 3
management includes prior authorization of services, preauthorization of services, precertification 4
of services, post-service review, medical-necessity review, and benefits advisory; 5
(iii) Develop, maintain, and promote widespread adoption of a single, common website 6
where providers can obtain payors’ preauthorization, benefits advisory, and preadmission 7
requirements; 8
(iv) Establish guidelines for payors to develop and maintain a website that providers can 9
use to request a preauthorization, including a prospective clinical necessity review; receive an 10
authorization number; and transmit an admission notification; 11
(v) Develop and implement the use of programs that implement selective prior 12
authorization requirements, based on stratification of healthcare providers’ performance and 13
adherence to evidence-based medicine with the input of contracted healthcare providers and/or 14
provider organizations. Such criteria shall be transparent and easily accessible to contracted 15
providers. Such selective prior authorization programs shall be available when healthcare providers 16
participate directly with the insurer in risk-based payment contracts and may be available to 17
providers who do not participate in risk-based contracts; 18
(vi) Require the review of medical services, including behavioral health services, and 19
prescription drugs, subject to prior authorization on at least an annual basis, with the input of 20
contracted healthcare providers and/or provider organizations. Any changes to the list of medical 21
services, including behavioral health services, and prescription drugs requiring prior authorization, 22
shall be shared via provider-accessible websites; 23
(vii) Improve communication channels between health plans, healthcare providers, and 24
patients by: 25
(A) Requiring transparency and easy accessibility of prior authorization requirements, 26
criteria, rationale, and program changes to contracted healthcare providers and patients/health plan 27
enrollees which may be satisfied by posting to provider-accessible and member-accessible 28
websites; and 29
(B) Supporting: 30
(I) Timely submission by healthcare providers of the complete information necessary to 31
make a prior authorization determination, as early in the process as possible; and 32
(II) Timely notification of prior authorization determinations by health plans to impacted 33
health plan enrollees, and healthcare providers, including, but not limited to, ordering providers, 34
LC002773 - Page 17 of 23
and/or rendering providers, and dispensing pharmacists which may be satisfied by posting to 1
provider-accessible websites or similar electronic portals or services; 2
(viii) Increase and strengthen continuity of patient care by: 3
(A) Defining protections for continuity of care during a transition period for patients 4
undergoing an active course of treatment, when there is a formulary or treatment coverage change 5
or change of health plan that may disrupt their current course of treatment and when the treating 6
physician determines that a transition may place the patient at risk; and for prescription medication 7
by allowing a grace period of coverage to allow consideration of referred health plan options or 8
establishment of medical necessity of the current course of treatment; 9
(B) Requiring continuity of care for medical services, including behavioral health services, 10
and prescription medications for patients on appropriate, chronic, stable therapy through 11
minimizing repetitive prior authorization requirements; and which for prescription medication shall 12
be allowed only on an annual review, with exception for labeled limitation, to establish continued 13
benefit of treatment; and 14
(C) Requiring communication between healthcare providers, health plans, and patients to 15
facilitate continuity of care and minimize disruptions in needed treatment which may be satisfied 16
by posting to provider-accessible websites or similar electronic portals or services; 17
(D) Continuity of care for formulary or drug coverage shall distinguish between FDA 18
designated interchangeable products and proprietary or marketed versions of a medication; 19
(ix) Encourage healthcare providers and/or provider organizations and health plans to 20
accelerate use of electronic prior authorization technology, including adoption of national standards 21
where applicable; and 22
(x) For the purposes of subsections (h)(3)(v) through (h)(3)(x) of this section, the 23
workgroup meeting may be conducted in part or whole through electronic methods. 24
(4) To provide a report to the house and senate, on or before January 1, 2017, with 25
recommendations for establishing guidelines and regulations for systems that give patients 26
electronic access to their claims information, particularly to information regarding their obligations 27
to pay for received medical services, pursuant to 45 C.F.R. § 164.524. 28
(5) No provision of this subsection (h) shall preclude the ongoing work of the office of 29
health insurance commissioner’s administrative simplification task force, which includes meetings 30
with key stakeholders in order to improve, and provide recommendations regarding, the prior 31
authorization process. 32
(i) To issue an anti-cancer medication report. Not later than June 30, 2014, and annually 33
thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate 34
LC002773 - Page 18 of 23
committee on health and human services, and the house committee on corporations, with: (1) 1
Information on the availability in the commercial market of coverage for anti-cancer medication 2
options; (2) For the state employee’s health benefit plan, the costs of various cancer-treatment 3
