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| 4 | 4 | | |
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| 5 | 5 | | 2025 -- S 0116 |
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| 6 | 6 | | ======== |
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| 7 | 7 | | LC000194 |
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| 8 | 8 | | ======== |
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| 9 | 9 | | S T A T E O F R H O D E I S L A N D |
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| 10 | 10 | | IN GENERAL ASSEMBLY |
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| 11 | 11 | | JANUARY SESSION, A.D. 2025 |
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| 12 | 12 | | ____________ |
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| 13 | 13 | | |
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| 14 | 14 | | A N A C T |
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| 15 | 15 | | RELATING TO INSURANCE -- BENEFIT DETERMINATION AND UT ILIZATION |
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| 16 | 16 | | REVIEW ACT |
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| 17 | 17 | | Introduced By: Senators Ujifusa, Lawson, Murray, Valverde, Mack, Acosta, Euer, Zurier, |
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| 18 | 18 | | and Vargas |
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| 19 | 19 | | Date Introduced: January 31, 2025 |
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| 20 | 20 | | Referred To: Senate Health & Human Services |
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| 21 | 21 | | |
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| 22 | 22 | | |
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| 23 | 23 | | It is enacted by the General Assembly as follows: |
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| 24 | 24 | | SECTION 1. Section 27-18.9-5 of the General Laws in Chapter 27-18.9 entitled "Benefit 1 |
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| 25 | 25 | | Determination and Utilization Review Act" is hereby amended to read as follows: 2 |
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| 26 | 26 | | 27-18.9-5. Administrative and non-administrative benefit determination procedural 3 |
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| 27 | 27 | | requirements. 4 |
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| 28 | 28 | | (a) Procedural failure by claimant. 5 |
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| 29 | 29 | | (1) In the event of the failure of claimant or an authorized representative to follow the 6 |
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| 30 | 30 | | healthcare entities claims procedures for a pre-service claim the healthcare entity or its review agent 7 |
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| 31 | 31 | | must: 8 |
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| 32 | 32 | | (i) Notify claimant or the authorized representative, as appropriate, of this failure as soon 9 |
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| 33 | 33 | | as possible and no later than five (5) calendar days following the failure and this notification must 10 |
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| 34 | 34 | | also inform claimant of the proper procedures to file a pre-service claim; and 11 |
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| 35 | 35 | | (ii) Notwithstanding the above, if the pre-service claim relates to urgent or emergent 12 |
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| 36 | 36 | | healthcare services, the healthcare entity or its review agent must notify and inform claimant or the 13 |
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| 37 | 37 | | authorized representative, as appropriate, of the failure and proper procedures within twenty-four 14 |
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| 38 | 38 | | (24) hours following the failure. Notification may be oral, unless written notification is requested 15 |
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| 39 | 39 | | by the claimant or authorized representative. 16 |
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| 40 | 40 | | (2) Claimant must have stated name, specific medical condition or symptom and specific 17 |
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| 41 | 41 | | treatment, service, or product for which approval is requested and submitted to proper claim 18 |
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| 42 | 42 | | |
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| 43 | 43 | | |
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| 44 | 44 | | LC000194 - Page 2 of 15 |
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| 45 | 45 | | processing unit. 1 |
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| 46 | 46 | | (b) Utilization review agent procedural requirements: 2 |
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| 47 | 47 | | (1) All initial, prospective, and concurrent non-administrative, adverse benefit 3 |
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| 48 | 48 | | determinations of a healthcare service that had been ordered by a physician, dentist, or other 4 |
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| 49 | 49 | | practitioner shall be made, documented, and signed by a licensed practitioner with the same 5 |
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| 50 | 50 | | licensure status as the ordering provider; 6 |
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| 51 | 51 | | (2) Utilization review agents are not prohibited from allowing appropriately qualified 7 |
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| 52 | 52 | | review agency staff from engaging in discussions with the attending provider, the attending 8 |
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| 53 | 53 | | provider’s designee or appropriate healthcare facility and office personnel regarding alternative 9 |
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| 54 | 54 | | service and/or treatment options. Such a discussion shall not constitute an adverse benefit 10 |
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| 55 | 55 | | determination; provided, however, that any change to the attending provider’s original order and/or 11 |
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| 56 | 56 | | any decision for an alternative level of care must be made and/or appropriately consented to by the 12 |
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| 57 | 57 | | attending provider or the provider’s designee responsible for treating the beneficiary and must be 13 |
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| 58 | 58 | | documented by the review agent; and 14 |
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| 59 | 59 | | (3) A utilization review agent shall not retrospectively deny authorization for healthcare 15 |
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| 60 | 60 | | services provided to a covered person when an authorization has been obtained for that service 16 |
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| 61 | 61 | | from the review agent unless the approval was based upon inaccurate information material to the 17 |
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| 62 | 62 | | review or the healthcare services were not provided consistent with the provider’s submitted plan 18 |
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| 63 | 63 | | of care and/or any restrictions included in the prior approval granted by the review agent. 19 |
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| 64 | 64 | | (c) Step therapy exceptions. 20 |
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| 65 | 65 | | (1) For purposes of this subsection, the following terms shall have the following meanings: 21 |
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| 66 | 66 | | (i) “Healthcare professional” means a physician or other healthcare practitioner licensed, 22 |
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| 67 | 67 | | accredited, or certified to perform specified healthcare services consistent with state law. 23 |
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| 68 | 68 | | (ii) “Insurer” has the meaning set forth in § 27-20.7-2. 24 |
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| 69 | 69 | | (iii) “Step therapy” means a protocol or program that establishes a specific sequence in 25 |
