2025 -- S 0485
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LC001680
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S T A T E O F R H O D E I S L A N D
IN GENERAL ASSEMBLY
JANUARY SESSION, A.D. 2025
____________
A N A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES --
REGULATE HEALTH INSU RANCE PRIOR AUTHORIZATION REQUIREMENTS FOR
REHABILITATIVE AND HABILITATIVE SERVICES ACT
Introduced By: Senators Mack, Lauria, Acosta, Valverde, Thompson, Kallman, DiMario,
Pearson, and Ujifusa
Date Introduced: February 26, 2025
Referred To: Senate Health & Human Services
It is enacted by the General Assembly as follows:
SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness Insurance 1
Policies" is hereby amended by adding thereto the following section: 2
27-18-95. Prior authorization for rehabilitative and habilitative services. 3
(a) An individual or group health insurance plan shall not require prior authorization for 4
rehabilitative or habilitative services, including, but not limited to, physical therapy or occupational 5
therapy services for the first twelve (12) visits of each new episode of care. For purposes of this 6
section, "new episode of care" means treatment for a new or recurring condition for which an 7
insured has not been treated by the provider within the previous ninety (90) days. After the twelve 8
(12) visits of each new episode of care, an individual or group health insurance plan shall not require 9
prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever 10
time period is longer. 11
(b) An individual or group health insurance plan shall not require prior authorization for 12
physical medicine or rehabilitation services provided to patients with chronic pain for the first 13
ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic 14
management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an 15
individual or group health insurance plan shall not require prior authorization more frequently than 16
every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this 17
subsection, "chronic pain" means pain that persists or recurs for more than three (3) months. 18
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(c) An individual or group health insurance plan shall respond to a prior authorization 1
request for services or visits in an ongoing plan of care under this section within twenty-four (24) 2
hours. If an individual or group health insurance plan requires more information to make a decision 3
on the prior authorization request, the individual or group health insurance plan shall notify the 4
patient and the provider within twenty-four (24) hours of the initial request with the information 5
that is needed to complete the prior authorization request including, but not limited to, the specific 6
tests and measures needed from the patient and provider. An individual or group health insurance 7
plan shall make a decision on the prior authorization request within twenty-four (24) hours of 8
receiving the requested information. 9
(d) With regard to circumstances in which a prior authorization for covered services under 10
this section is deemed to be approved by an individual or group health insurance plan, a prior 11
authorization is deemed to be approved if an individual or group health insurance plan: 12
(1) Fails to timely answer a prior authorization request in accordance with subsection (c) 13
of this section, including due to a failure of the individual or group health insurance plan’s prior 14
authorization platform or process; or 15
(2) Informs a provider that prior authorization is not required orally, via an online platform 16
or program, through the patient's health plan documents or by any other means. 17
(e) An individual or group health insurance plan shall provide a procedure for providers 18
and insureds to obtain retroactive authorization for services under this section that are medically 19
necessary covered benefits. An individual or group health insurance plan shall not deny coverage 20
for medically necessary services under this section only for failure to obtain a prior authorization, 21
if a medical necessity determination can be made after the services have been provided and the 22
services would have been covered benefits if prior authorization had been obtained. 23
(f) An individual or group health insurance plan’s failure to approve a prior authorization 24
for all services or visits in a plan of care under this section is subject to the same appeal rights as a 25
denial under the office of the health insurance commissioner's rule or regulation regarding health 26
plan accountability and the provider's network agreement with the carrier, if any. 27
(g) Nothing in this section is intended to prohibit an individual or group health insurance 28
plan from performing a retrospective medical necessity review. 29
SECTION 2. Chapter 27-19 of the General Laws entitled " Nonprofit Hospital Service 30
Corporations " is hereby amended by adding thereto the following section: 31
27-19-87. Prior authorization for rehabilitative and habilitative services. 32
(a) An individual or group health insurance plan shall not require prior authorization for 33
rehabilitative or habilitative services, including, but not limited to, physical therapy or occupational 34
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therapy services for the first twelve (12) visits of each new episode of care. For purposes of this 1
section, "new episode of care" means treatment for a new or recurring condition for which an 2
insured has not been treated by the provider within the previous ninety (90) days. After the twelve 3
(12) visits of each new episode of care, an individual or group health insurance plan shall not require 4
prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever 5
time period is longer. 6
(b) An individual or group health insurance plan shall not require prior authorization for 7
physical medicine or rehabilitation services provided to patients with chronic pain for the first 8
ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic 9
management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an 10
individual or group health insurance plan shall not require prior authorization more frequently than 11
