Chapter 435 |
2025 -- S 0168 SUBSTITUTE B Enacted 07/02/2025 |
A N A C T |
RELATING TO INSURANCE -- BENEFIT DETERMINATION AND UTILIZATION REVIEW ACT |
Introduced By: Senators Murray, Felag, Sosnowski, Vargas, Bissaillon, Ruggerio, Lawson, and Tikoian |
Date Introduced: February 05, 2025 |
It is enacted by the General Assembly as follows: |
SECTION 1. This act may be cited as the "Rhode Island Prior Authorization Reform Act |
of 2025." |
SECTION 2. Section 27-18.9-2 of the General Laws in Chapter 27-18.9 entitled "Benefit |
Determination and Utilization Review Act" is hereby amended to read as follows: |
27-18.9-2. Definitions. |
As used in this chapter, the following terms are defined as follows: |
(1) “Adverse benefit determination” means a decision not to authorize a healthcare service, |
including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole |
or in part, for a benefit. A decision by a utilization-review agent to authorize a healthcare service |
in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute |
an adverse determination if the review agent and provider are in agreement regarding the decision. |
Adverse benefit determinations include: |
(i) “Administrative adverse benefit determinations,” meaning any adverse benefit |
determination that does not require the use of medical judgment or clinical criteria such as a |
determination of an individual’s eligibility to participate in coverage, a determination that a benefit |
is not a covered benefit, or any rescission of coverage; and |
(ii) “Non-administrative adverse benefit determinations,” meaning any adverse benefit |
determination that requires or involves the use of medical judgement or clinical criteria to |
determine whether the service being reviewed is medically necessary and/or appropriate. This |
includes the denial of treatments determined to be experimental or investigational, and any denial |
of coverage of a prescription drug because that drug is not on the healthcare entity’s formulary. |
(2) “Appeal” or “internal appeal” means a subsequent review of an adverse benefit |
determination upon request by a claimant to include the beneficiary or provider to reconsider all or |
part of the original adverse benefit determination. |
(3) “Authorization” means a review by a review agent, performed according to this chapter, |
concluding that the allocation of healthcare services ordered by a provider, given or proposed to be |
given to a beneficiary, was approved or authorized. |
(4) “Authorized representative” means an individual acting on behalf of the beneficiary |
and shall include: the ordering provider; any individual to whom the beneficiary has given express |
written consent to act on his or herthe individual’s behalf; a person authorized by law to provide |
substituted consent for the beneficiary; and, when the beneficiary is unable to provide consent, a |
family member of the beneficiary. |
(5) “Beneficiary” means a policy-holder subscriber, enrollee, or other individual |
participating in a health-benefit plan. |
(6) “Benefit determination” means a decision to approve or deny a request to provide or |
make payment for a healthcare service or treatment. |
(7) “Certificate” means a certificate granted by the commissioner to a review agent meeting |
the requirements of this chapter. |
(8) “Claim” means a request for plan benefit(s) made by a claimant in accordance with the |
healthcare entity’s reasonable procedures for filing benefit claims. This shall include pre-service, |
concurrent, and post-service claims. |
(9) “Claimant” means a healthcare entity participant, beneficiary, and/or authorized |
representative who makes a request for plan benefit(s). |
(10) “Commissioner” means the health insurance commissioner. |
(11) “Complaint” means an oral or written expression of dissatisfaction by a beneficiary, |
authorized representative, or a provider. The appeal of an adverse benefit determination is not |
considered a complaint. |
(12) “Concurrent assessment” means an assessment of healthcare services conducted |
during a beneficiary’s hospital stay, course of treatment or services over a period of time, or for the |
number of treatments. If the medical problem is ongoing, this assessment may include the review |
of services after they have been rendered and billed. |
(13) “Concurrent claim” means a request for a plan benefit(s) by a claimant that is for an |
ongoing course of treatment or services over a period of time or for the number of treatments. |
(14) “Delegate” means a person or entity authorized pursuant to a delegation of authority |
or re-delegation of authority, by a healthcare entity or network plan to perform one or more of the |
functions and responsibilities of a healthcare entity and/or network plan set forth in this chapter or |
regulations or guidance promulgated thereunder. |
(15) “Emergency services” or “emergent services” means those resources provided in the |
event of the sudden onset of a medical, behavioral health, or other health condition that the absence |
of immediate medical attention could reasonably be expected, by a prudent layperson, to result in |
placing the patient’s health in serious jeopardy, serious impairment to bodily or mental functions, |
or serious dysfunction of any bodily organ or part. |
(16) “External review” means a review of a non-administrative adverse benefit |
determination (including final internal adverse benefit determination) conducted pursuant to an |
applicable external review process performed by an independent review organization. |
(17) “External review decision” means a determination by an independent review |
organization at the conclusion of the external review. |
(18) “Final internal adverse benefit determination” means an adverse benefit determination |
that has been upheld by a plan or issuer at the completion of the internal appeals process or when |