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| 70 | 70 | | which prescription drugs, therapies, medical tests, or other services for a specified medical 26 |
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| 71 | 71 | | condition are covered by an insurer. 27 |
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| 72 | 72 | | (2) Implementation. 28 |
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| 73 | 73 | | (i) When an insurer uses a step therapy protocol to deny or restrict coverage of a 29 |
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| 74 | 74 | | prescription drug, therapy, medical test, or other service prescribed by a healthcare professional to 30 |
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| 75 | 75 | | diagnose or treat any medical condition, the insurer shall grant an exception to permit immediate 31 |
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| 76 | 76 | | coverage if the step it requires: 32 |
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| 77 | 77 | | (A) Is contraindicated or expected to cause an adverse reaction; 33 |
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| 78 | 78 | | (B) Has been tried and found to be ineffective; 34 |
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| 79 | 79 | | |
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| 80 | 80 | | |
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| 81 | 81 | | LC000194 - Page 3 of 15 |
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| 82 | 82 | | (C) Has not been tried, but is expected to be ineffective; 1 |
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| 83 | 83 | | (D) Will delay or prevent medically necessary care; or 2 |
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| 84 | 84 | | (E) Will disrupt the patient’s current effective drug regimen. 3 |
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| 85 | 85 | | (ii) Insurers shall create a clear, easily accessible, and convenient process for healthcare 4 |
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| 86 | 86 | | professionals to submit exception requests online. 5 |
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| 87 | 87 | | (iii) Insurers shall approve or deny the exception request within seventy-two (72) hours 6 |
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| 88 | 88 | | from receipt of the request. If the healthcare professional identifies the request as an urgent 7 |
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| 89 | 89 | | medically necessary service, the insurer shall approve or deny the request within twenty-four (24) 8 |
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| 90 | 90 | | hours of receipt of the request. If no determination occurs within these time frames, the request 9 |
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| 91 | 91 | | shall be presumed granted. 10 |
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| 92 | 92 | | (3) Insurers shall ensure that individuals who review or discuss exceptions with healthcare 11 |
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| 93 | 93 | | professionals are themselves healthcare professionals with expertise in the medical service for 12 |
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| 94 | 94 | | which an exception is sought. 13 |
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| 95 | 95 | | (4) The determinations shall be valid for the length of time deemed medically necessary by 14 |
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| 96 | 96 | | the provider, up to one year from the date of the determination. 15 |
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| 97 | 97 | | (5) Insurers shall provide the office of health insurance commissioner information and 16 |
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| 98 | 98 | | documents about their use of step therapy protocols that permit an accurate analysis of whether step 17 |
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| 99 | 99 | | therapy protocols have been used to delay or deny medically necessary care. 18 |
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| 100 | 100 | | SECTION 2. Section 42-14.5-3 of the General Laws in Chapter 42-14.5 entitled "The 19 |
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| 101 | 101 | | Rhode Island Health Care Reform Act of 2004 — Health Insurance Oversight" is hereby amended 20 |
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| 102 | 102 | | to read as follows: 21 |
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| 103 | 103 | | 42-14.5-3. Powers and duties. 22 |
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| 104 | 104 | | The health insurance commissioner shall have the following powers and duties: 23 |
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| 105 | 105 | | (a) To conduct quarterly public meetings throughout the state, separate and distinct from 24 |
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| 106 | 106 | | rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers 25 |
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| 107 | 107 | | licensed to provide health insurance in the state; the effects of such rates, services, and operations 26 |
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| 108 | 108 | | on consumers, medical care providers, patients, and the market environment in which the insurers 27 |
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| 109 | 109 | | operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less 28 |
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| 110 | 110 | | than ten (10) days of the hearing(s) shall go to the general assembly, the governor, the Rhode Island 29 |
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| 111 | 111 | | Medical Society, the Hospital Association of Rhode Island, the director of health, the attorney 30 |
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| 112 | 112 | | general, and the chambers of commerce. Public notice shall be posted on the department’s website 31 |
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| 113 | 113 | | and given in the newspaper of general circulation, and to any entity in writing requesting notice. 32 |
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| 114 | 114 | | (b) To make recommendations to the governor and the house of representatives and senate 33 |
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| 115 | 115 | | finance committees regarding healthcare insurance and the regulations, rates, services, 34 |
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| 116 | 116 | | |
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| 117 | 117 | | |
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| 118 | 118 | | LC000194 - Page 4 of 15 |
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| 119 | 119 | | administrative expenses, reserve requirements, and operations of insurers providing health 1 |
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| 120 | 120 | | insurance in the state, and to prepare or comment on, upon the request of the governor or 2 |
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| 121 | 121 | | chairpersons of the house or senate finance committees, draft legislation to improve the regulation 3 |
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| 122 | 122 | | of health insurance. In making the recommendations, the commissioner shall recognize that it is 4 |
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| 123 | 123 | | the intent of the legislature that the maximum disclosure be provided regarding the reasonableness 5 |
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| 124 | 124 | | of individual administrative expenditures as well as total administrative costs. The commissioner 6 |
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| 125 | 125 | | shall make recommendations on the levels of reserves, including consideration of: targeted reserve 7 |
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| 126 | 126 | | levels; trends in the increase or decrease of reserve levels; and insurer plans for distributing excess 8 |
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| 127 | 127 | | reserves. 9 |
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| 128 | 128 | | (c) To establish a consumer/business/labor/medical advisory council to obtain information 10 |
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| 129 | 129 | | and present concerns of consumers, business, and medical providers affected by health insurance 11 |
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| 130 | 130 | | decisions. The council shall develop proposals to allow the market for small business health 12 |
