Rhode Island 2025 Regular Session

Rhode Island Senate Bill S0684 Compare Versions

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

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5	5	2025 -- S 0684
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7	7	LC000609
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9	9	S T A T E O F R H O D E I S L A N D
10	10	IN GENERAL ASSEMBLY
11	11	JANUARY SESSION, A.D. 2025
12	12	____________
13	13
14	14	A N A C T
15	15	RELATING TO INSURANCE -- INDIVIDUAL HEALTH INSURANCE COV ERAGE--PRIOR
16	16	AUTHORIZATIONS
17	17	Introduced By: Senators Valverde, Ujifusa, Lauria, Murray, Thompson, Kallman, and
18	18	Appollonio
19	19	Date Introduced: March 07, 2025
20	20	Referred To: Senate Health & Human Services
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23	23	It is enacted by the General Assembly as follows:
24	24	SECTION 1. Section 27-18.5-2 of the General Laws in Chapter 27-18.5 entitled 1
25	25	"Individual Health Insurance Coverage" is hereby amended to read as follows: 2
26	26	27-18.5-2. Definitions. 3
27	27	The following words and phrases as used in this chapter have the following meanings 4
28	28	unless a different meaning is required by the context: 5
29	29	(1) “Bona fide association” means, with respect to health insurance coverage offered in 6
30	30	this state, an association that: 7
31	31	(i) Has been actively in existence for at least five (5) years; 8
32	32	(ii) Has been formed and maintained in good faith for purposes other than obtaining 9
33	33	insurance; 10
34	34	(iii) Does not condition membership in the association on any health status-related factor 11
35	35	relating to an individual (including an employee of an employer or a dependent of an employee); 12
36	36	(iv) Makes health insurance coverage offered through the association available to all 13
37	37	members regardless of any health status-related factor relating to the members (or individuals 14
38	38	eligible for coverage through a member); 15
39	39	(v) Does not make health insurance coverage offered through the association available 16
40	40	other than in connection with a member of the association; 17
41	41	(vi) Is composed of persons having a common interest or calling; 18
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45	45	(vii) Has a constitution and bylaws; and 1
46	46	(viii) Meets any additional requirements that the director may prescribe by regulation; 2
47	47	(2) “COBRA continuation provision” means any of the following: 3
48	48	(i) Section 4980(B) of the Internal Revenue Code of 1986, 26 U.S.C. § 4980B, other than 4
49	49	subsection (f)(1) of that section insofar as it relates to pediatric vaccines; 5
50	50	(ii) Part 6 of subtitle B of Title I of the Employee Retirement Income Security Act of 1974, 6
51	51	29 U.S.C. § 1161 et seq., other than Section 609 of that act, 29 U.S.C. § 1169; or 7
52	52	(iii) Title XXII of the United States Public Health Service Act, 42 U.S.C. § 300bb-1 et seq.; 8
53	53	(3) “Commissioner” means the health insurance commissioner; 9
54	54	(4) “Creditable coverage” has the same meaning as defined in the United States Public 10
55	55	Health Service Act, Section 2701(c), 42 U.S.C. § 300gg(c), as added by P.L. 104-191; 11
56	56	(5) “Director” means the director of the department of business regulation; 12
57	57	(6) “Eligible individual” means an individual: 13
58	58	(i) For whom, as of the date on which the individual seeks coverage under this chapter, the 14
59	59	aggregate of the periods of creditable coverage is eighteen (18) or more months and whose most 15
60	60	recent prior creditable coverage was under a group health plan, a governmental plan established or 16
61	61	maintained for its employees by the government of the United States or by any of its agencies or 17
62	62	instrumentalities, or church plan (as defined by the Employee Retirement Income Security Act of 18
63	63	1974, 29 U.S.C. § 1001 et seq.); 19
64	64	(ii) Who is not eligible for coverage under a group health plan, part A or part B of title 20
65	65	XVIII of the Social Security Act, 42 U.S.C. § 1395c et seq. or 42 U.S.C. § 1395j et seq., or any 21
66	66	state plan under title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (or any successor 22
67	67	program), and does not have other health insurance coverage; 23
68	68	(iii) With respect to whom the most recent coverage within the coverage period was not 24