the internal appeals process has been deemed exhausted as defined in § 27-18.9-7(b)(1). |
(19) “Health-benefit plan” or “health plan” means a policy, contract, certificate, or |
agreement entered into, offered, or issued by a healthcare entity to provide, deliver, arrange for, |
pay for, or reimburse any of the costs of healthcare services. |
(20) “Healthcare entity” means an insurance company licensed, or required to be licensed, |
by the state of Rhode Island or other entity subject to the jurisdiction of the commissioner or the |
jurisdiction of the department of business regulation pursuant to chapter 62 of title 42, that contracts |
or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or |
reimburse any of the costs of healthcare services, including, without limitation: a for-profit or |
nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, |
a health insurance company, or any other entity providing a plan of health insurance, accident and |
sickness insurance, health benefits, or healthcare services. |
(21) “Healthcare services” means and includes, but is not limited to: an admission, |
diagnostic procedure, therapeutic procedure, treatment, extension of stay, the ordering and/or filling |
of formulary or non-formulary medications, and any other medical, behavioral, dental, vision care |
services, activities, or supplies that are covered by the beneficiary’s health-benefit plan. |
(22) “Independent review organization” or “IRO” means an entity that conducts |
independent external reviews of adverse benefit determinations or final internal adverse benefit |
determinations. |
(23) "Insurer", for the purposes of § 27-18.9-16, means all insurance companies licensed |
to do business in Rhode Island, including those subject to chapter 1 of title 27, a foreign insurance |
company licensed to do business in Rhode Island and subject to chapter 2 of title 27, a health |
insurance carrier subject and organized pursuant to chapter 18 of title 27, a nonprofit hospital |
service corporation subject and organized pursuant to chapter 19 of title 27, a nonprofit medical |
services corporation subject and organized pursuant to chapter 20 of title 27, and a qualified health |
maintenance organization subject and organized pursuant to chapter 41 of title 27. |
(23)(24) “Network” means the group or groups of participating providers providing |
healthcare services under a network plan. |
(24)(25) “Network plan” means a health-benefit plan or health plan that either requires a |
beneficiary to use, or creates incentives, including financial incentives, for a beneficiary to use the |
providers managed, owned, under contract with, or employed by the healthcare entity. |
(25)(26) “Office” means the office of the health insurance commissioner. |
(26)(27) “Pre-service claim” means the request for a plan benefit(s) by a claimant prior to |
a service being rendered and is not considered a concurrent claim. |
(28) "Primary care provider” or “PCP", for the purposes of § 27-18.9-16, means a provider |
within the practice type of family medicine, geriatric medicine, internal medicine, obstetrics and |
gynecology, or pediatrics, with the following professional credentials: a doctor of medicine or |
doctor of osteopathic medicine, a nurse practitioner, or a physician assistant, and who is |
credentialed with the insurer as a primary care provider. |
(29) "Prior authorization", for the purposes of § 27-18.9-16, means the pre-service |
assessment for purposes of utilization review that a PCP is required by an insurer to undergo before |
a covered healthcare service is approved for a patient. |
(29)(30) “Professional provider” means an individual provider or healthcare professional |
licensed, accredited, or certified to perform specified healthcare services consistent with state law |
and who provides healthcare services and is not part of a separate facility or institutional contract. |
(28)(31) “Prospective assessment” or “pre-service assessment” means an assessment of |
healthcare services prior to services being rendered. |
(29)(32) “Provider” means a physician, hospital, professional provider, pharmacy, |
laboratory, dental, medical, or behavioral health provider or other state-licensed or other state- |
recognized provider of health care or behavioral health services or supplies. |
(30)(33) “Retrospective assessment” or “post-service assessment” means an assessment of |
healthcare services that have been rendered. This shall not include reviews conducted when the |
review agency has been obtaining ongoing information. |
(31)(34) “Retrospective claim” or “post-service claim” means any claim for a health-plan |
benefit that is not a pre-service or concurrent claim. |
(32)(35) “Review agent” means a person or healthcare entity performing benefit |
determination reviews that is either employed by, affiliated with, under contract with, or acting on |
behalf of a healthcare entity. |
(33)(36) “Same or similar specialty” means a practitioner who has the appropriate training |
and experience that is the same or similar as the attending provider in addition to experience in |
treating the same problems to include any potential complications as those under review. |
(34)(37) “Therapeutic interchange” means the interchange or substitution of a drug with a |
dissimilar chemical structure within the same therapeutic or pharmacological class that can be |
expected to have similar outcomes and similar adverse reaction profiles when given in equivalent |
doses, in accordance with protocols approved by the president of the medical staff or medical |
director and the director of pharmacy. |
(35)(38) “Tiered network” means a network that identifies and groups some or all types of |
providers into specific groups to which different provider reimbursement, beneficiary cost-sharing, |