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| 131 | 131 | | insurance to be affordable and fairer. The council shall be involved in the planning and conduct of 13 |
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| 132 | 132 | | the quarterly public meetings in accordance with subsection (a). The advisory council shall develop 14 |
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| 133 | 133 | | measures to inform small businesses of an insurance complaint process to ensure that small 15 |
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| 134 | 134 | | businesses that experience rate increases in a given year may request and receive a formal review 16 |
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| 135 | 135 | | by the department. The advisory council shall assess views of the health provider community 17 |
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| 136 | 136 | | relative to insurance rates of reimbursement, billing, and reimbursement procedures, and the 18 |
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| 137 | 137 | | insurers’ role in promoting efficient and high-quality health care. The advisory council shall issue 19 |
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| 138 | 138 | | an annual report of findings and recommendations to the governor and the general assembly and 20 |
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| 139 | 139 | | present its findings at hearings before the house and senate finance committees. The advisory 21 |
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| 140 | 140 | | council is to be diverse in interests and shall include representatives of community consumer 22 |
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| 141 | 141 | | organizations; small businesses, other than those involved in the sale of insurance products; and 23 |
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| 142 | 142 | | hospital, medical, and other health provider organizations. Such representatives shall be nominated 24 |
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| 143 | 143 | | by their respective organizations. The advisory council shall be co-chaired by the health insurance 25 |
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| 144 | 144 | | commissioner and a community consumer organization or small business member to be elected by 26 |
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| 145 | 145 | | the full advisory council. 27 |
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| 146 | 146 | | (d) To establish and provide guidance and assistance to a subcommittee (“the professional-28 |
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| 147 | 147 | | provider-health-plan work group”) of the advisory council created pursuant to subsection (c), 29 |
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| 148 | 148 | | composed of healthcare providers and Rhode Island licensed health plans. This subcommittee shall 30 |
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| 149 | 149 | | include in its annual report and presentation before the house and senate finance committees the 31 |
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| 150 | 150 | | following information: 32 |
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| 151 | 151 | | (1) A method whereby health plans shall disclose to contracted providers the fee schedules 33 |
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| 152 | 152 | | used to provide payment to those providers for services rendered to covered patients; 34 |
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| 153 | 153 | | |
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| 154 | 154 | | |
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| 155 | 155 | | LC000194 - Page 5 of 15 |
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| 156 | 156 | | (2) A standardized provider application and credentials verification process, for the 1 |
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| 157 | 157 | | purpose of verifying professional qualifications of participating healthcare providers; 2 |
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| 158 | 158 | | (3) The uniform health plan claim form utilized by participating providers; 3 |
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| 159 | 159 | | (4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit 4 |
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| 160 | 160 | | hospital or medical service corporations, as defined by chapters 19 and 20 of title 27, to make 5 |
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| 161 | 161 | | facility-specific data and other medical service-specific data available in reasonably consistent 6 |
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| 162 | 162 | | formats to patients regarding quality and costs. This information would help consumers make 7 |
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| 163 | 163 | | informed choices regarding the facilities and clinicians or physician practices at which to seek care. 8 |
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| 164 | 164 | | Among the items considered would be the unique health services and other public goods provided 9 |
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| 165 | 165 | | by facilities and clinicians or physician practices in establishing the most appropriate cost 10 |
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| 166 | 166 | | comparisons; 11 |
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| 167 | 167 | | (5) All activities related to contractual disclosure to participating providers of the 12 |
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| 168 | 168 | | mechanisms for resolving health plan/provider disputes; 13 |
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| 169 | 169 | | (6) The uniform process being utilized for confirming, in real time, patient insurance 14 |
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| 170 | 170 | | enrollment status, benefits coverage, including copays and deductibles; 15 |
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| 171 | 171 | | (7) Information related to temporary credentialing of providers seeking to participate in the 16 |
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| 172 | 172 | | plan’s network and the impact of the activity on health plan accreditation; 17 |
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| 173 | 173 | | (8) The feasibility of regular contract renegotiations between plans and the providers in 18 |
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| 174 | 174 | | their networks; and 19 |
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| 175 | 175 | | (9) Efforts conducted related to reviewing impact of silent PPOs on physician practices. 20 |
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| 176 | 176 | | (e) To enforce the provisions of title 27 and title 42 as set forth in § 42-14-5(d). 21 |
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| 177 | 177 | | (f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The 22 |
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| 178 | 178 | | fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17. 23 |
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| 179 | 179 | | (g) To analyze the impact of changing the rating guidelines and/or merging the individual 24 |
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| 180 | 180 | | health insurance market, as defined in chapter 18.5 of title 27, and the small-employer health 25 |
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| 181 | 181 | | insurance market, as defined in chapter 50 of title 27, in accordance with the following: 26 |
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| 182 | 182 | | (1) The analysis shall forecast the likely rate increases required to effect the changes 27 |
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| 183 | 183 | | recommended pursuant to the preceding subsection (g) in the direct-pay market and small-employer 28 |
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| 184 | 184 | | health insurance market over the next five (5) years, based on the current rating structure and 29 |
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| 185 | 185 | | current products. 30 |
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| 186 | 186 | | (2) The analysis shall include examining the impact of merging the individual and small-31 |