69	69	terminated based on a factor described in § 27-18.5-4(b) (relating to nonpayment of premiums or 25
70	70	fraud); 26
71	71	(iv) If the individual had been offered the option of continuation coverage under a COBRA 27
72	72	continuation provision, or under chapter 19.1 of this title or under a similar state program of this 28
73	73	state or any other state, who elected the coverage; and 29
74	74	(v) Who, if the individual elected COBRA continuation coverage, has exhausted the 30
75	75	continuation coverage under the provision or program; 31
76	76	(7) “Generic” means the chemical or established name of a drug or drug product; 32
77	77	(7)(8) “Group health plan” means an employee welfare benefit plan as defined in section 33
78	78	3(1) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1002(1), to the extent 34
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82	82	that the plan provides medical care and including items and services paid for as medical care to 1
83	83	employees or their dependents as defined under the terms of the plan directly or through insurance, 2
84	84	reimbursement or otherwise; 3
85	85	(8)(9) “Health insurance carrier” or “carrier” means any entity subject to the insurance laws 4
86	86	and regulations of this state, or subject to the jurisdiction of the director, that contracts or offers to 5
87	87	contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare 6
88	88	services, including, without limitation, an insurance company offering accident and sickness 7
89	89	insurance, a health maintenance organization, a nonprofit hospital, medical or dental service 8
90	90	corporation, or any other entity providing a plan of health insurance or health benefits by which 9
91	91	healthcare services are paid or financed for an eligible individual or his or her dependents by such 10
92	92	entity on the basis of a periodic premium, paid directly or through an association, trust, or other 11
93	93	intermediary, and issued, renewed, or delivered within or without Rhode Island to cover a natural 12
94	94	person who is a resident of this state, including a certificate issued to a natural person that evidences 13
95	95	coverage under a policy or contract issued to a trust or association; 14
96	96	(9)(10)(i) “Health insurance coverage” means a policy, contract, certificate, or agreement 15
97	97	offered by a health insurance carrier to provide, deliver, arrange for, pay for, or reimburse any of 16
98	98	the costs of healthcare services. Health insurance coverage includes short-term limited-duration 17
99	99	policies and any policy that pays on a cost-incurred basis, except as otherwise specifically exempted 18
100	100	by subsection (9)(ii), (iii), (iv), or (v) of this section. 19
101	101	(ii) “Health insurance coverage” does not include one or more, or any combination of, the 20
102	102	following: 21
103	103	(A) Coverage only for accident, or disability income insurance, or any combination of 22
104	104	those; 23
105	105	(B) Coverage issued as a supplement to liability insurance; 24
106	106	(C) Liability insurance, including general liability insurance and automobile liability 25
107	107	insurance; 26
108	108	(D) Workers’ compensation or similar insurance; 27
109	109	(E) Automobile medical payment insurance; 28
110	110	(F) Credit-only insurance; 29
111	111	(G) Coverage for on-site medical clinics; and 30
112	112	(H) Other similar insurance coverage, specified in federal regulations issued pursuant to 31
113	113	P.L. 104-191, under which benefits for medical care are secondary or incidental to other insurance 32
114	114	benefits; 33
115	115	(I) [Deleted by P.L. 2019, ch. 88, art. 11, § 1]; 34
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119	119	(iii) “Health insurance coverage” does not include the following benefits if they are 1
120	120	provided under a separate policy, certificate, or contract of insurance or are not an integral part of 2
121	121	the coverage: 3
122	122	(A) Limited scope dental or vision benefits; 4
123	123	(B) Benefits for long-term care, nursing home care, home health care, community-based 5
124	124	care, or any combination of these; 6
125	125	(C) Any other similar, limited benefits that are specified in federal regulation issued 7
126	126	pursuant to P.L. 104-191; 8
127	127	(iv) “Health insurance coverage” does not include the following benefits if the benefits are 9
128	128	provided under a separate policy, certificate, or contract of insurance, there is no coordination 10