or provider access requirements, or any combination thereof, apply for the same services. |
(36)(39) “Urgent healthcare services” includes those resources necessary to treat a |
symptomatic medical, mental health, substance use, or other healthcare condition that a prudent |
layperson, acting reasonably, would believe necessitates treatment within a twenty-four hour (24) |
period of the onset of such a condition in order that the patient’s health status not decline as a |
consequence. This does not include those conditions considered to be emergent healthcare services |
as defined in this section. |
(37)(40) “Utilization review” means the prospective, concurrent, or retrospective |
assessment of the medical necessity and/or appropriateness of the allocation of healthcare services |
of a provider, given or proposed to be given, to a beneficiary. Utilization review does not include: |
(i) The therapeutic interchange of drugs or devices by a pharmacy operating as part of a |
licensed inpatient healthcare facility; or |
(ii) The assessment by a pharmacist licensed pursuant to the provisions of chapter 19.1 of |
title 5, and practicing in a pharmacy operating as part of a licensed inpatient healthcare facility, in |
the interpretation, evaluation and implementation of medical orders, including assessments and/or |
comparisons involving formularies and medical orders. |
(38)(41) “Utilization review plan” means a description of the standards governing |
utilization review activities performed by a review agent. |
SECTION 3. Chapter 27-18.9 of the General Laws entitled "Benefit Determination and |
Utilization Review Act" is hereby amended by adding thereto the following section: |
27-18.9-16. Prior authorization reduction and improvement. |
(a) The purpose of this chapter is to authorize a three-(3)year (3) pilot program whereby, |
except as provided in subsection (b), of this section,an insurer shall not impose a prior authorization |
requirement for any admission, item, service, treatment, or procedure ordered by a primary care |
provider in the normal course of providing primary care treatment. |
(b) The prohibition set forth in subsection (a) of this sectionshall not be construed to |
prohibit prior authorization requirements for prescription drugs. |
(c) Nothing in this section shall be construed to modify the rights or obligations of an |
insurer or provider with respect to procedures relating to the investigation, audit, reporting, or |
appeal, under applicable law of potentially fraudulent billing activities, waste or abuse. |
(d) Annually on or before July 1, each insurer shall submit to the office of the governor, |
the speaker of the house of representatives, the president of the senate, and the office of the health |
insurance commissioner a written report in compliance with the rules and regulations to be |
promulgated by the office of the health insurance commissioner on or before January 1, 2026. |
(e) Unless an act of the general assembly expressly authorizes the continuation of the |
program, the provisions of this chapter shall sunset and expire on October 1, 2028. |
SECTION 4. Section 42-7.2-5 of the General Laws in Chapter 42-7.2 entitled "Office of |
Health and Human Services" is hereby amended to read as follows: |
42-7.2-5. Duties of the secretary. |
The secretary shall be subject to the direction and supervision of the governor for the |
oversight, coordination, and cohesive direction of state-administered health and human services |
and in ensuring the laws are faithfully executed, notwithstanding any law to the contrary. In this |
capacity, the secretary of the executive office of health and human services (EOHHS) shall be |
authorized to: |
(1) Coordinate the administration and financing of healthcare benefits, human services, and |
programs including those authorized by the state’s Medicaid section 1115 demonstration waiver |
and, as applicable, the Medicaid state plan under Title XIX of the U.S. Social Security Act. |
However, nothing in this section shall be construed as transferring to the secretary the powers, |
duties, or functions conferred upon the departments by Rhode Island public and general laws for |
the administration of federal/state programs financed in whole or in part with Medicaid funds or |
the administrative responsibility for the preparation and submission of any state plans, state plan |
amendments, or authorized federal waiver applications, once approved by the secretary. |
(2) Serve as the governor’s chief advisor and liaison to federal policymakers on Medicaid |
reform issues as well as the principal point of contact in the state on any such related matters. |
(3)(i) Review and ensure the coordination of the state’s Medicaid section 1115 |
demonstration waiver requests and renewals as well as any initiatives and proposals requiring |
amendments to the Medicaid state plan or formal amendment changes, as described in the special |
terms and conditions of the state’s Medicaid section 1115 demonstration waiver with the potential |
to affect the scope, amount, or duration of publicly funded healthcare services, provider payments |
or reimbursements, or access to or the availability of benefits and services as provided by Rhode |
Island general and public laws. The secretary shall consider whether any such changes are legally |
and fiscally sound and consistent with the state’s policy and budget priorities. The secretary shall |
also assess whether a proposed change is capable of obtaining the necessary approvals from federal |
officials and achieving the expected positive consumer outcomes. Department directors shall, |
within the timelines specified, provide any information and resources the secretary deems necessary |
in order to perform the reviews authorized in this section. |
(ii) Direct the development and implementation of any Medicaid policies, procedures, or |
