Chapter 223
2024 -- H 7365 SUBSTITUTE A
Enacted 06/24/2024

A N   A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

Introduced By: Representatives Caldwell, Casimiro, and McGaw

Date Introduced: January 31, 2024

It is enacted by the General Assembly as follows:
     SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness Insurance
Policies" is hereby amended by adding thereto the following section:
     27-18-33.3. Patient choice in dispensing of clinician-administered drugs.
     (a) As used in this section,
     (1) "Clinician-administered drug" means an outpatient infused prescription drug other than
a vaccine that:
     (i) Cannot reasonably be self-administered by the patient to whom the drug is prescribed
or by a non-clinician individual assisting the patient with the self-administration; and
     (ii) Is typically administered:
     (A) By a health care healthcare professional authorized under the laws of this state to
administer the drug, including when acting under a physician's delegation and supervision; and
     (B) In a physician's office, hospital outpatient infusion center, or other clinical setting.
     (b) A health insurer or a third party acting on its behalf shall not refuse to authorize,
approve, or pay a provider for a covered clinician-administered drug that was administered and
dispensed by any in-network hospital or clinic; provided that:
     (1) The dispensing and administering and any associated authorizations and approvals are
consistent with the provider contract and the issuer's medical and payment policies provided such
policies do not prohibit the procurement, administration, and dispensing by an in-network hospital
or clinic; and
     (2) The reimbursement to the provider shall be negotiated between the health insurer and
provider at a rate equal to payments between the insurer and a preferred pharmacy.
     (c) After January 1, 2025, the office of the health insurance commissioner, in consultation
with health insurers and providers, shall conduct an analysis of the payment for
clinician­administered drugs under this section.
     (1) In conducting the analysis, the office of the health insurance commissioner may:
     (i) Gather data from providers regarding potentially inaccurate payments; and
     (ii) Obtain necessary information from health insurers to understand how reimbursements
to providers for clinician-administered drugs are calculated.
     (2) The office of the health insurance commissioner shall publish on its website a summary
of its analysis, without identifying any health insurers or providers.
     (3) The office of the health insurance commissioner may include in its analysis legislative
recommendations to improve the reimbursement process for clinician-administered drugs under
this section, as necessary. Any recommendations shall include a description of the
recommendation's potential costs to consumers, health insurers, providers, and the state.
     (4) The office of the health insurance commissioner shall provide the general assembly
with their analysis no later than February 28, 2026.
     SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service
Corporations" is hereby amended by adding thereto the following section:
     27-19-26.3. Patient choice in dispensing of clinician-administered drugs.
     (a) As used in this section,
     (1) "Clinician-administered drug" means an outpatient infused prescription drug other than
a vaccine that:
     (i) Cannot reasonably be self-administered by the patient to whom the drug is prescribed
or by a non-clinician individual assisting the patient with the self-administration; and
     (ii) Is typically administered:
     (A) By a health care healthcare professional authorized under the laws of this state to
administer the drug, including when acting under a physician's delegation and supervision; and
     (B) In a physician's office, hospital outpatient infusion center, or other clinical setting.
     (b) A health insurer or a third party acting on its behalf shall not refuse to authorize,
approve, or pay a provider for a covered clinician-administered drug that was administered and
dispensed by any in-network hospital or clinic; provided that:
     (1) The dispensing and administering and any associated authorizations and approvals are
consistent with the provider contract and the issuer's medical and payment policies provided such
policies do not prohibit the procurement, administration, and dispensing by an in-network hospital
or clinic; and
     (2) The reimbursement to the provider shall be negotiated between the health insurer and
provider at a rate equal to payments between the insurer and a preferred pharmacy.
     (c) After January 1, 2025, the office of the health insurance commissioner, in consultation
with health insurers and providers, shall conduct an analysis of the payment for
clinician­administered drugs under this section.
     (1) In conducting the analysis, the office of the health insurance commissioner may:
     (i) Gather data from providers regarding potentially inaccurate payments; and
     (ii) Obtain necessary information from health insurers to understand how reimbursements
to providers for clinician-administered drugs are calculated.
     (2) The office of the health insurance commissioner shall publish on its website a summary
of its analysis, without identifying any health insurers or providers.
     (3) The office of the health insurance commissioner may include in its analysis legislative
recommendations to improve the reimbursement process for clinician-administered drugs under
this section, as necessary. Any recommendations shall include a description of the
recommendation's potential costs to consumers, health insurers, providers, and the state.
     (4) The office of the health insurance commissioner shall provide the general assembly
