Rhode Island 2025 Regular Session

Rhode Island Senate Bill S0053 Compare Versions

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

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5	5	2025 -- S 0053
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7	7	LC000456
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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
16	16	REVIEW ACT
17	17	Introduced By: Senators Ujifusa, Lauria, Lawson, Tikoian, Euer, Pearson, Valverde, Bell,
18	18	and DiMario
19	19	Date Introduced: January 23, 2025
20	20	Referred To: Senate Health & Human Services
21	21
22	22
23	23	It is enacted by the General Assembly as follows:
24	24	SECTION 1. This act may be cited as the "Rhode Island Prior Authorization Reform Act 1
25	25	of 2025." 2
26	26	SECTION 2. Section 27-18.9-2 of the General Laws in Chapter 27-18.9 entitled "Benefit 3
27	27	Determination and Utilization Review Act" is hereby amended to read as follows: 4
28	28	27-18.9-2. Definitions. 5
29	29	As used in this chapter, the following terms are defined as follows: 6
30	30	(1) “Adverse benefit determination” means a decision not to authorize a healthcare service, 7
31	31	including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole 8
32	32	or in part, for a benefit. A decision by a utilization-review agent to authorize a healthcare service 9
33	33	in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute 10
34	34	an adverse determination if the review agent and provider are in agreement regarding the decision. 11
35	35	Adverse benefit determinations include: 12
36	36	(i) “Administrative adverse benefit determinations,” meaning any adverse benefit 13
37	37	determination that does not require the use of medical judgment or clinical criteria such as a 14
38	38	determination of an individual’s eligibility to participate in coverage, a determination that a benefit 15
39	39	is not a covered benefit, or any rescission of coverage; and 16
40	40	(ii) “Non-administrative adverse benefit determinations,” meaning any adverse benefit 17
41	41	determination that requires or involves the use of medical judgement or clinical criteria to 18
42	42
43	43
44	44	LC000456 - Page 2 of 22
45	45	determine whether the service being reviewed is medically necessary and/or appropriate. This 1
46	46	includes the denial of treatments determined to be experimental or investigational, and any denial 2
47	47	of coverage of a prescription drug because that drug is not on the healthcare entity’s formulary. 3
48	48	(2) “Appeal” or “internal appeal” means a subsequent review of an adverse benefit 4
49	49	determination upon request by a claimant to include the beneficiary or provider to reconsider all or 5
50	50	part of the original adverse benefit determination. 6
51	51	(3) “Authorization” means a review by a review agent, performed according to this chapter, 7
52	52	concluding that the allocation of healthcare services ordered by a provider, given or proposed to be 8
53	53	given to a beneficiary, was approved or authorized. 9
54	54	(4) “Authorized representative” means an individual acting on behalf of the beneficiary 10
55	55	and shall include: the ordering provider; any individual to whom the beneficiary has given express 11
56	56	written consent to act on his or her behalf; a person authorized by law to provide substituted consent 12
57	57	for the beneficiary; and, when the beneficiary is unable to provide consent, a family member of the 13
58	58	beneficiary. 14
59	59	(5) “Beneficiary” means a policy-holder subscriber, enrollee, or other individual 15
60	60	participating in a health-benefit plan. 16
61	61	(6) “Benefit determination” means a decision to approve or deny a request to provide or 17
62	62	make payment for a healthcare service or treatment. 18
63	63	(7) “Certificate” means a certificate granted by the commissioner to a review agent meeting 19
64	64	the requirements of this chapter. 20
65	65	(8) “Claim” means a request for plan benefit(s) made by a claimant in accordance with the 21
66	66	healthcare entity’s reasonable procedures for filing benefit claims. This shall include pre-service, 22
67	67	concurrent, and post-service claims. 23
68	68	(9) “Claimant” means a healthcare entity participant, beneficiary, and/or authorized 24
69	69	representative who makes a request for plan benefit(s). 25
70	70	(10) “Commissioner” means the health insurance commissioner. 26
71	71	(11) “Complaint” means an oral or written expression of dissatisfaction by a beneficiary, 27
72	72	authorized representative, or a provider. The appeal of an adverse benefit determination is not 28
73	73	considered a complaint. 29
74	74	(12) “Concurrent assessment” means an assessment of healthcare services conducted 30
75	75	during a beneficiary’s hospital stay, course of treatment or services over a period of time, or for the 31
76	76	number of treatments. If the medical problem is ongoing, this assessment may include the review 32
77	77	of services after they have been rendered and billed. 33
78	78	(13) “Concurrent claim” means a request for a plan benefit(s) by a claimant that is for an 34
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82	82	ongoing course of treatment or services over a period of time or for the number of treatments. 1
83	83	(14) “Delegate” means a person or entity authorized pursuant to a delegation of authority 2
84	84	or re-delegation of authority, by a healthcare entity or network plan to perform one or more of the 3
85	85	functions and responsibilities of a healthcare entity and/or network plan set forth in this chapter or 4
86	86	regulations or guidance promulgated thereunder. 5
87	87	(15) “Emergency services” or “emergent services” means those resources provided in the 6
88	88	event of the sudden onset of a medical, behavioral health, or other health condition that the absence 7
89	89	of immediate medical attention could reasonably be expected, by a prudent layperson, to result in 8
90	90	placing the patient’s health in serious jeopardy, serious impairment to bodily or mental functions, 9
91	91	or serious dysfunction of any bodily organ or part. 10
92	92	(16) “External review” means a review of a non-administrative adverse benefit 11
93	93	determination (including final internal adverse benefit determination) conducted pursuant to an 12
94	94	applicable external review process performed by an independent review organization. 13
95	95	(17) “External review decision” means a determination by an independent review 14
96	96	organization at the conclusion of the external review. 15
97	97	(18) “Final internal adverse benefit determination” means an adverse benefit determination 16
98	98	that has been upheld by a plan or issuer at the completion of the internal appeals process or when 17
99	99	the internal appeals process has been deemed exhausted as defined in § 27-18.9-7(b)(1). 18
100	100	(19) “Health-benefit plan” or “health plan” means a policy, contract, certificate, or 19
101	101	agreement entered into, offered, or issued by a healthcare entity to provide, deliver, arrange for, 20
102	102	pay for, or reimburse any of the costs of healthcare services. 21
103	103	(20) “Healthcare entity” means an insurance company licensed, or required to be licensed, 22
104	104	by the state of Rhode Island or other entity subject to the jurisdiction of the commissioner or the 23
105	105	jurisdiction of the department of business regulation pursuant to chapter 62 of title 42, that contracts 24
106	106	or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or 25
107	107	reimburse any of the costs of healthcare services, including, without limitation: a for-profit or 26
108	108	nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, 27
109	109	a health insurance company, or any other entity providing a plan of health insurance, accident and 28
110	110	sickness insurance, health benefits, or healthcare services. 29
111	111	(21) “Healthcare services” means and includes, but is not limited to: an admission, 30
112	112	diagnostic procedure, therapeutic procedure, treatment, extension of stay, the ordering and/or filling 31