systems that may be required to assure successful operation of the state’s health and human services |
integrated eligibility system and coordination with HealthSource RI, the state’s health insurance |
marketplace. |
(iii) Beginning in 2015, conduct on a biennial basis a comprehensive review of the |
Medicaid eligibility criteria for one or more of the populations covered under the state plan or a |
waiver to ensure consistency with federal and state laws and policies, coordinate and align systems, |
and identify areas for improving quality assurance, fair and equitable access to services, and |
opportunities for additional financial participation. |
(iv) Implement service organization and delivery reforms that facilitate service integration, |
increase value, and improve quality and health outcomes. |
(4) Beginning in 2020, prepare and submit to the governor, the chairpersons of the house |
and senate finance committees, the caseload estimating conference, and to the joint legislative |
committee for health-care oversight, by no later than September 15 of each year, a comprehensive |
overview of all Medicaid expenditures outcomes, administrative costs, and utilization rates. The |
overview shall include, but not be limited to, the following information: |
(i) Expenditures under Titles XIX and XXI of the Social Security Act, as amended; |
(ii) Expenditures, outcomes, and utilization rates by population and sub-population served |
(e.g., families with children, persons with disabilities, children in foster care, children receiving |
adoption assistance, adults ages nineteen (19) to sixty-four (64), and elders); |
(iii) Expenditures, outcomes, and utilization rates by each state department or other |
municipal or public entity receiving federal reimbursement under Titles XIX and XXI of the Social |
Security Act, as amended; |
(iv) Expenditures, outcomes, and utilization rates by type of service and/or service |
provider; |
(v) Expenditures by mandatory population receiving mandatory services and, reported |
separately, optional services, as well as optional populations receiving mandatory services and, |
reported separately, optional services for each state agency receiving Title XIX and XXI funds; and |
(vi) Information submitted to the Centers for Medicare & Medicaid Services for the |
mandatory annual state reporting of the Core Set of Children’s Health Care Quality Measures for |
Medicaid and Children’s Health Insurance Program, behavioral health measures on the Core Set of |
Adult Health Care Quality Measures for Medicaid and the Core Sets of Health Home Quality |
Measures for Medicaid to ensure compliance with the Bipartisan Budget Act of 2018, Pub. L. No. |
115-123. |
The directors of the departments, as well as local governments and school departments, |
shall assist and cooperate with the secretary in fulfilling this responsibility by providing whatever |
resources, information and support shall be necessary. |
(5) Resolve administrative, jurisdictional, operational, program, or policy conflicts among |
departments and their executive staffs and make necessary recommendations to the governor. |
(6) Ensure continued progress toward improving the quality, the economy, the |
accountability, and the efficiency of state-administered health and human services. In this capacity, |
the secretary shall: |
(i) Direct implementation of reforms in the human resources practices of the executive |
office and the departments that streamline and upgrade services, achieve greater economies of scale |
and establish the coordinated system of the staff education, cross-training, and career development |
services necessary to recruit and retain a highly-skilled, responsive, and engaged health and human |
services workforce; |
(ii) Encourage EOHHS-wide consumer-centered approaches to service design and delivery |
that expand their capacity to respond efficiently and responsibly to the diverse and changing needs |
of the people and communities they serve; |
(iii) Develop all opportunities to maximize resources by leveraging the state’s purchasing |
power, centralizing fiscal service functions related to budget, finance, and procurement, |
centralizing communication, policy analysis and planning, and information systems and data |
management, pursuing alternative funding sources through grants, awards, and partnerships and |
securing all available federal financial participation for programs and services provided EOHHS- |
wide; |
(iv) Improve the coordination and efficiency of health and human services legal functions |
by centralizing adjudicative and legal services and overseeing their timely and judicious |
administration; |
(v) Facilitate the rebalancing of the long-term system by creating an assessment and |
coordination organization or unit for the expressed purpose of developing and implementing |
procedures EOHHS-wide that ensure that the appropriate publicly funded health services are |
provided at the right time and in the most appropriate and least restrictive setting; |
(vi) Strengthen health and human services program integrity, quality control and |
collections, and recovery activities by consolidating functions within the office in a single unit that |
ensures all affected parties pay their fair share of the cost of services and are aware of alternative |
financing; |
(vii) Assure protective services are available to vulnerable elders and adults with |
developmental and other disabilities by reorganizing existing services, establishing new services |
where gaps exist, and centralizing administrative responsibility for oversight of all related |
initiatives and programs. |
(7) Prepare and integrate comprehensive budgets for the health and human services |
departments and any other functions and duties assigned to the office. The budgets shall be |