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| 187 | 187 | | employer markets on premiums charged to individuals and small-employer groups. 32 |
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| 188 | 188 | | (3) The analysis shall include examining the impact on rates in each of the individual and 33 |
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| 189 | 189 | | small-employer health insurance markets and the number of insureds in the context of possible 34 |
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| 190 | 190 | | |
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| 191 | 191 | | |
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| 192 | 192 | | LC000194 - Page 6 of 15 |
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| 193 | 193 | | changes to the rating guidelines used for small-employer groups, including: community rating 1 |
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| 194 | 194 | | principles; expanding small-employer rate bonds beyond the current range; increasing the employer 2 |
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| 195 | 195 | | group size in the small-group market; and/or adding rating factors for broker and/or tobacco use. 3 |
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| 196 | 196 | | (4) The analysis shall include examining the adequacy of current statutory and regulatory 4 |
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| 197 | 197 | | oversight of the rating process and factors employed by the participants in the proposed, new 5 |
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| 198 | 198 | | merged market. 6 |
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| 199 | 199 | | (5) The analysis shall include assessment of possible reinsurance mechanisms and/or 7 |
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| 200 | 200 | | federal high-risk pool structures and funding to support the health insurance market in Rhode Island 8 |
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| 201 | 201 | | by reducing the risk of adverse selection and the incremental insurance premiums charged for this 9 |
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| 202 | 202 | | risk, and/or by making health insurance affordable for a selected at-risk population. 10 |
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| 203 | 203 | | (6) The health insurance commissioner shall work with an insurance market merger task 11 |
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| 204 | 204 | | force to assist with the analysis. The task force shall be chaired by the health insurance 12 |
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| 205 | 205 | | commissioner and shall include, but not be limited to, representatives of the general assembly, the 13 |
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| 206 | 206 | | business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage in 14 |
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| 207 | 207 | | the individual market in Rhode Island, health insurance brokers, and members of the general public. 15 |
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| 208 | 208 | | (7) For the purposes of conducting this analysis, the commissioner may contract with an 16 |
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| 209 | 209 | | outside organization with expertise in fiscal analysis of the private insurance market. In conducting 17 |
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| 210 | 210 | | its study, the organization shall, to the extent possible, obtain and use actual health plan data. Said 18 |
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| 211 | 211 | | data shall be subject to state and federal laws and regulations governing confidentiality of health 19 |
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| 212 | 212 | | care and proprietary information. 20 |
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| 213 | 213 | | (8) The task force shall meet as necessary and include its findings in the annual report, and 21 |
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| 214 | 214 | | the commissioner shall include the information in the annual presentation before the house and 22 |
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| 215 | 215 | | senate finance committees. 23 |
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| 216 | 216 | | (h) To establish and convene a workgroup representing healthcare providers and health 24 |
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| 217 | 217 | | insurers for the purpose of coordinating the development of processes, guidelines, and standards to 25 |
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| 218 | 218 | | streamline healthcare administration that are to be adopted by payors and providers of healthcare 26 |
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| 219 | 219 | | services operating in the state. This workgroup shall include representatives with expertise who 27 |
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| 220 | 220 | | would contribute to the streamlining of healthcare administration and who are selected from 28 |
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| 221 | 221 | | hospitals, physician practices, community behavioral health organizations, each health insurer, and 29 |
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| 222 | 222 | | other affected entities. The workgroup shall also include at least one designee each from the Rhode 30 |
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| 223 | 223 | | Island Medical Society, Rhode Island Council of Community Mental Health Organizations, the 31 |
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| 224 | 224 | | Rhode Island Health Center Association, and the Hospital Association of Rhode Island. In any year 32 |
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| 225 | 225 | | that the workgroup meets and submits recommendations to the office of the health insurance 33 |
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| 226 | 226 | | commissioner, the office of the health insurance commissioner shall submit such recommendations 34 |
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| 227 | 227 | | |
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| 228 | 228 | | |
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| 229 | 229 | | LC000194 - Page 7 of 15 |
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| 230 | 230 | | to the health and human services committees of the Rhode Island house of representatives and the 1 |
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| 231 | 231 | | Rhode Island senate prior to the implementation of any such recommendations and subsequently 2 |
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| 232 | 232 | | shall submit a report to the general assembly by June 30, 2024. The report shall include the 3 |
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| 233 | 233 | | recommendations the commissioner may implement, with supporting rationale. The workgroup 4 |
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| 234 | 234 | | shall consider and make recommendations for: 5 |
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| 235 | 235 | | (1) Establishing a consistent standard for electronic eligibility and coverage verification. 6 |
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| 236 | 236 | | Such standard shall: 7 |
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| 237 | 237 | | (i) Include standards for eligibility inquiry and response and, wherever possible, be 8 |
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| 238 | 238 | | consistent with the standards adopted by nationally recognized organizations, such as the Centers 9 |
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| 239 | 239 | | for Medicare & Medicaid Services; 10 |
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| 240 | 240 | | (ii) Enable providers and payors to exchange eligibility requests and responses on a system-11 |
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| 241 | 241 | | to-system basis or using a payor-supported web browser; 12 |
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| 242 | 242 | | (iii) Provide reasonably detailed information on a consumer’s eligibility for healthcare 13 |
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| 243 | 243 | | coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing 14 |