113	113	of formulary or non-formulary medications, and any other medical, behavioral, dental, vision care 32
114	114	services, activities, or supplies that are covered by the beneficiary’s health-benefit plan. 33
115	115	(22) “Independent review organization” or “IRO” means an entity that conducts 34
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117	117
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119	119	independent external reviews of adverse benefit determinations or final internal adverse benefit 1
120	120	determinations. 2
121	121	(23) "Insurer", for the purposes of § 27-18.9-16, means all insurance companies licensed 3
122	122	to do business in Rhode Island, including those subject to chapter 1 of title 27, a foreign insurance 4
123	123	company licensed to do business in Rhode Island and subject to chapter 2 of title 27, a health 5
124	124	insurance carrier subject and organized pursuant to chapter 18 of title 27, a nonprofit hospital 6
125	125	service corporation subject and organized pursuant to chapter 19 of title 27, a nonprofit medical 7
126	126	services corporation subject and organized pursuant to chapter 20 of title 27, a qualified health 8
127	127	maintenance organization subject and organized pursuant to chapter 41 of title 27, and Medicaid 9
128	128	Managed Care Organizations. 10
129	129	(23)(24) “Network” means the group or groups of participating providers providing 11
130	130	healthcare services under a network plan. 12
131	131	(24)(25) “Network plan” means a health-benefit plan or health plan that either requires a 13
132	132	beneficiary to use, or creates incentives, including financial incentives, for a beneficiary to use the 14
133	133	providers managed, owned, under contract with, or employed by the healthcare entity. 15
134	134	(25)(26) “Office” means the office of the health insurance commissioner. 16
135	135	(26)(27) “Pre-service claim” means the request for a plan benefit(s) by a claimant prior to 17
136	136	a service being rendered and is not considered a concurrent claim. 18
137	137	(28) "Primary care provider (PCP)", for the purposes of § 27-18.9-16, means general 19
138	138	internists, family physicians, pediatricians, geriatricians, OB-GYNs, nurse practitioners, 20
139	139	physician’s assistants and other healthcare providers who are licensed to provide, coordinate, and 21
140	140	supervise primary care and order healthcare services and goods, including preventive and 22
141	141	diagnostic services for patients. 23
142	142	(29) "Prior authorization", for the purposes of § 27-18.9-16, means the approval a PCP is 24
143	143	required by an insurer to obtain from an insurer or pharmacy benefit manager before healthcare is 25
144	144	covered for a patient. 26
145	145	(29)(30) “Professional provider” means an individual provider or healthcare professional 27
146	146	licensed, accredited, or certified to perform specified healthcare services consistent with state law 28
147	147	and who provides healthcare services and is not part of a separate facility or institutional contract. 29
148	148	(28)(31) “Prospective assessment” or “pre-service assessment” means an assessment of 30
149	149	healthcare services prior to services being rendered. 31
150	150	(29)(32) “Provider” means a physician, hospital, professional provider, pharmacy, 32
151	151	laboratory, dental, medical, or behavioral health provider or other state-licensed or other state-33
152	152	recognized provider of health care or behavioral health services or supplies. 34
153	153
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156	156	(30)(33) “Retrospective assessment” or “post-service assessment” means an assessment of 1
157	157	healthcare services that have been rendered. This shall not include reviews conducted when the 2
158	158	review agency has been obtaining ongoing information. 3
159	159	(31)(34) “Retrospective claim” or “post-service claim” means any claim for a health-plan 4
160	160	benefit that is not a pre-service or concurrent claim. 5
161	161	(32)(35) “Review agent” means a person or healthcare entity performing benefit 6
162	162	determination reviews that is either employed by, affiliated with, under contract with, or acting on 7
163	163	behalf of a healthcare entity. 8
164	164	(33)(36) “Same or similar specialty” means a practitioner who has the appropriate training 9
165	165	and experience that is the same or similar as the attending provider in addition to experience in 10
166	166	treating the same problems to include any potential complications as those under review. 11
167	167	(34)(37) “Therapeutic interchange” means the interchange or substitution of a drug with a 12
168	168	dissimilar chemical structure within the same therapeutic or pharmacological class that can be 13
169	169	expected to have similar outcomes and similar adverse reaction profiles when given in equivalent 14
170	170	doses, in accordance with protocols approved by the president of the medical staff or medical 15
171	171	director and the director of pharmacy. 16
172	172	(35)(38) “Tiered network” means a network that identifies and groups some or all types of 17
173	173	providers into specific groups to which different provider reimbursement, beneficiary cost-sharing, 18
174	174	or provider access requirements, or any combination thereof, apply for the same services. 19
175	175	(36)(39) “Urgent healthcare services” includes those resources necessary to treat a 20
176	176	symptomatic medical, mental health, substance use, or other healthcare condition that a prudent 21
177	177	layperson, acting reasonably, would believe necessitates treatment within a twenty-four hour (24) 22
178	178	period of the onset of such a condition in order that the patient’s health status not decline as a 23
179	179	consequence. This does not include those conditions considered to be emergent healthcare services 24
180	180	as defined in this section. 25
181	181	(37)(40) “Utilization review” means the prospective, concurrent, or retrospective 26
182	182	assessment of the medical necessity and/or appropriateness of the allocation of healthcare services 27
183	183	of a provider, given or proposed to be given, to a beneficiary. Utilization review does not include: 28
184	184	(i) The therapeutic interchange of drugs or devices by a pharmacy operating as part of a 29
185	185	licensed inpatient healthcare facility; or 30
186	186	(ii) The assessment by a pharmacist licensed pursuant to the provisions of chapter 19.1 of 31
187	187	title 5, and practicing in a pharmacy operating as part of a licensed inpatient healthcare facility, in 32
188	188	the interpretation, evaluation and implementation of medical orders, including assessments and/or 33
189	189	comparisons involving formularies and medical orders. 34
190	190
191	191
192	192	LC000456 - Page 6 of 22
193	193	(38)(41) “Utilization review plan” means a description of the standards governing 1
194	194	utilization review activities performed by a review agent. 2
195	195	SECTION 3. Chapter 27-18.9 of the General Laws entitled "Benefit Determination and 3
196	196	Utilization Review Act" is hereby amended by adding thereto the following section: 4
197	197	27-18.9-16. Primary care exception. 5
198	198	(a) Except as provided in section (b) of this subsection, an insurer shall not impose any 6
199	199	prior authorization requirement for any admission, item, service, treatment, or procedure ordered 7
200	200	by a primary care provider. 8
201	201	(b) The prohibition set forth in subsection (a) of this section shall not be construed to 9
202	202	prohibit prior authorization requirements for prescription drugs. 10
203	203	SECTION 4. Section 42-7.2-5 of the General Laws in Chapter 42-7.2 entitled "Office of 11
204	204	Health and Human Services" is hereby amended to read as follows: 12
205	205	42-7.2-5. Duties of the secretary. 13
206	206	The secretary shall be subject to the direction and supervision of the governor for the 14
207	207	oversight, coordination, and cohesive direction of state-administered health and human services 15
