Limits prior authorization requirements for rehabilitative and habilitative services. Also prohibits prior authorization for the first twelve (12) visits of a new episode of care and for ninety (90) days following a chronic pain diagnosis.
Impact
In addition, the bill allows patients with chronic pain to avoid prior authorization for the first ninety days post-diagnosis, thereby facilitating timely access to necessary nonpharmacologic management. This change aims to ease the burden often placed on patients receiving rehabilitation services by streamlining the process for obtaining care, with a focus on enhancing patient experience and outcomes. Moreover, if a health insurance plan fails to respond to prior authorization requests in a timely manner, the requests may be automatically approved.
Summary
Bill S0485, Introduced in the Rhode Island General Assembly, aims to modify the current health insurance policies regarding prior authorization requirements for rehabilitative and habilitative services. The legislation stipulates that individual or group health insurance plans will not require prior authorization for rehabilitative or habilitative services for the first twelve visits of a new episode of care. A 'new episode of care' is defined as treatment for a new or recurring condition for which the patient has not received care within the last ninety days.
Contention
While supporters of S0485 argue that these amendments will improve access to vital therapies for patients, particularly those dealing with chronic pain, there may be concerns regarding insurers' financial implications. Critics may express apprehensions that reducing prior authorization oversight could lead to increased costs or potential overuse of services. Moreover, the balance between ensuring necessary care and managing healthcare costs consistently raises debates within legislative discussions regarding health policy reforms.
Prohibits prior authorization or a step therapy protocol for the prescription of a nonpreferred medication on their drug formulary used to assess or treat an enrollee's bipolar disorder, schizophrenia or schizotypal.
Requires insurance coverage for at a minimum up to ninety (90) days of residential or inpatient services for mental health and/or substance use disorders for American Society of Addiction Medicine levels of care 3.1 and 3.3.
Requires insurance coverage for at a minimum up to ninety (90) days of residential or inpatient services for mental health and/or substance use disorders for American Society of Addiction Medicine levels of care 3.1 and 3.3.
Eliminates prior authorization or step therapy requirement for prescriptions for any HIV prevention drug/prohibits the requirement of any copayment or the meeting of any deductible to obtain the prescription covered by the contract, plan, or policy.
Eliminates prior authorization or step therapy requirement for prescriptions for any HIV prevention drug/prohibits the requirement of any copayment or the meeting of any deductible to obtain the prescription covered by the contract, plan, or policy.
Defines step therapy and prohibits certain groups and agreements from requiring prior authorization or a step therapy protocol when prescribing certain medications.
Requires coverage for residential/inpatient mental health services for detox/stabilization/substance abuse disorders without preauthorization or be subject to concurrent review during the first 28 days.
Prohibits health insurance plans from requiring prior authorization for a new episode of rehabilitative care for twelve visits, or from requiring prior authorization for rehabilitative care for chronic pain for ninety days.