submitted to the state budget office by the secretary, for consideration by the governor, on behalf |
of the state’s health and human services agencies in accordance with the provisions set forth in § |
35-3-4. |
(8) Utilize objective data to evaluate health and human services policy goals, resource use |
and outcome evaluation and to perform short and long-term policy planning and development. |
(9) Establishment of an integrated approach to interdepartmental information and data |
management that complements and furthers the goals of the unified health infrastructure project |
initiative and that will facilitate the transition to a consumer-centered integrated system of state- |
administered health and human services. |
(10) At the direction of the governor or the general assembly, conduct independent reviews |
of state-administered health and human services programs, policies, and related agency actions and |
activities and assist the department directors in identifying strategies to address any issues or areas |
of concern that may emerge thereof. The department directors shall provide any information and |
assistance deemed necessary by the secretary when undertaking such independent reviews. |
(11) Provide regular and timely reports to the governor and make recommendations with |
respect to the state’s health and human services agenda. |
(12) Employ such personnel and contract for such consulting services as may be required |
to perform the powers and duties lawfully conferred upon the secretary. |
(13) Assume responsibility for complying with the provisions of any general or public law |
or regulation related to the disclosure, confidentiality, and privacy of any information or records, |
in the possession or under the control of the executive office or the departments assigned to the |
executive office, that may be developed or acquired or transferred at the direction of the governor |
or the secretary for purposes directly connected with the secretary’s duties set forth herein. |
(14) Hold the director of each health and human services department accountable for their |
administrative, fiscal, and program actions in the conduct of the respective powers and duties of |
their agencies. |
(15) Identify opportunities for inclusion with the EOHHS’ October 1, 2023, budget |
submission, to remove fixed eligibility thresholds for programs under its purview by establishing |
sliding scale decreases in benefits commensurate with income increases up to four hundred fifty |
percent (450%) of the federal poverty level. These shall include but not be limited to, medical |
assistance, childcare assistance, and food assistance. |
(16) Ensure that insurers minimize administrative burdens on providers that may delay |
medically necessary care, including requiring that insurers do not impose a prior authorization |
requirement for any admission, item, service, treatment, or procedure ordered by an in-network |
primary care provider. Provided, the prohibition shall not be construed to prohibit prior |
authorization requirements for prescription drugs. Provided further, that as used in this subsection |
(16) of this section, the terms "insurer," "primary care provider," and "prior authorization" means |
the same as those terms are defined in § 27-18.9-2. |
SECTION 5. Section 42-14.5-3 of the General Laws in Chapter 42-14.5 entitled "The |
Rhode Island Health Care Reform Act of 2004 — Health Insurance Oversight" is hereby amended |
to read as follows: |
42-14.5-3. Powers and duties. |
The health insurance commissioner shall have the following powers and duties: |
(a) To conduct quarterly public meetings throughout the state, separate and distinct from |
rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers |
licensed to provide health insurance in the state; the effects of such rates, services, and operations |
on consumers, medical care providers, patients, and the market environment in which the insurers |
operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less |
than ten (10) days of the hearing(s) shall go to the general assembly, the governor, the Rhode Island |
Medical Society, the Hospital Association of Rhode Island, the director of health, the attorney |
general, and the chambers of commerce. Public notice shall be posted on the department’s website |
and given in the newspaper of general circulation, and to any entity in writing requesting notice. |
(b) To make recommendations to the governor and the house of representatives and senate |
finance committees regarding healthcare insurance and the regulations, rates, services, |
administrative expenses, reserve requirements, and operations of insurers providing health |
insurance in the state, and to prepare or comment on, upon the request of the governor or |
chairpersons of the house or senate finance committees, draft legislation to improve the regulation |
of health insurance. In making the recommendations, the commissioner shall recognize that it is |
the intent of the legislature that the maximum disclosure be provided regarding the reasonableness |
of individual administrative expenditures as well as total administrative costs. The commissioner |
shall make recommendations on the levels of reserves, including consideration of: targeted reserve |
levels; trends in the increase or decrease of reserve levels; and insurer plans for distributing excess |
reserves. |
(c) To establish a consumer/business/labor/medical advisory council to obtain information |
and present concerns of consumers, business, and medical providers affected by health insurance |
decisions. The council shall develop proposals to allow the market for small business health |
insurance to be affordable and fairer. The council shall be involved in the planning and conduct of |
the quarterly public meetings in accordance with subsection (a). The advisory council shall develop |