every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this 12
subsection, "chronic pain" means pain that persists or recurs for more than three (3) months. 13
(c) An individual or group health insurance plan shall respond to a prior authorization 14
request for services or visits in an ongoing plan of care under this section within twenty-four (24) 15
hours. If an individual or group health insurance plan requires more information to make a decision 16
on the prior authorization request, the individual or group health insurance plan shall notify the 17
patient and the provider within twenty-four (24) hours of the initial request with the information 18
that is needed to complete the prior authorization request including, but not limited to, the specific 19
tests and measures needed from the patient and provider. An individual or group health insurance 20
plan shall make a decision on the prior authorization request within twenty-four (24) hours of 21
receiving the requested information. 22
(d) With regard to circumstances in which a prior authorization for covered services under 23
this section is deemed to be approved by an individual or group health insurance plan, a prior 24
authorization is deemed to be approved if an individual or group health insurance plan: 25
(1) Fails to timely answer a prior authorization request in accordance with subsection (c) 26
of this section, including due to a failure of the individual or group health insurance plan’s prior 27
authorization platform or process; or 28
(2) Informs a provider that prior authorization is not required orally, via an online platform 29
or program, through the patient's health plan documents or by any other means. 30
(e) An individual or group health insurance plan shall provide a procedure for providers 31
and insureds to obtain retroactive authorization for services under this section that are medically 32
necessary covered benefits. An individual or group health insurance plan shall not deny coverage 33
for medically necessary services under this section only for failure to obtain a prior authorization, 34
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if a medical necessity determination can be made after the services have been provided and the 1
services would have been covered benefits if prior authorization had been obtained. 2
(f) An individual or group health insurance plan’s failure to approve a prior authorization 3
for all services or visits in a plan of care under this section is subject to the same appeal rights as a 4
denial under the office of the health insurance commissioner's rule or regulation regarding health 5
plan accountability and the provider's network agreement with the carrier, if any. 6
(g) Nothing in this section is intended to prohibit an individual or group health insurance 7
plan from performing a retrospective medical necessity review. 8
SECTION 3. Chapter 27-20 of the General Laws entitled " Nonprofit Medical Service 9
Corporations " is hereby amended by adding thereto the following section: 10
27-20-83. Prior authorization for rehabilitative and habilitative services. 11
(a) An individual or group health insurance plan shall not require prior authorization for 12
rehabilitative or habilitative services, including, but not limited to, physical therapy or occupational 13
therapy services for the first twelve (12) visits of each new episode of care. For purposes of this 14
section, "new episode of care" means treatment for a new or recurring condition for which an 15
insured has not been treated by the provider within the previous ninety (90) days. After the twelve 16
(12) visits of each new episode of care, an individual or group health insurance plan shall not require 17
prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever 18
time period is longer. 19
(b) An individual or group health insurance plan shall not require prior authorization for 20
physical medicine or rehabilitation services provided to patients with chronic pain for the first 21
ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic 22
management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an 23
individual or group health insurance plan shall not require prior authorization more frequently than 24
every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this 25
subsection, "chronic pain" means pain that persists or recurs for more than three (3) months. 26
(c) An individual or group health insurance plan shall respond to a prior authorization 27
request for services or visits in an ongoing plan of care under this section within twenty-four (24) 28
hours. If an individual or group health insurance plan requires more information to make a decision 29
on the prior authorization request, the individual or group health insurance plan shall notify the 30
patient and the provider within twenty-four (24) hours of the initial request with the information 31
that is needed to complete the prior authorization request including, but not limited to, the specific 32
tests and measures needed from the patient and provider. An individual or group health insurance 33
plan shall make a decision on the prior authorization request within twenty-four (24) hours of 34
LC001680 - Page 5 of 8
receiving the requested information. 1
(d) With regard to circumstances in which a prior authorization for covered services under 2
this section is deemed to be approved by an individual or group health insurance plan, a prior 3
authorization is deemed to be approved if an individual or group health insurance plan: 4
(1) Fails to timely answer a prior authorization request in accordance with subsection (c) 5
of this section, including due to a failure of the individual or group health insurance plan’s prior 6
authorization platform or process; or 7
(2) Informs a provider that prior authorization is not required orally, via an online platform 8
or program, through the patient's health plan documents or by any other means. 9
(e) An individual or group health insurance plan shall provide a procedure for providers 10
and insureds to obtain retroactive authorization for services under this section that are medically 11
necessary covered benefits. An individual or group health insurance plan shall not deny coverage 12