208	208	and in ensuring the laws are faithfully executed, notwithstanding any law to the contrary. In this 16
209	209	capacity, the secretary of the executive office of health and human services (EOHHS) shall be 17
210	210	authorized to: 18
211	211	(1) Coordinate the administration and financing of healthcare benefits, human services, and 19
212	212	programs including those authorized by the state’s Medicaid section 1115 demonstration waiver 20
213	213	and, as applicable, the Medicaid state plan under Title XIX of the U.S. Social Security Act. 21
214	214	However, nothing in this section shall be construed as transferring to the secretary the powers, 22
215	215	duties, or functions conferred upon the departments by Rhode Island public and general laws for 23
216	216	the administration of federal/state programs financed in whole or in part with Medicaid funds or 24
217	217	the administrative responsibility for the preparation and submission of any state plans, state plan 25
218	218	amendments, or authorized federal waiver applications, once approved by the secretary. 26
219	219	(2) Serve as the governor’s chief advisor and liaison to federal policymakers on Medicaid 27
220	220	reform issues as well as the principal point of contact in the state on any such related matters. 28
221	221	(3)(i) Review and ensure the coordination of the state’s Medicaid section 1115 29
222	222	demonstration waiver requests and renewals as well as any initiatives and proposals requiring 30
223	223	amendments to the Medicaid state plan or formal amendment changes, as described in the special 31
224	224	terms and conditions of the state’s Medicaid section 1115 demonstration waiver with the potential 32
225	225	to affect the scope, amount, or duration of publicly funded healthcare services, provider payments 33
226	226	or reimbursements, or access to or the availability of benefits and services as provided by Rhode 34
227	227
228	228
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230	230	Island general and public laws. The secretary shall consider whether any such changes are legally 1
231	231	and fiscally sound and consistent with the state’s policy and budget priorities. The secretary shall 2
232	232	also assess whether a proposed change is capable of obtaining the necessary approvals from federal 3
233	233	officials and achieving the expected positive consumer outcomes. Department directors shall, 4
234	234	within the timelines specified, provide any information and resources the secretary deems necessary 5
235	235	in order to perform the reviews authorized in this section. 6
236	236	(ii) Direct the development and implementation of any Medicaid policies, procedures, or 7
237	237	systems that may be required to assure successful operation of the state’s health and human services 8
238	238	integrated eligibility system and coordination with HealthSource RI, the state’s health insurance 9
239	239	marketplace. 10
240	240	(iii) Beginning in 2015, conduct on a biennial basis a comprehensive review of the 11
241	241	Medicaid eligibility criteria for one or more of the populations covered under the state plan or a 12
242	242	waiver to ensure consistency with federal and state laws and policies, coordinate and align systems, 13
243	243	and identify areas for improving quality assurance, fair and equitable access to services, and 14
244	244	opportunities for additional financial participation. 15
245	245	(iv) Implement service organization and delivery reforms that facilitate service integration, 16
246	246	increase value, and improve quality and health outcomes. 17
247	247	(4) Beginning in 2020, prepare and submit to the governor, the chairpersons of the house 18
248	248	and senate finance committees, the caseload estimating conference, and to the joint legislative 19
249	249	committee for health-care oversight, by no later than September 15 of each year, a comprehensive 20
250	250	overview of all Medicaid expenditures outcomes, administrative costs, and utilization rates. The 21
251	251	overview shall include, but not be limited to, the following information: 22
252	252	(i) Expenditures under Titles XIX and XXI of the Social Security Act, as amended; 23
253	253	(ii) Expenditures, outcomes, and utilization rates by population and sub-population served 24
254	254	(e.g., families with children, persons with disabilities, children in foster care, children receiving 25
255	255	adoption assistance, adults ages nineteen (19) to sixty-four (64), and elders); 26
256	256	(iii) Expenditures, outcomes, and utilization rates by each state department or other 27
257	257	municipal or public entity receiving federal reimbursement under Titles XIX and XXI of the Social 28
258	258	Security Act, as amended; 29
259	259	(iv) Expenditures, outcomes, and utilization rates by type of service and/or service 30
260	260	provider; 31
261	261	(v) Expenditures by mandatory population receiving mandatory services and, reported 32
262	262	separately, optional services, as well as optional populations receiving mandatory services and, 33
263	263	reported separately, optional services for each state agency receiving Title XIX and XXI funds; and 34
264	264
265	265
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267	267	(vi) Information submitted to the Centers for Medicare & Medicaid Services for the 1
268	268	mandatory annual state reporting of the Core Set of Children’s Health Care Quality Measures for 2
269	269	Medicaid and Children’s Health Insurance Program, behavioral health measures on the Core Set of 3
270	270	Adult Health Care Quality Measures for Medicaid and the Core Sets of Health Home Quality 4
271	271	Measures for Medicaid to ensure compliance with the Bipartisan Budget Act of 2018, Pub. L. No. 5
272	272	115-123. 6
273	273	The directors of the departments, as well as local governments and school departments, 7
274	274	shall assist and cooperate with the secretary in fulfilling this responsibility by providing whatever 8
275	275	resources, information and support shall be necessary. 9
276	276	(5) Resolve administrative, jurisdictional, operational, program, or policy conflicts among 10
277	277	departments and their executive staffs and make necessary recommendations to the governor. 11
278	278	(6) Ensure continued progress toward improving the quality, the economy, the 12
279	279	accountability, and the efficiency of state-administered health and human services. In this capacity, 13
280	280	the secretary shall: 14
281	281	(i) Direct implementation of reforms in the human resources practices of the executive 15
282	282	office and the departments that streamline and upgrade services, achieve greater economies of scale 16
283	283	and establish the coordinated system of the staff education, cross-training, and career development 17
284	284	services necessary to recruit and retain a highly-skilled, responsive, and engaged health and human 18
285	285	services workforce; 19
286	286	(ii) Encourage EOHHS-wide consumer-centered approaches to service design and delivery 20
287	287	that expand their capacity to respond efficiently and responsibly to the diverse and changing needs 21
288	288	of the people and communities they serve; 22
289	289	(iii) Develop all opportunities to maximize resources by leveraging the state’s purchasing 23
290	290	power, centralizing fiscal service functions related to budget, finance, and procurement, 24
291	291	centralizing communication, policy analysis and planning, and information systems and data 25
292	292	management, pursuing alternative funding sources through grants, awards, and partnerships and 26
293	293	securing all available federal financial participation for programs and services provided EOHHS-27
294	294	wide; 28
295	295	(iv) Improve the coordination and efficiency of health and human services legal functions 29
296	296	by centralizing adjudicative and legal services and overseeing their timely and judicious 30
297	297	administration; 31
298	298	(v) Facilitate the rebalancing of the long-term system by creating an assessment and 32