measures to inform small businesses of an insurance complaint process to ensure that small |
businesses that experience rate increases in a given year may request and receive a formal review |
by the department. The advisory council shall assess views of the health provider community |
relative to insurance rates of reimbursement, billing, and reimbursement procedures, and the |
insurers’ role in promoting efficient and high-quality health care. The advisory council shall issue |
an annual report of findings and recommendations to the governor and the general assembly and |
present its findings at hearings before the house and senate finance committees. The advisory |
council is to be diverse in interests and shall include representatives of community consumer |
organizations; small businesses, other than those involved in the sale of insurance products; and |
hospital, medical, and other health provider organizations. Such representatives shall be nominated |
by their respective organizations. The advisory council shall be co-chaired by the health insurance |
commissioner and a community consumer organization or small business member to be elected by |
the full advisory council. |
(d) To establish and provide guidance and assistance to a subcommittee (“the professional- |
provider-health-plan work group”) of the advisory council created pursuant to subsection (c), |
composed of healthcare providers and Rhode Island licensed health plans. This subcommittee shall |
include in its annual report and presentation before the house and senate finance committees the |
following information: |
(1) A method whereby health plans shall disclose to contracted providers the fee schedules |
used to provide payment to those providers for services rendered to covered patients; |
(2) A standardized provider application and credentials verification process, for the |
purpose of verifying professional qualifications of participating healthcare providers; |
(3) The uniform health plan claim form utilized by participating providers; |
(4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit |
hospital or medical service corporations, as defined by chapters 19 and 20 of title 27, to make |
facility-specific data and other medical service-specific data available in reasonably consistent |
formats to patients regarding quality and costs. This information would help consumers make |
informed choices regarding the facilities and clinicians or physician practices at which to seek care. |
Among the items considered would be the unique health services and other public goods provided |
by facilities and clinicians or physician practices in establishing the most appropriate cost |
comparisons; |
(5) All activities related to contractual disclosure to participating providers of the |
mechanisms for resolving health plan/provider disputes; |
(6) The uniform process being utilized for confirming, in real time, patient insurance |
enrollment status, benefits coverage, including copays and deductibles; |
(7) Information related to temporary credentialing of providers seeking to participate in the |
plan’s network and the impact of the activity on health plan accreditation; |
(8) The feasibility of regular contract renegotiations between plans and the providers in |
their networks; and |
(9) Efforts conducted related to reviewing impact of silent PPOs on physician practices. |
(e) To enforce the provisions of title 27 and title 42 as set forth in § 42-14-5(d). |
(f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The |
fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17. |
(g) To analyze the impact of changing the rating guidelines and/or merging the individual |
health insurance market, as defined in chapter 18.5 of title 27, and the small-employer health |
insurance market, as defined in chapter 50 of title 27, in accordance with the following: |
(1) The analysis shall forecast the likely rate increases required to effect the changes |
recommended pursuant to the preceding subsection (g) in the direct-pay market and small-employer |
health insurance market over the next five (5) years, based on the current rating structure and |
current products. |
(2) The analysis shall include examining the impact of merging the individual and small- |
employer markets on premiums charged to individuals and small-employer groups. |
(3) The analysis shall include examining the impact on rates in each of the individual and |
small-employer health insurance markets and the number of insureds in the context of possible |
changes to the rating guidelines used for small-employer groups, including: community rating |
principles; expanding small-employer rate bonds beyond the current range; increasing the employer |
group size in the small-group market; and/or adding rating factors for broker and/or tobacco use. |
(4) The analysis shall include examining the adequacy of current statutory and regulatory |
oversight of the rating process and factors employed by the participants in the proposed, new |
merged market. |
(5) The analysis shall include assessment of possible reinsurance mechanisms and/or |
federal high-risk pool structures and funding to support the health insurance market in Rhode Island |
by reducing the risk of adverse selection and the incremental insurance premiums charged for this |
risk, and/or by making health insurance affordable for a selected at-risk population. |
(6) The health insurance commissioner shall work with an insurance market merger task |
force to assist with the analysis. The task force shall be chaired by the health insurance |
commissioner and shall include, but not be limited to, representatives of the general assembly, the |
business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage in |
the individual market in Rhode Island, health insurance brokers, and members of the general public. |