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| 244 | 244 | | requirements for specific services at the specific time of the inquiry; current deductible amounts; 15 |
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| 245 | 245 | | accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and 16 |
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| 246 | 246 | | other information required for the provider to collect the patient’s portion of the bill; 17 |
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| 247 | 247 | | (iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility 18 |
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| 248 | 248 | | and benefits information; 19 |
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| 249 | 249 | | (v) Recommend a standard or common process to protect all providers from the costs of 20 |
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| 250 | 250 | | services to patients who are ineligible for insurance coverage in circumstances where a payor 21 |
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| 251 | 251 | | provides eligibility verification based on best information available to the payor at the date of the 22 |
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| 252 | 252 | | request of eligibility. 23 |
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| 253 | 253 | | (2) Developing implementation guidelines and promoting adoption of the guidelines for: 24 |
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| 254 | 254 | | (i) The use of the National Correct Coding Initiative code-edit policy by payors and 25 |
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| 255 | 255 | | providers in the state; 26 |
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| 256 | 256 | | (ii) Publishing any variations from codes and mutually exclusive codes by payors in a 27 |
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| 257 | 257 | | manner that makes for simple retrieval and implementation by providers; 28 |
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| 258 | 258 | | (iii) Use of Health Insurance Portability and Accountability Act standard group codes, 29 |
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| 259 | 259 | | reason codes, and remark codes by payors in electronic remittances sent to providers; 30 |
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| 260 | 260 | | (iv) Uniformity in the processing of claims by payors; and the processing of corrections to 31 |
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| 261 | 261 | | claims by providers and payors; 32 |
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| 262 | 262 | | (v) A standard payor-denial review process for providers when they request a 33 |
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| 263 | 263 | | reconsideration of a denial of a claim that results from differences in clinical edits where no single, 34 |
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| 264 | 264 | | |
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| 265 | 265 | | |
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| 266 | 266 | | LC000194 - Page 8 of 15 |
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| 267 | 267 | | common-standards body or process exists and multiple conflicting sources are in use by payors and 1 |
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| 268 | 268 | | providers. 2 |
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| 269 | 269 | | (vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual 3 |
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| 270 | 270 | | payor’s ability to employ, and not disclose to providers, temporary code edits for the purpose of 4 |
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| 271 | 271 | | detecting and deterring fraudulent billing activities. The guidelines shall require that each payor 5 |
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| 272 | 272 | | disclose to the provider its adjudication decision on a claim that was denied or adjusted based on 6 |
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| 273 | 273 | | the application of such edits and that the provider have access to the payor’s review and appeal 7 |
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| 274 | 274 | | process to challenge the payor’s adjudication decision. 8 |
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| 275 | 275 | | (vii) Nothing in this subsection shall be construed to modify the rights or obligations of 9 |
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| 276 | 276 | | payors or providers with respect to procedures relating to the investigation, reporting, appeal, or 10 |
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| 277 | 277 | | prosecution under applicable law of potentially fraudulent billing activities. 11 |
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| 278 | 278 | | (3) Developing and promoting widespread adoption by payors and providers of guidelines 12 |
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| 279 | 279 | | to: 13 |
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| 280 | 280 | | (i) Ensure payors do not automatically deny claims for services when extenuating 14 |
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| 281 | 281 | | circumstances make it impossible for the provider to obtain a preauthorization before services are 15 |
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| 282 | 282 | | performed or notify a payor within an appropriate standardized timeline of a patient’s admission; 16 |
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| 283 | 283 | | (ii) Require payors to use common and consistent processes and time frames when 17 |
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| 284 | 284 | | responding to provider requests for medical management approvals. Whenever possible, such time 18 |
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| 285 | 285 | | frames shall be consistent with those established by leading national organizations and be based 19 |
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| 286 | 286 | | upon the acuity of the patient’s need for care or treatment. For the purposes of this section, medical 20 |
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| 287 | 287 | | management includes prior authorization of services, preauthorization of services, precertification 21 |
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| 288 | 288 | | of services, post-service review, medical-necessity review, and benefits advisory; 22 |
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| 289 | 289 | | (iii) Develop, maintain, and promote widespread adoption of a single, common website 23 |
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| 290 | 290 | | where providers can obtain payors’ preauthorization, benefits advisory, and preadmission 24 |
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| 291 | 291 | | requirements; 25 |
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| 292 | 292 | | (iv) Establish guidelines for payors to develop and maintain a website that providers can 26 |
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| 293 | 293 | | use to request a preauthorization, including a prospective clinical necessity review; receive an 27 |
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| 294 | 294 | | authorization number; and transmit an admission notification; 28 |
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| 295 | 295 | | (v) Develop and implement the use of programs that implement selective prior 29 |
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| 296 | 296 | | authorization requirements, based on stratification of healthcare providers’ performance and 30 |
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| 297 | 297 | | adherence to evidence-based medicine with the input of contracted healthcare providers and/or 31 |
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| 298 | 298 | | provider organizations. Such criteria shall be transparent and easily accessible to contracted 32 |
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| 299 | 299 | | providers. Such selective prior authorization programs shall be available when healthcare providers 33 |
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| 300 | 300 | | participate directly with the insurer in risk-based payment contracts and may be available to 34 |
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| 301 | 301 | | |
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| 302 | 302 | | |