299	299	coordination organization or unit for the expressed purpose of developing and implementing 33
300	300	procedures EOHHS-wide that ensure that the appropriate publicly funded health services are 34
301	301
302	302
303	303	LC000456 - Page 9 of 22
304	304	provided at the right time and in the most appropriate and least restrictive setting; 1
305	305	(vi) Strengthen health and human services program integrity, quality control and 2
306	306	collections, and recovery activities by consolidating functions within the office in a single unit that 3
307	307	ensures all affected parties pay their fair share of the cost of services and are aware of alternative 4
308	308	financing; 5
309	309	(vii) Assure protective services are available to vulnerable elders and adults with 6
310	310	developmental and other disabilities by reorganizing existing services, establishing new services 7
311	311	where gaps exist, and centralizing administrative responsibility for oversight of all related 8
312	312	initiatives and programs. 9
313	313	(7) Prepare and integrate comprehensive budgets for the health and human services 10
314	314	departments and any other functions and duties assigned to the office. The budgets shall be 11
315	315	submitted to the state budget office by the secretary, for consideration by the governor, on behalf 12
316	316	of the state’s health and human services agencies in accordance with the provisions set forth in § 13
317	317	35-3-4. 14
318	318	(8) Utilize objective data to evaluate health and human services policy goals, resource use 15
319	319	and outcome evaluation and to perform short and long-term policy planning and development. 16
320	320	(9) Establishment of an integrated approach to interdepartmental information and data 17
321	321	management that complements and furthers the goals of the unified health infrastructure project 18
322	322	initiative and that will facilitate the transition to a consumer-centered integrated system of state-19
323	323	administered health and human services. 20
324	324	(10) At the direction of the governor or the general assembly, conduct independent reviews 21
325	325	of state-administered health and human services programs, policies and related agency actions and 22
326	326	activities and assist the department directors in identifying strategies to address any issues or areas 23
327	327	of concern that may emerge thereof. The department directors shall provide any information and 24
328	328	assistance deemed necessary by the secretary when undertaking such independent reviews. 25
329	329	(11) Provide regular and timely reports to the governor and make recommendations with 26
330	330	respect to the state’s health and human services agenda. 27
331	331	(12) Employ such personnel and contract for such consulting services as may be required 28
332	332	to perform the powers and duties lawfully conferred upon the secretary. 29
333	333	(13) Assume responsibility for complying with the provisions of any general or public law 30
334	334	or regulation related to the disclosure, confidentiality, and privacy of any information or records, 31
335	335	in the possession or under the control of the executive office or the departments assigned to the 32
336	336	executive office, that may be developed or acquired or transferred at the direction of the governor 33
337	337	or the secretary for purposes directly connected with the secretary’s duties set forth herein. 34
338	338
339	339
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341	341	(14) Hold the director of each health and human services department accountable for their 1
342	342	administrative, fiscal, and program actions in the conduct of the respective powers and duties of 2
343	343	their agencies. 3
344	344	(15) Identify opportunities for inclusion with the EOHHS’ October 1, 2023 budget 4
345	345	submission, to remove fixed eligibility thresholds for programs under its purview by establishing 5
346	346	sliding scale decreases in benefits commensurate with income increases up to four hundred fifty 6
347	347	percent (450%) of the federal poverty level. These shall include but not be limited to, medical 7
348	348	assistance, childcare assistance, and food assistance. 8
349	349	(16) Ensure that insurers minimize administrative burdens on providers that may delay 9
350	350	medically necessary care, including requiring that insurers do not impose a prior authorization 10
351	351	requirement for any admission, item, service, treatment, or procedure ordered by an in-network 11
352	352	primary care provider. Provided, the prohibition shall not be construed to prohibit prior 12
353	353	authorization requirements for prescription drugs. Provided further, that as used in this subsection 13
354	354	(16) of this section, the terms "insurer," "primary care provider," and "prior authorization" means 14
355	355	the same as those terms are defined in § 27-18.9-2. 15
356	356	SECTION 5. Section 42-14.5-3 of the General Laws in Chapter 42-14.5 entitled "The 16
357	357	Rhode Island Health Care Reform Act of 2004 — Health Insurance Oversight" is hereby amended 17
358	358	to read as follows: 18
359	359	42-14.5-3. Powers and duties. 19
360	360	The health insurance commissioner shall have the following powers and duties: 20
361	361	(a) To conduct quarterly public meetings throughout the state, separate and distinct from 21
362	362	rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers 22
363	363	licensed to provide health insurance in the state; the effects of such rates, services, and operations 23
364	364	on consumers, medical care providers, patients, and the market environment in which the insurers 24
365	365	operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less 25
366	366	than ten (10) days of the hearing(s) shall go to the general assembly, the governor, the Rhode Island 26
367	367	Medical Society, the Hospital Association of Rhode Island, the director of health, the attorney 27
368	368	general, and the chambers of commerce. Public notice shall be posted on the department’s website 28
369	369	and given in the newspaper of general circulation, and to any entity in writing requesting notice. 29
370	370	(b) To make recommendations to the governor and the house of representatives and senate 30
371	371	finance committees regarding healthcare insurance and the regulations, rates, services, 31
372	372	administrative expenses, reserve requirements, and operations of insurers providing health 32
373	373	insurance in the state, and to prepare or comment on, upon the request of the governor or 33
374	374	chairpersons of the house or senate finance committees, draft legislation to improve the regulation 34
375	375
376	376
377	377	LC000456 - Page 11 of 22
378	378	of health insurance. In making the recommendations, the commissioner shall recognize that it is 1
379	379	the intent of the legislature that the maximum disclosure be provided regarding the reasonableness 2
380	380	of individual administrative expenditures as well as total administrative costs. The commissioner 3
381	381	shall make recommendations on the levels of reserves, including consideration of: targeted reserve 4
382	382	levels; trends in the increase or decrease of reserve levels; and insurer plans for distributing excess 5
383	383	reserves. 6
384	384	(c) To establish a consumer/business/labor/medical advisory council to obtain information 7
385	385	and present concerns of consumers, business, and medical providers affected by health insurance 8
386	386	decisions. The council shall develop proposals to allow the market for small business health 9
387	387	insurance to be affordable and fairer. The council shall be involved in the planning and conduct of 10
388	388	the quarterly public meetings in accordance with subsection (a). The advisory council shall develop 11
389	389	measures to inform small businesses of an insurance complaint process to ensure that small 12
390	390	businesses that experience rate increases in a given year may request and receive a formal review 13