options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member 4
utilization and cost-sharing expense. 5
(j) To monitor the adequacy of each health plan’s compliance with the provisions of the 6
federal Mental Health Parity Act, including a review of related claims processing and 7
reimbursement procedures. Findings, recommendations, and assessments shall be made available 8
to the public. 9
(k) To monitor the transition from fee-for-service and toward global and other alternative 10
payment methodologies for the payment for healthcare services. Alternative payment 11
methodologies should be assessed for their likelihood to promote access to affordable health 12
insurance, health outcomes, and performance. 13
(l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital 14
payment variation, including findings and recommendations, subject to available resources. 15
(m) Notwithstanding any provision of the general or public laws or regulation to the 16
contrary, provide a report with findings and recommendations to the president of the senate and the 17
speaker of the house, on or before April 1, 2014, including, but not limited to, the following 18
information: 19
(1) The impact of the current, mandated healthcare benefits as defined in §§ 27-18-48.1, 20
27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41 of title 27, and §§ 27-21
18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health 22
insurance for fully insured employers, subject to available resources; 23
(2) Current provider and insurer mandates that are unnecessary and/or duplicative due to 24
the existing standards of care and/or delivery of services in the healthcare system; 25
(3) A state-by-state comparison of health insurance mandates and the extent to which 26
Rhode Island mandates exceed other states benefits; and 27
(4) Recommendations for amendments to existing mandated benefits based on the findings 28
in (m)(1), (m)(2), and (m)(3) above. 29
(n) On or before July 1, 2014, the office of the health insurance commissioner, in 30
collaboration with the director of health and lieutenant governor’s office, shall submit a report to 31
the general assembly and the governor to inform the design of accountable care organizations 32
(ACOs) in Rhode Island as unique structures for comprehensive healthcare delivery and value-33
based payment arrangements, that shall include, but not be limited to: 34
LC002773 - Page 19 of 23
(1) Utilization review; 1
(2) Contracting; and 2
(3) Licensing and regulation. 3
(o) On or before February 3, 2015, the office of the health insurance commissioner shall 4
submit a report to the general assembly and the governor that describes, analyzes, and proposes 5
recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard 6
to patients with mental health and substance use disorders. 7
(p) To work to ensure the health insurance coverage of behavioral health care under the 8
same terms and conditions as other health care, and to integrate behavioral health parity 9
requirements into the office of the health insurance commissioner insurance oversight and 10
healthcare transformation efforts. 11
(q) To work with other state agencies to seek delivery system improvements that enhance 12
access to a continuum of mental health and substance use disorder treatment in the state; and 13
integrate that treatment with primary and other medical care to the fullest extent possible. 14
(r) To direct insurers toward policies and practices that address the behavioral health needs 15
of the public and greater integration of physical and behavioral healthcare delivery. 16
(s) The office of the health insurance commissioner shall conduct an analysis of the impact 17
of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and 18
submit a report of its findings to the general assembly on or before June 1, 2023. 19
(t) To undertake the analyses, reports, and studies contained in this section: 20
(1) The office shall hire the necessary staff and prepare a request for proposal for a qualified 21
and competent firm or firms to undertake the following analyses, reports, and studies: 22
(i) The firm shall undertake a comprehensive review of all social and human service 23
programs having a contract with or licensed by the state or any subdivision of the department of 24
children, youth and families (DCYF), the department of behavioral healthcare, developmental 25
disabilities and hospitals (BHDDH), the department of human services (DHS), the department of 26
health (DOH), and Medicaid for the purposes of: 27
(A) Establishing a baseline of the eligibility factors for receiving services; 28
(B) Establishing a baseline of the service offering through each agency for those 29
determined eligible; 30
(C) Establishing a baseline understanding of reimbursement rates for all social and human 31
service programs including rates currently being paid, the date of the last increase, and a proposed 32
model that the state may use to conduct future studies and analyses; 33
(D) Ensuring accurate and adequate reimbursement to social and human service providers 34
LC002773 - Page 20 of 23
that facilitate the availability of high-quality services to individuals receiving home and 1
community-based long-term services and supports provided by social and human service providers; 2
(E) Ensuring the general assembly is provided accurate financial projections on social and 3
human service program costs, demand for services, and workforce needs to ensure access to entitled 4
beneficiaries and services; 5
(F) Establishing a baseline and determining the relationship between state government and 6
the provider network including functions, responsibilities, and duties; 7
(G) Determining a set of measures and accountability standards to be used by EOHHS and 8