for medically necessary services under this section only for failure to obtain a prior authorization, 13
if a medical necessity determination can be made after the services have been provided and the 14
services would have been covered benefits if prior authorization had been obtained. 15
(f) An individual or group health insurance plan’s failure to approve a prior authorization 16
for all services or visits in a plan of care under this section is subject to the same appeal rights as a 17
denial under the office of the health insurance commissioner's rule or regulation regarding health 18
plan accountability and the provider's network agreement with the carrier, if any. 19
(g) Nothing in this section is intended to prohibit an individual or group health insurance 20
plan from performing a retrospective medical necessity review. 21
SECTION 4. Chapter 27-41 of the General Laws entitled " Health Maintenance 22
Organizations " is hereby amended by adding thereto the following section: 23
27-41-100. Prior authorization for rehabilitative and habilitative services. 24
(a) An individual or group health insurance plan shall not require prior authorization for 25
rehabilitative or habilitative services, including, but not limited to, physical therapy or occupational 26
therapy services for the first twelve (12) visits of each new episode of care. For purposes of this 27
section, "new episode of care" means treatment for a new or recurring condition for which an 28
insured has not been treated by the provider within the previous ninety (90) days. After the twelve 29
(12) visits of each new episode of care, an individual or group health insurance plan shall not require 30
prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever 31
time period is longer. 32
(b) An individual or group health insurance plan shall not require prior authorization for 33
physical medicine or rehabilitation services provided to patients with chronic pain for the first 34
LC001680 - Page 6 of 8
ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic 1
management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an 2
individual or group health insurance plan shall not require prior authorization more frequently than 3
every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this 4
subsection, "chronic pain" means pain that persists or recurs for more than three (3) months. 5
(c) An individual or group health insurance plan shall respond to a prior authorization 6
request for services or visits in an ongoing plan of care under this section within twenty-four (24) 7
hours. If an individual or group health insurance plan requires more information to make a decision 8
on the prior authorization request, the individual or group health insurance plan shall notify the 9
patient and the provider within twenty-four (24) hours of the initial request with the information 10
that is needed to complete the prior authorization request including, but not limited to, the specific 11
tests and measures needed from the patient and provider. An individual or group health insurance 12
plan shall make a decision on the prior authorization request within twenty-four (24) hours of 13
receiving the requested information. 14
(d) With regard to circumstances in which a prior authorization for covered services under 15
this section is deemed to be approved by an individual or group health insurance plan, a prior 16
authorization is deemed to be approved if an individual or group health insurance plan: 17
(1) Fails to timely answer a prior authorization request in accordance with subsection (c) 18
of this section, including due to a failure of the individual or group health insurance plan’s prior 19
authorization platform or process; or 20
(2) Informs a provider that prior authorization is not required orally, via an online platform 21
or program, through the patient's health plan documents or by any other means. 22
(e) An individual or group health insurance plan shall provide a procedure for providers 23
and insureds to obtain retroactive authorization for services under this section that are medically 24
necessary covered benefits. An individual or group health insurance plan shall not deny coverage 25
for medically necessary services under this section only for failure to obtain a prior authorization, 26
if a medical necessity determination can be made after the services have been provided and the 27
services would have been covered benefits if prior authorization had been obtained. 28
(f) An individual or group health insurance plan’s failure to approve a prior authorization 29
for all services or visits in a plan of care under this section is subject to the same appeal rights as a 30
denial under the office of the health insurance commissioner's rule or regulation regarding health 31
plan accountability and the provider's network agreement with the carrier, if any. 32
(g) Nothing in this section is intended to prohibit an individual or group health insurance 33
plan from performing a retrospective medical necessity review. 34
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SECTION 2. This act shall take effect on January 1, 2026. 1
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LC001680
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EXPLANATION
BY THE LEGISLATIVE COUNCIL
OF
A N A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES --
REGULATE HEALTH INSU RANCE PRIOR AUTHORIZATION REQUIREMENTS FOR
REHABILITATIVE AND HABILITATIVE SERVICES ACT
***
This act would limit prior authorization requirements for rehabilitative and habilitative 1
services. This act would prohibit prior authorization for the first twelve (12) visits of a new episode 2
of care and for ninety (90) days following a chronic pain diagnosis. This act would also require that 3
insurers must respond to requests within twenty-four (24) hours, and delays result in automatic 4
approval. This act would further allow retroactive authorization for medically necessary services 5
and provides appeal rights for denied requests. 6
This act would take effect on January 1, 2026. 7
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LC001680
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