391	391	by the department. The advisory council shall assess views of the health provider community 14
392	392	relative to insurance rates of reimbursement, billing, and reimbursement procedures, and the 15
393	393	insurers’ role in promoting efficient and high-quality health care. The advisory council shall issue 16
394	394	an annual report of findings and recommendations to the governor and the general assembly and 17
395	395	present its findings at hearings before the house and senate finance committees. The advisory 18
396	396	council is to be diverse in interests and shall include representatives of community consumer 19
397	397	organizations; small businesses, other than those involved in the sale of insurance products; and 20
398	398	hospital, medical, and other health provider organizations. Such representatives shall be nominated 21
399	399	by their respective organizations. The advisory council shall be co-chaired by the health insurance 22
400	400	commissioner and a community consumer organization or small business member to be elected by 23
401	401	the full advisory council. 24
402	402	(d) To establish and provide guidance and assistance to a subcommittee (“the professional-25
403	403	provider-health-plan work group”) of the advisory council created pursuant to subsection (c), 26
404	404	composed of healthcare providers and Rhode Island licensed health plans. This subcommittee shall 27
405	405	include in its annual report and presentation before the house and senate finance committees the 28
406	406	following information: 29
407	407	(1) A method whereby health plans shall disclose to contracted providers the fee schedules 30
408	408	used to provide payment to those providers for services rendered to covered patients; 31
409	409	(2) A standardized provider application and credentials verification process, for the 32
410	410	purpose of verifying professional qualifications of participating healthcare providers; 33
411	411	(3) The uniform health plan claim form utilized by participating providers; 34
412	412
413	413
414	414	LC000456 - Page 12 of 22
415	415	(4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit 1
416	416	hospital or medical service corporations, as defined by chapters 19 and 20 of title 27, to make 2
417	417	facility-specific data and other medical service-specific data available in reasonably consistent 3
418	418	formats to patients regarding quality and costs. This information would help consumers make 4
419	419	informed choices regarding the facilities and clinicians or physician practices at which to seek care. 5
420	420	Among the items considered would be the unique health services and other public goods provided 6
421	421	by facilities and clinicians or physician practices in establishing the most appropriate cost 7
422	422	comparisons; 8
423	423	(5) All activities related to contractual disclosure to participating providers of the 9
424	424	mechanisms for resolving health plan/provider disputes; 10
425	425	(6) The uniform process being utilized for confirming, in real time, patient insurance 11
426	426	enrollment status, benefits coverage, including copays and deductibles; 12
427	427	(7) Information related to temporary credentialing of providers seeking to participate in the 13
428	428	plan’s network and the impact of the activity on health plan accreditation; 14
429	429	(8) The feasibility of regular contract renegotiations between plans and the providers in 15
430	430	their networks; and 16
431	431	(9) Efforts conducted related to reviewing impact of silent PPOs on physician practices. 17
432	432	(e) To enforce the provisions of title 27 and title 42 as set forth in § 42-14-5(d). 18
433	433	(f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The 19
434	434	fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17. 20
435	435	(g) To analyze the impact of changing the rating guidelines and/or merging the individual 21
436	436	health insurance market, as defined in chapter 18.5 of title 27, and the small-employer health 22
437	437	insurance market, as defined in chapter 50 of title 27, in accordance with the following: 23
438	438	(1) The analysis shall forecast the likely rate increases required to effect the changes 24
439	439	recommended pursuant to the preceding subsection (g) in the direct-pay market and small-employer 25
440	440	health insurance market over the next five (5) years, based on the current rating structure and 26
441	441	current products. 27
442	442	(2) The analysis shall include examining the impact of merging the individual and small-28
443	443	employer markets on premiums charged to individuals and small-employer groups. 29
444	444	(3) The analysis shall include examining the impact on rates in each of the individual and 30
445	445	small-employer health insurance markets and the number of insureds in the context of possible 31
446	446	changes to the rating guidelines used for small-employer groups, including: community rating 32
447	447	principles; expanding small-employer rate bonds beyond the current range; increasing the employer 33
448	448	group size in the small-group market; and/or adding rating factors for broker and/or tobacco use. 34
449	449
450	450
451	451	LC000456 - Page 13 of 22
452	452	(4) The analysis shall include examining the adequacy of current statutory and regulatory 1
453	453	oversight of the rating process and factors employed by the participants in the proposed, new 2
454	454	merged market. 3
455	455	(5) The analysis shall include assessment of possible reinsurance mechanisms and/or 4
456	456	federal high-risk pool structures and funding to support the health insurance market in Rhode Island 5
457	457	by reducing the risk of adverse selection and the incremental insurance premiums charged for this 6
458	458	risk, and/or by making health insurance affordable for a selected at-risk population. 7
459	459	(6) The health insurance commissioner shall work with an insurance market merger task 8
460	460	force to assist with the analysis. The task force shall be chaired by the health insurance 9
461	461	commissioner and shall include, but not be limited to, representatives of the general assembly, the 10
462	462	business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage in 11
463	463	the individual market in Rhode Island, health insurance brokers, and members of the general public. 12
464	464	(7) For the purposes of conducting this analysis, the commissioner may contract with an 13
465	465	outside organization with expertise in fiscal analysis of the private insurance market. In conducting 14
466	466	its study, the organization shall, to the extent possible, obtain and use actual health plan data. Said 15
467	467	data shall be subject to state and federal laws and regulations governing confidentiality of health 16
468	468	care and proprietary information. 17
469	469	(8) The task force shall meet as necessary and include its findings in the annual report, and 18
470	470	the commissioner shall include the information in the annual presentation before the house and 19
471	471	senate finance committees. 20
472	472	(h) To establish and convene a workgroup representing healthcare providers and health 21
473	473	insurers for the purpose of coordinating the development of processes, guidelines, and standards to 22
474	474	streamline healthcare administration that are to be adopted by payors and providers of healthcare 23
475	475	services operating in the state. This workgroup shall include representatives with expertise who 24
476	476	would contribute to the streamlining of healthcare administration and who are selected from 25
477	477	hospitals, physician practices, community behavioral health organizations, each health insurer, and 26
478	478	other affected entities. The workgroup shall also include at least one designee each from the Rhode 27
479	479	Island Medical Society, Rhode Island Council of Community Mental Health Organizations, the 28
480	480	Rhode Island Health Center Association, and the Hospital Association of Rhode Island. In any year 29