the general assembly to measure the outcomes of the provision of services including budgetary 9
reporting requirements, transparency portals, and other methods; and 10
(H) Reporting the findings of human services analyses and reports to the speaker of the 11
house, senate president, chairs of the house and senate finance committees, chairs of the house and 12
senate health and human services committees, and the governor. 13
(2) The analyses, reports, and studies required pursuant to this section shall be 14
accomplished and published as follows and shall provide: 15
(i) An assessment and detailed reporting on all social and human service program rates to 16
be completed by January 1, 2023, including rates currently being paid and the date of the last 17
increase; 18
(ii) An assessment and detailed reporting on eligibility standards and processes of all 19
mandatory and discretionary social and human service programs to be completed by January 1, 20
2023; 21
(iii) An assessment and detailed reporting on utilization trends from the period of January 22
1, 2017, through December 31, 2021, for social and human service programs to be completed by 23
January 1, 2023; 24
(iv) An assessment and detailed reporting on the structure of the state government as it 25
relates to the provision of services by social and human service providers including eligibility and 26
functions of the provider network to be completed by January 1, 2023; 27
(v) An assessment and detailed reporting on accountability standards for services for social 28
and human service programs to be completed by January 1, 2023; 29
(vi) An assessment and detailed reporting by April 1, 2023, on all professional licensed 30
and unlicensed personnel requirements for established rates for social and human service programs 31
pursuant to a contract or established fee schedule; 32
(vii) An assessment and reporting on access to social and human service programs, to 33
include any wait lists and length of time on wait lists, in each service category by April 1, 2023; 34
LC002773 - Page 21 of 23
(viii) An assessment and reporting of national and regional Medicaid rates in comparison 1
to Rhode Island social and human service provider rates by April 1, 2023; 2
(ix) An assessment and reporting on usual and customary rates paid by private insurers and 3
private pay for similar social and human service providers, both nationally and regionally, by April 4
1, 2023; and 5
(x) Completion of the development of an assessment and review process that includes the 6
following components: eligibility; scope of services; relationship of social and human service 7
provider and the state; national and regional rate comparisons and accountability standards that 8
result in recommended rate adjustments; and this process shall be completed by September 1, 2023, 9
and conducted biennially hereafter. The biennial rate setting shall be consistent with payment 10
requirements established in § 1902(a)(30)(A) of the Social Security Act, 42 U.S.C. § 11
1396a(a)(30)(A), and all federal and state law, regulations, and quality and safety standards. The 12
results and findings of this process shall be transparent, and public meetings shall be conducted to 13
allow providers, recipients, and other interested parties an opportunity to ask questions and provide 14
comment beginning in September 2023 and biennially thereafter. 15
(3) In fulfillment of the responsibilities defined in subsection (t), the office of the health 16
insurance commissioner shall consult with the Executive Office of Health and Human Services. 17
(u) Annually, each department (namely, EOHHS, DCYF, DOH, DHS, and BHDDH) shall 18
include the corresponding components of the assessment and review (i.e., eligibility; scope of 19
services; relationship of social and human service provider and the state; and national and regional 20
rate comparisons and accountability standards including any changes or substantive issues between 21
biennial reviews) including the recommended rates from the most recent assessment and review 22
with their annual budget submission to the office of management and budget and provide a detailed 23
explanation and impact statement if any rate variances exist between submitted recommended 24
budget and the corresponding recommended rate from the most recent assessment and review 25
process starting October 1, 2023, and biennially thereafter. 26
(v) The general assembly shall appropriate adequate funding as it deems necessary to 27
undertake the analyses, reports, and studies contained in this section relating to the powers and 28
duties of the office of the health insurance commissioner. 29
(w) Ensure that insurers minimize administrative burdens that may delay medically 30
necessary care, including by promulgating rules and regulations and taking enforcement actions to 31
implement § 27-18.9-16. 32
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SECTION 5. This act shall take effect on January 1, 2026. 1
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EXPLANATION
BY THE LEGISLATIVE COUNCIL
OF
A N A C T
RELATING TO INSURANCE -- BENEFIT DETERMINATION AND UTILIZATION ACT
***
This act would prohibit an insurer from imposing a requirement of prior authorization for 1
any admission, item, service, treatment, test, exam, study, procedure, or any generic or brand name 2
prescription drug ordered by a primary care provider unless it was a requirement for controlled 3
substances, or individual primary care providers with documented cases of fraud, waste or abuse. 4
The act would also require any issuer issuing any lawful prior authorization to use a single, 5
standardized prior authorization form. 6
This act would take effect on January 1, 2026. 7
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