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| 303 | 303 | | LC000194 - Page 9 of 15 |
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| 304 | 304 | | providers who do not participate in risk-based contracts; 1 |
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| 305 | 305 | | (vi) Require the review of medical services, including behavioral health services, and 2 |
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| 306 | 306 | | prescription drugs, subject to prior authorization on at least an annual basis, with the input of 3 |
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| 307 | 307 | | contracted healthcare providers and/or provider organizations. Any changes to the list of medical 4 |
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| 308 | 308 | | services, including behavioral health services, and prescription drugs requiring prior authorization, 5 |
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| 309 | 309 | | shall be shared via provider-accessible websites; 6 |
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| 310 | 310 | | (vii) Improve communication channels between health plans, healthcare providers, and 7 |
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| 311 | 311 | | patients by: 8 |
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| 312 | 312 | | (A) Requiring transparency and easy accessibility of prior authorization requirements, 9 |
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| 313 | 313 | | criteria, rationale, and program changes to contracted healthcare providers and patients/health plan 10 |
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| 314 | 314 | | enrollees which may be satisfied by posting to provider-accessible and member-accessible 11 |
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| 315 | 315 | | websites; and 12 |
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| 316 | 316 | | (B) Supporting: 13 |
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| 317 | 317 | | (I) Timely submission by healthcare providers of the complete information necessary to 14 |
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| 318 | 318 | | make a prior authorization determination, as early in the process as possible; and 15 |
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| 319 | 319 | | (II) Timely notification of prior authorization determinations by health plans to impacted 16 |
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| 320 | 320 | | health plan enrollees, and healthcare providers, including, but not limited to, ordering providers, 17 |
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| 321 | 321 | | and/or rendering providers, and dispensing pharmacists which may be satisfied by posting to 18 |
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| 322 | 322 | | provider-accessible websites or similar electronic portals or services; 19 |
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| 323 | 323 | | (viii) Increase and strengthen continuity of patient care by: 20 |
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| 324 | 324 | | (A) Defining protections for continuity of care during a transition period for patients 21 |
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| 325 | 325 | | undergoing an active course of treatment, when there is a formulary or treatment coverage change 22 |
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| 326 | 326 | | or change of health plan that may disrupt their current course of treatment and when the treating 23 |
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| 327 | 327 | | physician determines that a transition may place the patient at risk; and for prescription medication 24 |
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| 328 | 328 | | by allowing a grace period of coverage to allow consideration of referred health plan options or 25 |
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| 329 | 329 | | establishment of medical necessity of the current course of treatment; 26 |
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| 330 | 330 | | (B) Requiring continuity of care for medical services, including behavioral health services, 27 |
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| 331 | 331 | | and prescription medications for patients on appropriate, chronic, stable therapy through 28 |
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| 332 | 332 | | minimizing repetitive prior authorization requirements; and which for prescription medication shall 29 |
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| 333 | 333 | | be allowed only on an annual review, with exception for labeled limitation, to establish continued 30 |
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| 334 | 334 | | benefit of treatment; and 31 |
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| 335 | 335 | | (C) Requiring communication between healthcare providers, health plans, and patients to 32 |
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| 336 | 336 | | facilitate continuity of care and minimize disruptions in needed treatment which may be satisfied 33 |
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| 337 | 337 | | by posting to provider-accessible websites or similar electronic portals or services; 34 |
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| 338 | 338 | | |
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| 339 | 339 | | |
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| 340 | 340 | | LC000194 - Page 10 of 15 |
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| 341 | 341 | | (D) Continuity of care for formulary or drug coverage shall distinguish between FDA 1 |
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| 342 | 342 | | designated interchangeable products and proprietary or marketed versions of a medication; 2 |
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| 343 | 343 | | (ix) Encourage healthcare providers and/or provider organizations and health plans to 3 |
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| 344 | 344 | | accelerate use of electronic prior authorization technology, including adoption of national standards 4 |
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| 345 | 345 | | where applicable; and 5 |
|---|
| 346 | 346 | | (x) For the purposes of subsections (h)(3)(v) through (h)(3)(x) of this section, the 6 |
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| 347 | 347 | | workgroup meeting may be conducted in part or whole through electronic methods. 7 |
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| 348 | 348 | | (4) To provide a report to the house and senate, on or before January 1, 2017, with 8 |
|---|
| 349 | 349 | | recommendations for establishing guidelines and regulations for systems that give patients 9 |
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| 350 | 350 | | electronic access to their claims information, particularly to information regarding their obligations 10 |
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| 351 | 351 | | to pay for received medical services, pursuant to 45 C.F.R. § 164.524. 11 |
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| 352 | 352 | | (5) No provision of this subsection (h) shall preclude the ongoing work of the office of 12 |
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| 353 | 353 | | health insurance commissioner’s administrative simplification task force, which includes meetings 13 |
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| 354 | 354 | | with key stakeholders in order to improve, and provide recommendations regarding, the prior 14 |
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| 355 | 355 | | authorization process. 15 |
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| 356 | 356 | | (i) To issue an anti-cancer medication report. Not later than June 30, 2014, and annually 16 |
|---|
| 357 | 357 | | thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate 17 |
|---|
| 358 | 358 | | committee on health and human services, and the house committee on corporations, with: (1) 18 |
|---|
| 359 | 359 | | Information on the availability in the commercial market of coverage for anti-cancer medication 19 |
|---|
| 360 | 360 | | options; (2) For the state employee’s health benefit plan, the costs of various cancer-treatment 20 |
|---|
| 361 | 361 | | options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member 21 |
|---|
| 362 | 362 | | utilization and cost-sharing expense. 22 |
|---|
| 363 | 363 | | (j) To monitor the adequacy of each health plan’s compliance with the provisions of the 23 |