129	129	between the provision of the benefits and any exclusion of benefits under any group health plan 11
130	130	maintained by the same plan sponsor, and the benefits are paid with respect to an event without 12
131	131	regard to whether benefits are provided with respect to the event under any group health plan 13
132	132	maintained by the same plan sponsor: 14
133	133	(A) Coverage only for a specified disease or illness; or 15
134	134	(B) Hospital indemnity or other fixed indemnity insurance; and 16
135	135	(v) “Health insurance coverage” does not include the following if it is offered as a separate 17
136	136	policy, certificate, or contract of insurance: 18
137	137	(A) Medicare supplemental health insurance as defined under section 1882(g)(1) of the 19
138	138	Social Security Act, 42 U.S.C. § 1395ss(g)(1); 20
139	139	(B) Coverage supplemental to the coverage provided under 10 U.S.C. § 1071 et seq.; and 21
140	140	(C) Similar supplemental coverage provided to coverage under a group health plan; 22
141	141	(10)(11) “Health status-related factor” means any of the following factors: 23
142	142	(i) Health status; 24
143	143	(ii) Medical condition, including both physical and mental illnesses; 25
144	144	(iii) Claims experience; 26
145	145	(iv) Receipt of health care; 27
146	146	(v) Medical history; 28
147	147	(vi) Genetic information; 29
148	148	(vii) Evidence of insurability, including conditions arising out of acts of domestic violence; 30
149	149	and 31
150	150	(viii) Disability; 32
151	151	(11)(12) “High-risk individuals” means those individuals who do not pass medical 33
152	152	underwriting standards due to high healthcare needs or risks; 34
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156	156	(12)(13) “Individual market” means the market for health insurance coverage offered to 1
157	157	individuals other than in connection with a group health plan; 2
158	158	(13)(14) “Network plan” means health insurance coverage offered by a health insurance 3
159	159	carrier under which the financing and delivery of medical care, including items and services paid 4
160	160	for as medical care, are provided, in whole or in part, through a defined set of providers under 5
161	161	contract with the carrier; 6
162	162	(14)(15) “Preexisting condition” means, with respect to health insurance coverage, a 7
163	163	condition (whether physical or mental), regardless of the cause of the condition, that was present 8
164	164	before the date of enrollment for the coverage, for which medical advice, diagnosis, care, or 9
165	165	treatment was recommended or received within the six-month (6) period ending on the enrollment 10
166	166	date. Genetic information shall not be treated as a preexisting condition in the absence of a 11
167	167	diagnosis of the condition related to that information; and 12
168	168	(16) “Prior authorization (PA)” means a requirement from a health insurance company that 13
169	169	a doctor or provider must obtain approval before prescribing a medication or providing other health 14
170	170	care services; and 15
171	171	(15)(17) “Wellness health benefit plan” means that health benefit plan offered in the 16
172	172	individual market pursuant to § 27-18.5-8. 17
173	173	SECTION 2. Chapter 27-18.5 of the General Laws entitled "Individual Health Insurance 18
174	174	Coverage" is hereby amended by adding thereto the following section: 19
175	175	27-18.5-12. Prior authorization prohibited for generic medication prescriptions. 20
176	176	No policy of individual health insurance issued in this state shall require prior authorization 21
177	177	for a prescription for generic medication. 22
178	178	SECTION 3. This act shall take effect on January 1, 2026. 23
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180	180	LC000609
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185	185	EXPLANATION
186	186	BY THE LEGISLATIVE COUNCIL
187	187	OF
188	188	A N A C T
189	189	RELATING TO INSURANCE -- INDIVIDUAL HEALTH INSURANCE COVERAG E--PRIOR
190	190	AUTHORIZATIONS
191	191	***
192	192	This act would prohibit a policy of individual health insurance coverage from requiring 1
193	193	prior authorization for prescriptions of generic medication. 2
194	194	This act would take effect on January 1, 2026. 3
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196	196	LC000609
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