481	481	that the workgroup meets and submits recommendations to the office of the health insurance 30
482	482	commissioner, the office of the health insurance commissioner shall submit such recommendations 31
483	483	to the health and human services committees of the Rhode Island house of representatives and the 32
484	484	Rhode Island senate prior to the implementation of any such recommendations and subsequently 33
485	485	shall submit a report to the general assembly by June 30, 2024. The report shall include the 34
486	486
487	487
488	488	LC000456 - Page 14 of 22
489	489	recommendations the commissioner may implement, with supporting rationale. The workgroup 1
490	490	shall consider and make recommendations for: 2
491	491	(1) Establishing a consistent standard for electronic eligibility and coverage verification. 3
492	492	Such standard shall: 4
493	493	(i) Include standards for eligibility inquiry and response and, wherever possible, be 5
494	494	consistent with the standards adopted by nationally recognized organizations, such as the Centers 6
495	495	for Medicare & Medicaid Services; 7
496	496	(ii) Enable providers and payors to exchange eligibility requests and responses on a system-8
497	497	to-system basis or using a payor-supported web browser; 9
498	498	(iii) Provide reasonably detailed information on a consumer’s eligibility for healthcare 10
499	499	coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing 11
500	500	requirements for specific services at the specific time of the inquiry; current deductible amounts; 12
501	501	accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and 13
502	502	other information required for the provider to collect the patient’s portion of the bill; 14
503	503	(iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility 15
504	504	and benefits information; 16
505	505	(v) Recommend a standard or common process to protect all providers from the costs of 17
506	506	services to patients who are ineligible for insurance coverage in circumstances where a payor 18
507	507	provides eligibility verification based on best information available to the payor at the date of the 19
508	508	request of eligibility. 20
509	509	(2) Developing implementation guidelines and promoting adoption of the guidelines for: 21
510	510	(i) The use of the National Correct Coding Initiative code-edit policy by payors and 22
511	511	providers in the state; 23
512	512	(ii) Publishing any variations from codes and mutually exclusive codes by payors in a 24
513	513	manner that makes for simple retrieval and implementation by providers; 25
514	514	(iii) Use of Health Insurance Portability and Accountability Act standard group codes, 26
515	515	reason codes, and remark codes by payors in electronic remittances sent to providers; 27
516	516	(iv) Uniformity in the processing of claims by payors; and the processing of corrections to 28
517	517	claims by providers and payors; 29
518	518	(v) A standard payor-denial review process for providers when they request a 30
519	519	reconsideration of a denial of a claim that results from differences in clinical edits where no single, 31
520	520	common-standards body or process exists and multiple conflicting sources are in use by payors and 32
521	521	providers. 33
522	522	(vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual 34
523	523
524	524
525	525	LC000456 - Page 15 of 22
526	526	payor’s ability to employ, and not disclose to providers, temporary code edits for the purpose of 1
527	527	detecting and deterring fraudulent billing activities. The guidelines shall require that each payor 2
528	528	disclose to the provider its adjudication decision on a claim that was denied or adjusted based on 3
529	529	the application of such edits and that the provider have access to the payor’s review and appeal 4
530	530	process to challenge the payor’s adjudication decision. 5
531	531	(vii) Nothing in this subsection shall be construed to modify the rights or obligations of 6
532	532	payors or providers with respect to procedures relating to the investigation, reporting, appeal, or 7
533	533	prosecution under applicable law of potentially fraudulent billing activities. 8
534	534	(3) Developing and promoting widespread adoption by payors and providers of guidelines 9
535	535	to: 10
536	536	(i) Ensure payors do not automatically deny claims for services when extenuating 11
537	537	circumstances make it impossible for the provider to obtain a preauthorization before services are 12
538	538	performed or notify a payor within an appropriate standardized timeline of a patient’s admission; 13
539	539	(ii) Require payors to use common and consistent processes and time frames when 14
540	540	responding to provider requests for medical management approvals. Whenever possible, such time 15
541	541	frames shall be consistent with those established by leading national organizations and be based 16
542	542	upon the acuity of the patient’s need for care or treatment. For the purposes of this section, medical 17
543	543	management includes prior authorization of services, preauthorization of services, precertification 18
544	544	of services, post-service review, medical-necessity review, and benefits advisory; 19
545	545	(iii) Develop, maintain, and promote widespread adoption of a single, common website 20
546	546	where providers can obtain payors’ preauthorization, benefits advisory, and preadmission 21
547	547	requirements; 22
548	548	(iv) Establish guidelines for payors to develop and maintain a website that providers can 23
549	549	use to request a preauthorization, including a prospective clinical necessity review; receive an 24
550	550	authorization number; and transmit an admission notification; 25
551	551	(v) Develop and implement the use of programs that implement selective prior 26
552	552	authorization requirements, based on stratification of healthcare providers’ performance and 27
553	553	adherence to evidence-based medicine with the input of contracted healthcare providers and/or 28
554	554	provider organizations. Such criteria shall be transparent and easily accessible to contracted 29
555	555	providers. Such selective prior authorization programs shall be available when healthcare providers 30
556	556	participate directly with the insurer in risk-based payment contracts and may be available to 31
557	557	providers who do not participate in risk-based contracts; 32
558	558	(vi) Require the review of medical services, including behavioral health services, and 33
559	559	prescription drugs, subject to prior authorization on at least an annual basis, with the input of 34
560	560
561	561
562	562	LC000456 - Page 16 of 22
563	563	contracted healthcare providers and/or provider organizations. Any changes to the list of medical 1
564	564	services, including behavioral health services, and prescription drugs requiring prior authorization, 2
565	565	shall be shared via provider-accessible websites; 3
566	566	(vii) Improve communication channels between health plans, healthcare providers, and 4
567	567	patients by: 5
568	568	(A) Requiring transparency and easy accessibility of prior authorization requirements, 6
569	569	criteria, rationale, and program changes to contracted healthcare providers and patients/health plan 7
570	570	enrollees which may be satisfied by posting to provider-accessible and member-accessible 8
571	571	websites; and 9
572	572	(B) Supporting: 10
573	573	(I) Timely submission by healthcare providers of the complete information necessary to 11
574	574	make a prior authorization determination, as early in the process as possible; and 12
575	575	(II) Timely notification of prior authorization determinations by health plans to impacted 13
576	576	health plan enrollees, and healthcare providers, including, but not limited to, ordering providers, 14
577	577	and/or rendering providers, and dispensing pharmacists which may be satisfied by posting to 15
578	578	provider-accessible websites or similar electronic portals or services; 16
579	579	(viii) Increase and strengthen continuity of patient care by: 17