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| 364 | 364 | | federal Mental Health Parity Act, including a review of related claims processing and 24 |
|---|
| 365 | 365 | | reimbursement procedures. Findings, recommendations, and assessments shall be made available 25 |
|---|
| 366 | 366 | | to the public. 26 |
|---|
| 367 | 367 | | (k) To monitor the transition from fee-for-service and toward global and other alternative 27 |
|---|
| 368 | 368 | | payment methodologies for the payment for healthcare services. Alternative payment 28 |
|---|
| 369 | 369 | | methodologies should be assessed for their likelihood to promote access to affordable health 29 |
|---|
| 370 | 370 | | insurance, health outcomes, and performance. 30 |
|---|
| 371 | 371 | | (l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital 31 |
|---|
| 372 | 372 | | payment variation, including findings and recommendations, subject to available resources. 32 |
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| 373 | 373 | | (m) Notwithstanding any provision of the general or public laws or regulation to the 33 |
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| 374 | 374 | | contrary, provide a report with findings and recommendations to the president of the senate and the 34 |
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| 375 | 375 | | |
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| 376 | 376 | | |
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| 377 | 377 | | LC000194 - Page 11 of 15 |
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| 378 | 378 | | speaker of the house, on or before April 1, 2014, including, but not limited to, the following 1 |
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| 379 | 379 | | information: 2 |
|---|
| 380 | 380 | | (1) The impact of the current, mandated healthcare benefits as defined in §§ 27-18-48.1, 3 |
|---|
| 381 | 381 | | 27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41 of title 27, and §§ 27-4 |
|---|
| 382 | 382 | | 18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health 5 |
|---|
| 383 | 383 | | insurance for fully insured employers, subject to available resources; 6 |
|---|
| 384 | 384 | | (2) Current provider and insurer mandates that are unnecessary and/or duplicative due to 7 |
|---|
| 385 | 385 | | the existing standards of care and/or delivery of services in the healthcare system; 8 |
|---|
| 386 | 386 | | (3) A state-by-state comparison of health insurance mandates and the extent to which 9 |
|---|
| 387 | 387 | | Rhode Island mandates exceed other states benefits; and 10 |
|---|
| 388 | 388 | | (4) Recommendations for amendments to existing mandated benefits based on the findings 11 |
|---|
| 389 | 389 | | in (m)(1), (m)(2), and (m)(3) above. 12 |
|---|
| 390 | 390 | | (n) On or before July 1, 2014, the office of the health insurance commissioner, in 13 |
|---|
| 391 | 391 | | collaboration with the director of health and lieutenant governor’s office, shall submit a report to 14 |
|---|
| 392 | 392 | | the general assembly and the governor to inform the design of accountable care organizations 15 |
|---|
| 393 | 393 | | (ACOs) in Rhode Island as unique structures for comprehensive healthcare delivery and value-16 |
|---|
| 394 | 394 | | based payment arrangements, that shall include, but not be limited to: 17 |
|---|
| 395 | 395 | | (1) Utilization review; 18 |
|---|
| 396 | 396 | | (2) Contracting; and 19 |
|---|
| 397 | 397 | | (3) Licensing and regulation. 20 |
|---|
| 398 | 398 | | (o) On or before February 3, 2015, the office of the health insurance commissioner shall 21 |
|---|
| 399 | 399 | | submit a report to the general assembly and the governor that describes, analyzes, and proposes 22 |
|---|
| 400 | 400 | | recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard 23 |
|---|
| 401 | 401 | | to patients with mental health and substance use disorders. 24 |
|---|
| 402 | 402 | | (p) To work to ensure the health insurance coverage of behavioral health care under the 25 |
|---|
| 403 | 403 | | same terms and conditions as other health care, and to integrate behavioral health parity 26 |
|---|
| 404 | 404 | | requirements into the office of the health insurance commissioner insurance oversight and 27 |
|---|
| 405 | 405 | | healthcare transformation efforts. 28 |
|---|
| 406 | 406 | | (q) To work with other state agencies to seek delivery system improvements that enhance 29 |
|---|
| 407 | 407 | | access to a continuum of mental health and substance use disorder treatment in the state; and 30 |
|---|
| 408 | 408 | | integrate that treatment with primary and other medical care to the fullest extent possible. 31 |
|---|
| 409 | 409 | | (r) To direct insurers toward policies and practices that address the behavioral health needs 32 |
|---|
| 410 | 410 | | of the public and greater integration of physical and behavioral healthcare delivery. 33 |
|---|
| 411 | 411 | | (s) The office of the health insurance commissioner shall conduct an analysis of the impact 34 |
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| 412 | 412 | | |
|---|
| 413 | 413 | | |
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| 414 | 414 | | LC000194 - Page 12 of 15 |
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| 415 | 415 | | of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and 1 |
|---|
| 416 | 416 | | submit a report of its findings to the general assembly on or before June 1, 2023. 2 |
|---|
| 417 | 417 | | (t) To undertake the analyses, reports, and studies contained in this section: 3 |
|---|
| 418 | 418 | | (1) The office shall hire the necessary staff and prepare a request for proposal for a qualified 4 |
|---|
| 419 | 419 | | and competent firm or firms to undertake the following analyses, reports, and studies: 5 |
|---|
| 420 | 420 | | (i) The firm shall undertake a comprehensive review of all social and human service 6 |
|---|
| 421 | 421 | | programs having a contract with or licensed by the state or any subdivision of the department of 7 |
|---|
| 422 | 422 | | children, youth and families (DCYF), the department of behavioral healthcare, developmental 8 |
|---|
| 423 | 423 | | disabilities and hospitals (BHDDH), the department of human services (DHS), the department of 9 |
|---|
| 424 | 424 | | health (DOH), and Medicaid for the purposes of: 10 |
|---|
| 425 | 425 | | (A) Establishing a baseline of the eligibility factors for receiving services; 11 |
|---|
| 426 | 426 | | (B) Establishing a baseline of the service offering through each agency for those 12 |
|---|
| 427 | 427 | | determined eligible; 13 |
|---|
| 428 | 428 | | (C) Establishing a baseline understanding of reimbursement rates for all social and human 14 |
|---|
| 429 | 429 | | service programs including rates currently being paid, the date of the last increase, and a proposed 15 |
|---|
| 430 | 430 | | model that the state may use to conduct future studies and analyses; 16 |
|---|
| 431 | 431 | | (D) Ensuring accurate and adequate reimbursement to social and human service providers 17 |
|---|
| 432 | 432 | | that facilitate the availability of high-quality services to individuals receiving home and 18 |
|---|
| 433 | 433 | | community-based long-term services and supports provided by social and human service providers; 19 |
|---|
| 434 | 434 | | (E) Ensuring the general assembly is provided accurate financial projections on social and 20 |
|---|
| 435 | 435 | | human service program costs, demand for services, and workforce needs to ensure access to entitled 21 |
|---|
| 436 | 436 | | beneficiaries and services; 22 |
|---|
| 437 | 437 | | (F) Establishing a baseline and determining the relationship between state government and 23 |
|---|
| 438 | 438 | | the provider network including functions, responsibilities, and duties; 24 |
|---|
| 439 | 439 | | (G) Determining a set of measures and accountability standards to be used by EOHHS and 25 |
|---|
| 440 | 440 | | the general assembly to measure the outcomes of the provision of services including budgetary 26 |
|---|
| 441 | 441 | | reporting requirements, transparency portals, and other methods; and 27 |
|---|
| 442 | 442 | | (H) Reporting the findings of human services analyses and reports to the speaker of the 28 |
|---|
| 443 | 443 | | house, senate president, chairs of the house and senate finance committees, chairs of the house and 29 |
|---|
| 444 | 444 | | senate health and human services committees, and the governor. 30 |
|---|
| 445 | 445 | | (2) The analyses, reports, and studies required pursuant to this section shall be 31 |