(7) For the purposes of conducting this analysis, the commissioner may contract with an |
outside organization with expertise in fiscal analysis of the private insurance market. In conducting |
its study, the organization shall, to the extent possible, obtain and use actual health plan data. Said |
data shall be subject to state and federal laws and regulations governing confidentiality of health |
care and proprietary information. |
(8) The task force shall meet as necessary and include its findings in the annual report, and |
the commissioner shall include the information in the annual presentation before the house and |
senate finance committees. |
(h) To establish and convene a workgroup representing healthcare providers and health |
insurers for the purpose of coordinating the development of processes, guidelines, and standards to |
streamline healthcare administration that are to be adopted by payors and providers of healthcare |
services operating in the state. This workgroup shall include representatives with expertise who |
would contribute to the streamlining of healthcare administration and who are selected from |
hospitals, physician practices, community behavioral health organizations, each health insurer, and |
other affected entities. The workgroup shall also include at least one designee each from the Rhode |
Island Medical Society, Rhode Island Council of Community Mental Health Organizations, the |
Rhode Island Health Center Association, and the Hospital Association of Rhode Island. In any year |
that the workgroup meets and submits recommendations to the office of the health insurance |
commissioner, the office of the health insurance commissioner shall submit such recommendations |
to the health and human services committees of the Rhode Island house of representatives and the |
Rhode Island senate prior to the implementation of any such recommendations and subsequently |
shall submit a report to the general assembly by June 30, 2024. The report shall include the |
recommendations the commissioner may implement, with supporting rationale. The workgroup |
shall consider and make recommendations for: |
(1) Establishing a consistent standard for electronic eligibility and coverage verification. |
Such standard shall: |
(i) Include standards for eligibility inquiry and response and, wherever possible, be |
consistent with the standards adopted by nationally recognized organizations, such as the Centers |
for Medicare & Medicaid Services; |
(ii) Enable providers and payors to exchange eligibility requests and responses on a system- |
to-system basis or using a payor-supported web browser; |
(iii) Provide reasonably detailed information on a consumer’s eligibility for healthcare |
coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing |
requirements for specific services at the specific time of the inquiry; current deductible amounts; |
accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and |
other information required for the provider to collect the patient’s portion of the bill; |
(iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility |
and benefits information; |
(v) Recommend a standard or common process to protect all providers from the costs of |
services to patients who are ineligible for insurance coverage in circumstances where a payor |
provides eligibility verification based on best information available to the payor at the date of the |
request of eligibility. |
(2) Developing implementation guidelines and promoting adoption of the guidelines for: |
(i) The use of the National Correct Coding Initiative code-edit policy by payors and |
providers in the state; |
(ii) Publishing any variations from codes and mutually exclusive codes by payors in a |
manner that makes for simple retrieval and implementation by providers; |
(iii) Use of Health Insurance Portability and Accountability Act standard group codes, |
reason codes, and remark codes by payors in electronic remittances sent to providers; |
(iv) Uniformity in the processing of claims by payors; and the processing of corrections to |
claims by providers and payors; |
(v) A standard payor-denial review process for providers when they request a |
reconsideration of a denial of a claim that results from differences in clinical edits where no single, |
common-standards body or process exists and multiple conflicting sources are in use by payors and |
providers. |
(vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual |
payor’s ability to employ, and not disclose to providers, temporary code edits for the purpose of |
detecting and deterring fraudulent billing activities. The guidelines shall require that each payor |
disclose to the provider its adjudication decision on a claim that was denied or adjusted based on |
the application of such edits and that the provider have access to the payor’s review and appeal |
process to challenge the payor’s adjudication decision. |
(vii) Nothing in this subsection shall be construed to modify the rights or obligations of |
payors or providers with respect to procedures relating to the investigation, reporting, appeal, or |
prosecution under applicable law of potentially fraudulent billing activities. |
(3) Developing and promoting widespread adoption by payors and providers of guidelines |
to: |
(i) Ensure payors do not automatically deny claims for services when extenuating |
circumstances make it impossible for the provider to obtain a preauthorization before services are |
performed or notify a payor within an appropriate standardized timeline of a patient’s admission; |
(ii) Require payors to use common and consistent processes and time frames when |
responding to provider requests for medical management approvals. Whenever possible, such time |
frames shall be consistent with those established by leading national organizations and be based |