580	580	(A) Defining protections for continuity of care during a transition period for patients 18
581	581	undergoing an active course of treatment, when there is a formulary or treatment coverage change 19
582	582	or change of health plan that may disrupt their current course of treatment and when the treating 20
583	583	physician determines that a transition may place the patient at risk; and for prescription medication 21
584	584	by allowing a grace period of coverage to allow consideration of referred health plan options or 22
585	585	establishment of medical necessity of the current course of treatment; 23
586	586	(B) Requiring continuity of care for medical services, including behavioral health services, 24
587	587	and prescription medications for patients on appropriate, chronic, stable therapy through 25
588	588	minimizing repetitive prior authorization requirements; and which for prescription medication shall 26
589	589	be allowed only on an annual review, with exception for labeled limitation, to establish continued 27
590	590	benefit of treatment; and 28
591	591	(C) Requiring communication between healthcare providers, health plans, and patients to 29
592	592	facilitate continuity of care and minimize disruptions in needed treatment which may be satisfied 30
593	593	by posting to provider-accessible websites or similar electronic portals or services; 31
594	594	(D) Continuity of care for formulary or drug coverage shall distinguish between FDA 32
595	595	designated interchangeable products and proprietary or marketed versions of a medication; 33
596	596	(ix) Encourage healthcare providers and/or provider organizations and health plans to 34
597	597
598	598
599	599	LC000456 - Page 17 of 22
600	600	accelerate use of electronic prior authorization technology, including adoption of national standards 1
601	601	where applicable; and 2
602	602	(x) For the purposes of subsections (h)(3)(v) through (h)(3)(x) of this section, the 3
603	603	workgroup meeting may be conducted in part or whole through electronic methods. 4
604	604	(4) To provide a report to the house and senate, on or before January 1, 2017, with 5
605	605	recommendations for establishing guidelines and regulations for systems that give patients 6
606	606	electronic access to their claims information, particularly to information regarding their obligations 7
607	607	to pay for received medical services, pursuant to 45 C.F.R. § 164.524. 8
608	608	(5) No provision of this subsection (h) shall preclude the ongoing work of the office of 9
609	609	health insurance commissioner’s administrative simplification task force, which includes meetings 10
610	610	with key stakeholders in order to improve, and provide recommendations regarding, the prior 11
611	611	authorization process. 12
612	612	(i) To issue an anti-cancer medication report. Not later than June 30, 2014, and annually 13
613	613	thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate 14
614	614	committee on health and human services, and the house committee on corporations, with: (1) 15
615	615	Information on the availability in the commercial market of coverage for anti-cancer medication 16
616	616	options; (2) For the state employee’s health benefit plan, the costs of various cancer-treatment 17
617	617	options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member 18
618	618	utilization and cost-sharing expense. 19
619	619	(j) To monitor the adequacy of each health plan’s compliance with the provisions of the 20
620	620	federal Mental Health Parity Act, including a review of related claims processing and 21
621	621	reimbursement procedures. Findings, recommendations, and assessments shall be made available 22
622	622	to the public. 23
623	623	(k) To monitor the transition from fee-for-service and toward global and other alternative 24
624	624	payment methodologies for the payment for healthcare services. Alternative payment 25
625	625	methodologies should be assessed for their likelihood to promote access to affordable health 26
626	626	insurance, health outcomes, and performance. 27
627	627	(l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital 28
628	628	payment variation, including findings and recommendations, subject to available resources. 29
629	629	(m) Notwithstanding any provision of the general or public laws or regulation to the 30
630	630	contrary, provide a report with findings and recommendations to the president of the senate and the 31
631	631	speaker of the house, on or before April 1, 2014, including, but not limited to, the following 32
632	632	information: 33
633	633	(1) The impact of the current, mandated healthcare benefits as defined in §§ 27-18-48.1, 34
634	634
635	635
636	636	LC000456 - Page 18 of 22
637	637	27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41 of title 27, and §§ 27-1
638	638	18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health 2
639	639	insurance for fully insured employers, subject to available resources; 3
640	640	(2) Current provider and insurer mandates that are unnecessary and/or duplicative due to 4
641	641	the existing standards of care and/or delivery of services in the healthcare system; 5
642	642	(3) A state-by-state comparison of health insurance mandates and the extent to which 6
643	643	Rhode Island mandates exceed other states benefits; and 7
644	644	(4) Recommendations for amendments to existing mandated benefits based on the findings 8
645	645	in (m)(1), (m)(2), and (m)(3) above. 9
646	646	(n) On or before July 1, 2014, the office of the health insurance commissioner, in 10
647	647	collaboration with the director of health and lieutenant governor’s office, shall submit a report to 11
648	648	the general assembly and the governor to inform the design of accountable care organizations 12
649	649	(ACOs) in Rhode Island as unique structures for comprehensive healthcare delivery and value-13
650	650	based payment arrangements, that shall include, but not be limited to: 14
651	651	(1) Utilization review; 15
652	652	(2) Contracting; and 16
653	653	(3) Licensing and regulation. 17
654	654	(o) On or before February 3, 2015, the office of the health insurance commissioner shall 18
655	655	submit a report to the general assembly and the governor that describes, analyzes, and proposes 19
656	656	recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard 20
657	657	to patients with mental health and substance use disorders. 21
658	658	(p) To work to ensure the health insurance coverage of behavioral health care under the 22
659	659	same terms and conditions as other health care, and to integrate behavioral health parity 23
660	660	requirements into the office of the health insurance commissioner insurance oversight and 24
661	661	healthcare transformation efforts. 25
662	662	(q) To work with other state agencies to seek delivery system improvements that enhance 26
663	663	access to a continuum of mental health and substance use disorder treatment in the state; and 27
664	664	integrate that treatment with primary and other medical care to the fullest extent possible. 28
665	665	(r) To direct insurers toward policies and practices that address the behavioral health needs 29
666	666	of the public and greater integration of physical and behavioral healthcare delivery. 30
667	667	(s) The office of the health insurance commissioner shall conduct an analysis of the impact 31
668	668	of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and 32
669	669	submit a report of its findings to the general assembly on or before June 1, 2023. 33
670	670	(t) To undertake the analyses, reports, and studies contained in this section: 34
671	671
672	672
673	673	LC000456 - Page 19 of 22
674	674	(1) The office shall hire the necessary staff and prepare a request for proposal for a qualified 1
675	675	and competent firm or firms to undertake the following analyses, reports, and studies: 2
676	676	(i) The firm shall undertake a comprehensive review of all social and human service 3
677	677	programs having a contract with or licensed by the state or any subdivision of the department of 4