with their analysis no later than February 28, 2026.
     SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service
Corporations" is hereby amended by adding thereto the following section:
     27-20-23.3. Patient choice in dispensing of clinician-administered drugs.
     (a) As used in this section,
     (1) "Clinician-administered drug" means an outpatient infused prescription drug other than
a vaccine that:
     (i) Cannot reasonably be self-administered by the patient to whom the drug is prescribed
or by a non-clinician individual assisting the patient with the self-administration; and
     (ii) Is typically administered:
     (A) By a health care healthcare professional authorized under the laws of this state to
administer the drug, including when acting under a physician's delegation and supervision; and
     (B) In a physician's office, hospital outpatient infusion center, or other clinical setting.
     (b) A health insurer or a third party acting on its behalf shall not refuse to authorize,
approve, or pay a provider for a covered clinician-administered drug that was administered and
dispensed by any in-network hospital or clinic; provided that:
     (1) The dispensing and administering and any associated authorizations and approvals are
consistent with the provider contract and the issuer's medical and payment policies provided such
policies do not prohibit the procurement, administration, and dispensing by an in-network hospital
or clinic; and
     (2) The reimbursement to the provider shall be negotiated between the health insurer and
provider at a rate equal to payments between the insurer and a preferred pharmacy.
     (c) After January 1, 2025, the office of the health insurance commissioner, in consultation
with health insurers and providers, shall conduct an analysis of the payment for
clinician­administered drugs under this section.
     (1) In conducting the analysis, the office of the health insurance commissioner may:
     (i) Gather data from providers regarding potentially inaccurate payments; and
     (ii) Obtain necessary information from health insurers to understand how reimbursements
to providers for clinician-administered drugs are calculated.
     (2) The office of the health insurance commissioner shall publish on its website a summary
of its analysis, without identifying any health insurers or providers.
     (3) The office of the health insurance commissioner may include in its analysis legislative
recommendations to improve the reimbursement process for clinician-administered drugs under
this section, as necessary. Any recommendations shall include a description of the
recommendation's potential costs to consumers, health insurers, providers, and the state.
     (4) The office of the health insurance commissioner shall provide the general assembly
with their analysis no later than February 28, 2026.
     SECTION 4. Chapter 27-41 of the General Laws entitled "Health Maintenance
Organizations" is hereby amended by adding thereto the following section:
     27-41-38.4. Patient choice in dispensing of clinician-administered drugs.
     (a) As used in this section,
     (1) "Clinician-administered drug" means an outpatient infused prescription drug other than
a vaccine that:
     (i) Cannot reasonably be self-administered by the patient to whom the drug is prescribed
or by a non-clinician individual assisting the patient with the self-administration; and
     (ii) Is typically administered:
     (A) By a health care healthcare professional authorized under the laws of this state to
administer the drug, including when acting under a physician's delegation and supervision; and
     (B) In a physician's office, hospital outpatient infusion center, or other clinical setting.
     (b) A health insurer or a third party acting on its behalf shall not refuse to authorize,
approve, or pay a provider for a covered clinician-administered drug that was administered and
dispensed by any in-network hospital or clinic; provided that:
     (1) The dispensing and administering and any associated authorizations and approvals are
consistent with the provider contract and the issuer's medical and payment policies provided such
policies do not prohibit the procurement, administration, and dispensing by an in-network hospital
or clinic; and
     (2) The reimbursement to the provider shall be negotiated between the health insurer and
provider at a rate equal to payments between the insurer and a preferred pharmacy.
     (c) After January 1, 2025, the office of the health insurance commissioner, in consultation
with health insurers and providers, shall conduct an analysis of the payment for
clinician­administered drugs under this section.
     (1) In conducting the analysis, the office of the health insurance commissioner may:
     (i) Gather data from providers regarding potentially inaccurate payments; and
     (ii) Obtain necessary information from health insurers to understand how reimbursements
to providers for clinician-administered drugs are calculated.
     (2) The office of the health insurance commissioner shall publish on its website a summary
of its analysis, without identifying any health insurers or providers.
     (3) The office of the health insurance commissioner may include in its analysis legislative
recommendations to improve the reimbursement process for clinician-administered drugs under
this section, as necessary. Any recommendations shall include a description of the
recommendation's potential costs to consumers, health insurers, providers, and the state.
     (4) The office of the health insurance commissioner shall provide the general assembly
with their analysis no later than February 28, 2026.
     SECTION 5. This act shall take effect on January 1, 2025.
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LC004054/SUB A
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