|---|
| 446 | 446 | | accomplished and published as follows and shall provide: 32 |
|---|
| 447 | 447 | | (i) An assessment and detailed reporting on all social and human service program rates to 33 |
|---|
| 448 | 448 | | be completed by January 1, 2023, including rates currently being paid and the date of the last 34 |
|---|
| 449 | 449 | | |
|---|
| 450 | 450 | | |
|---|
| 451 | 451 | | LC000194 - Page 13 of 15 |
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| 452 | 452 | | increase; 1 |
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| 453 | 453 | | (ii) An assessment and detailed reporting on eligibility standards and processes of all 2 |
|---|
| 454 | 454 | | mandatory and discretionary social and human service programs to be completed by January 1, 3 |
|---|
| 455 | 455 | | 2023; 4 |
|---|
| 456 | 456 | | (iii) An assessment and detailed reporting on utilization trends from the period of January 5 |
|---|
| 457 | 457 | | 1, 2017, through December 31, 2021, for social and human service programs to be completed by 6 |
|---|
| 458 | 458 | | January 1, 2023; 7 |
|---|
| 459 | 459 | | (iv) An assessment and detailed reporting on the structure of the state government as it 8 |
|---|
| 460 | 460 | | relates to the provision of services by social and human service providers including eligibility and 9 |
|---|
| 461 | 461 | | functions of the provider network to be completed by January 1, 2023; 10 |
|---|
| 462 | 462 | | (v) An assessment and detailed reporting on accountability standards for services for social 11 |
|---|
| 463 | 463 | | and human service programs to be completed by January 1, 2023; 12 |
|---|
| 464 | 464 | | (vi) An assessment and detailed reporting by April 1, 2023, on all professional licensed 13 |
|---|
| 465 | 465 | | and unlicensed personnel requirements for established rates for social and human service programs 14 |
|---|
| 466 | 466 | | pursuant to a contract or established fee schedule; 15 |
|---|
| 467 | 467 | | (vii) An assessment and reporting on access to social and human service programs, to 16 |
|---|
| 468 | 468 | | include any wait lists and length of time on wait lists, in each service category by April 1, 2023; 17 |
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| 469 | 469 | | (viii) An assessment and reporting of national and regional Medicaid rates in comparison 18 |
|---|
| 470 | 470 | | to Rhode Island social and human service provider rates by April 1, 2023; 19 |
|---|
| 471 | 471 | | (ix) An assessment and reporting on usual and customary rates paid by private insurers and 20 |
|---|
| 472 | 472 | | private pay for similar social and human service providers, both nationally and regionally, by April 21 |
|---|
| 473 | 473 | | 1, 2023; and 22 |
|---|
| 474 | 474 | | (x) Completion of the development of an assessment and review process that includes the 23 |
|---|
| 475 | 475 | | following components: eligibility; scope of services; relationship of social and human service 24 |
|---|
| 476 | 476 | | provider and the state; national and regional rate comparisons and accountability standards that 25 |
|---|
| 477 | 477 | | result in recommended rate adjustments; and this process shall be completed by September 1, 2023, 26 |
|---|
| 478 | 478 | | and conducted biennially hereafter. The biennial rate setting shall be consistent with payment 27 |
|---|
| 479 | 479 | | requirements established in § 1902(a)(30)(A) of the Social Security Act, 42 U.S.C. § 28 |
|---|
| 480 | 480 | | 1396a(a)(30)(A), and all federal and state law, regulations, and quality and safety standards. The 29 |
|---|
| 481 | 481 | | results and findings of this process shall be transparent, and public meetings shall be conducted to 30 |
|---|
| 482 | 482 | | allow providers, recipients, and other interested parties an opportunity to ask questions and provide 31 |
|---|
| 483 | 483 | | comment beginning in September 2023 and biennially thereafter. 32 |
|---|
| 484 | 484 | | (3) In fulfillment of the responsibilities defined in subsection (t), the office of the health 33 |
|---|
| 485 | 485 | | insurance commissioner shall consult with the Executive Office of Health and Human Services. 34 |
|---|
| 486 | 486 | | |
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| 487 | 487 | | |
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| 488 | 488 | | LC000194 - Page 14 of 15 |
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| 489 | 489 | | (u) Annually, each department (namely, EOHHS, DCYF, DOH, DHS, and BHDDH) shall 1 |
|---|
| 490 | 490 | | include the corresponding components of the assessment and review (i.e., eligibility; scope of 2 |
|---|
| 491 | 491 | | services; relationship of social and human service provider and the state; and national and regional 3 |
|---|
| 492 | 492 | | rate comparisons and accountability standards including any changes or substantive issues between 4 |
|---|
| 493 | 493 | | biennial reviews) including the recommended rates from the most recent assessment and review 5 |
|---|
| 494 | 494 | | with their annual budget submission to the office of management and budget and provide a detailed 6 |
|---|
| 495 | 495 | | explanation and impact statement if any rate variances exist between submitted recommended 7 |
|---|
| 496 | 496 | | budget and the corresponding recommended rate from the most recent assessment and review 8 |
|---|
| 497 | 497 | | process starting October 1, 2023, and biennially thereafter. 9 |
|---|
| 498 | 498 | | (v) The general assembly shall appropriate adequate funding as it deems necessary to 10 |
|---|
| 499 | 499 | | undertake the analyses, reports, and studies contained in this section relating to the powers and 11 |
|---|
| 500 | 500 | | duties of the office of the health insurance commissioner. 12 |
|---|
| 501 | 501 | | (w) The office of health insurance commissioner shall have oversight and enforcement 13 |
|---|
| 502 | 502 | | authority over the requirements of this chapter, including the power to require disclosure of 14 |
|---|
| 503 | 503 | | information and documents, to clarify or simplify appeals procedures, and to limit step therapy 15 |
|---|
| 504 | 504 | | protocol use, to ensure delivery of medically necessary care, and to impose fines or other penalties 16 |
|---|
| 505 | 505 | | for noncompliance. 17 |
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| 506 | 506 | | SECTION 3. This act shall take effect upon passage. 18 |
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| 507 | 507 | | ======== |
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| 508 | 508 | | LC000194 |
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| 509 | 509 | | ======== |
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| 510 | 510 | | |
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| 511 | 511 | | |
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| 512 | 512 | | LC000194 - Page 15 of 15 |
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| 513 | 513 | | EXPLANATION |
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| 514 | 514 | | BY THE LEGISLATIVE COUNCIL |
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| 515 | 515 | | OF |
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| 516 | 516 | | A N A C T |
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| 517 | 517 | | RELATING TO INSURANCE -- BENEFIT DETERMINATION AND UTILIZATION |
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| 518 | 518 | | REVIEW ACT |
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| 519 | 519 | | *** |
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| 520 | 520 | | This act would limit the use by insurers of step therapy utilization management, a protocol 1 |
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| 521 | 521 | | or program that establishes a specific sequence in which prescription drugs for a specified medical 2 |
|---|
| 522 | 522 | | condition are covered by an insurer by allowing medical providers to request step therapy 3 |
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| 523 | 523 | | exceptions. 4 |
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| 524 | 524 | | This act would take effect upon passage. 5 |
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| 525 | 525 | | ======== |
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| 526 | 526 | | LC000194 |
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| 527 | 527 | | ======== |
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| 528 | 528 | | |
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