678	678	children, youth and families (DCYF), the department of behavioral healthcare, developmental 5
679	679	disabilities and hospitals (BHDDH), the department of human services (DHS), the department of 6
680	680	health (DOH), and Medicaid for the purposes of: 7
681	681	(A) Establishing a baseline of the eligibility factors for receiving services; 8
682	682	(B) Establishing a baseline of the service offering through each agency for those 9
683	683	determined eligible; 10
684	684	(C) Establishing a baseline understanding of reimbursement rates for all social and human 11
685	685	service programs including rates currently being paid, the date of the last increase, and a proposed 12
686	686	model that the state may use to conduct future studies and analyses; 13
687	687	(D) Ensuring accurate and adequate reimbursement to social and human service providers 14
688	688	that facilitate the availability of high-quality services to individuals receiving home and 15
689	689	community-based long-term services and supports provided by social and human service providers; 16
690	690	(E) Ensuring the general assembly is provided accurate financial projections on social and 17
691	691	human service program costs, demand for services, and workforce needs to ensure access to entitled 18
692	692	beneficiaries and services; 19
693	693	(F) Establishing a baseline and determining the relationship between state government and 20
694	694	the provider network including functions, responsibilities, and duties; 21
695	695	(G) Determining a set of measures and accountability standards to be used by EOHHS and 22
696	696	the general assembly to measure the outcomes of the provision of services including budgetary 23
697	697	reporting requirements, transparency portals, and other methods; and 24
698	698	(H) Reporting the findings of human services analyses and reports to the speaker of the 25
699	699	house, senate president, chairs of the house and senate finance committees, chairs of the house and 26
700	700	senate health and human services committees, and the governor. 27
701	701	(2) The analyses, reports, and studies required pursuant to this section shall be 28
702	702	accomplished and published as follows and shall provide: 29
703	703	(i) An assessment and detailed reporting on all social and human service program rates to 30
704	704	be completed by January 1, 2023, including rates currently being paid and the date of the last 31
705	705	increase; 32
706	706	(ii) An assessment and detailed reporting on eligibility standards and processes of all 33
707	707	mandatory and discretionary social and human service programs to be completed by January 1, 34
708	708
709	709
710	710	LC000456 - Page 20 of 22
711	711	2023; 1
712	712	(iii) An assessment and detailed reporting on utilization trends from the period of January 2
713	713	1, 2017, through December 31, 2021, for social and human service programs to be completed by 3
714	714	January 1, 2023; 4
715	715	(iv) An assessment and detailed reporting on the structure of the state government as it 5
716	716	relates to the provision of services by social and human service providers including eligibility and 6
717	717	functions of the provider network to be completed by January 1, 2023; 7
718	718	(v) An assessment and detailed reporting on accountability standards for services for social 8
719	719	and human service programs to be completed by January 1, 2023; 9
720	720	(vi) An assessment and detailed reporting by April 1, 2023, on all professional licensed 10
721	721	and unlicensed personnel requirements for established rates for social and human service programs 11
722	722	pursuant to a contract or established fee schedule; 12
723	723	(vii) An assessment and reporting on access to social and human service programs, to 13
724	724	include any wait lists and length of time on wait lists, in each service category by April 1, 2023; 14
725	725	(viii) An assessment and reporting of national and regional Medicaid rates in comparison 15
726	726	to Rhode Island social and human service provider rates by April 1, 2023; 16
727	727	(ix) An assessment and reporting on usual and customary rates paid by private insurers and 17
728	728	private pay for similar social and human service providers, both nationally and regionally, by April 18
729	729	1, 2023; and 19
730	730	(x) Completion of the development of an assessment and review process that includes the 20
731	731	following components: eligibility; scope of services; relationship of social and human service 21
732	732	provider and the state; national and regional rate comparisons and accountability standards that 22
733	733	result in recommended rate adjustments; and this process shall be completed by September 1, 2023, 23
734	734	and conducted biennially hereafter. The biennial rate setting shall be consistent with payment 24
735	735	requirements established in § 1902(a)(30)(A) of the Social Security Act, 42 U.S.C. § 25
736	736	1396a(a)(30)(A), and all federal and state law, regulations, and quality and safety standards. The 26
737	737	results and findings of this process shall be transparent, and public meetings shall be conducted to 27
738	738	allow providers, recipients, and other interested parties an opportunity to ask questions and provide 28
739	739	comment beginning in September 2023 and biennially thereafter. 29
740	740	(3) In fulfillment of the responsibilities defined in subsection (t), the office of the health 30
741	741	insurance commissioner shall consult with the Executive Office of Health and Human Services. 31
742	742	(u) Annually, each department (namely, EOHHS, DCYF, DOH, DHS, and BHDDH) shall 32
743	743	include the corresponding components of the assessment and review (i.e., eligibility; scope of 33
744	744	services; relationship of social and human service provider and the state; and national and regional 34
745	745
746	746
747	747	LC000456 - Page 21 of 22
748	748	rate comparisons and accountability standards including any changes or substantive issues between 1
749	749	biennial reviews) including the recommended rates from the most recent assessment and review 2
750	750	with their annual budget submission to the office of management and budget and provide a detailed 3
751	751	explanation and impact statement if any rate variances exist between submitted recommended 4
752	752	budget and the corresponding recommended rate from the most recent assessment and review 5
753	753	process starting October 1, 2023, and biennially thereafter. 6
754	754	(v) The general assembly shall appropriate adequate funding as it deems necessary to 7
755	755	undertake the analyses, reports, and studies contained in this section relating to the powers and 8
756	756	duties of the office of the health insurance commissioner. 9
757	757	(w) Ensure that insurers minimize administrative burdens that may delay medically 10
758	758	necessary care, including by promulgating rules and regulations and taking enforcement actions to 11
759	759	implement § 27-18.9-16. 12
760	760	SECTION 6. Should any provision of this act be found unconstitutional, preempted, or 13
761	761	otherwise invalid, that provision shall be severed and such decision shall not affect the validity of 14
762	762	the other parts of this act. 15
763	763	SECTION 7. This act shall take effect on July 1, 2026. 16
764	764	========
765	765	LC000456
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769	769	LC000456 - Page 22 of 22
770	770	EXPLANATION
771	771	BY THE LEGISLATIVE COUNCIL
772	772	OF
773	773	A N A C T
774	774	RELATING TO INSURANCE -- BENEFIT DETERMINATION AND UTILIZATION
775	775	REVIEW ACT
776	776	***
777	777	This act would provide that an insurer would not impose prior authorization requirements 1
778	778	for any admission, item, service, treatment, or procedure ordered by an in-network primary care 2
779	779	provider, with certain exceptions. 3
780	780	This act would take effect on July 1, 2026. 4
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782	782	LC000456
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