upon the acuity of the patient’s need for care or treatment. For the purposes of this section, medical |
management includes prior authorization of services, preauthorization of services, precertification |
of services, post-service review, medical-necessity review, and benefits advisory; |
(iii) Develop, maintain, and promote widespread adoption of a single, common website |
where providers can obtain payors’ preauthorization, benefits advisory, and preadmission |
requirements; |
(iv) Establish guidelines for payors to develop and maintain a website that providers can |
use to request a preauthorization, including a prospective clinical necessity review; receive an |
authorization number; and transmit an admission notification; |
(v) Develop and implement the use of programs that implement selective prior |
authorization requirements, based on stratification of healthcare providers’ performance and |
adherence to evidence-based medicine with the input of contracted healthcare providers and/or |
provider organizations. Such criteria shall be transparent and easily accessible to contracted |
providers. Such selective prior authorization programs shall be available when healthcare providers |
participate directly with the insurer in risk-based payment contracts and may be available to |
providers who do not participate in risk-based contracts; |
(vi) Require the review of medical services, including behavioral health services, and |
prescription drugs, subject to prior authorization on at least an annual basis, with the input of |
contracted healthcare providers and/or provider organizations. Any changes to the list of medical |
services, including behavioral health services, and prescription drugs requiring prior authorization, |
shall be shared via provider-accessible websites; |
(vii) Improve communication channels between health plans, healthcare providers, and |
patients by: |
(A) Requiring transparency and easy accessibility of prior authorization requirements, |
criteria, rationale, and program changes to contracted healthcare providers and patients/health plan |
enrollees which may be satisfied by posting to provider-accessible and member-accessible |
websites; and |
(B) Supporting: |
(I) Timely submission by healthcare providers of the complete information necessary to |
make a prior authorization determination, as early in the process as possible; and |
(II) Timely notification of prior authorization determinations by health plans to impacted |
health plan enrollees, and healthcare providers, including, but not limited to, ordering providers, |
and/or rendering providers, and dispensing pharmacists which may be satisfied by posting to |
provider-accessible websites or similar electronic portals or services; |
(viii) Increase and strengthen continuity of patient care by: |
(A) Defining protections for continuity of care during a transition period for patients |
undergoing an active course of treatment, when there is a formulary or treatment coverage change |
or change of health plan that may disrupt their current course of treatment and when the treating |
physician determines that a transition may place the patient at risk; and for prescription medication |
by allowing a grace period of coverage to allow consideration of referred health plan options or |
establishment of medical necessity of the current course of treatment; |
(B) Requiring continuity of care for medical services, including behavioral health services, |
and prescription medications for patients on appropriate, chronic, stable therapy through |
minimizing repetitive prior authorization requirements; and which for prescription medication shall |
be allowed only on an annual review, with exception for labeled limitation, to establish continued |
benefit of treatment; and |
(C) Requiring communication between healthcare providers, health plans, and patients to |
facilitate continuity of care and minimize disruptions in needed treatment which may be satisfied |
by posting to provider-accessible websites or similar electronic portals or services; |
(D) Continuity of care for formulary or drug coverage shall distinguish between FDA |
designated interchangeable products and proprietary or marketed versions of a medication; |
(ix) Encourage healthcare providers and/or provider organizations and health plans to |
accelerate use of electronic prior authorization technology, including adoption of national standards |
where applicable; and |
(x) For the purposes of subsections (h)(3)(v) through (h)(3)(x) of this section, the |
workgroup meeting may be conducted in part or whole through electronic methods. |
(4) To provide a report to the house and senate, on or before January 1, 2017, with |
recommendations for establishing guidelines and regulations for systems that give patients |
electronic access to their claims information, particularly to information regarding their obligations |
to pay for received medical services, pursuant to 45 C.F.R. § 164.524. |
(5) No provision of this subsection (h) shall preclude the ongoing work of the office of |
health insurance commissioner’s administrative simplification task force, which includes meetings |
with key stakeholders in order to improve, and provide recommendations regarding, the prior |
authorization process. |
(i) To issue an anti-cancer medication report. Not later than June 30, 2014, and annually |
thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate |
committee on health and human services, and the house committee on corporations, with: (1) |
Information on the availability in the commercial market of coverage for anti-cancer medication |
options; (2) For the state employee’s health benefit plan, the costs of various cancer-treatment |
options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member |
utilization and cost-sharing expense. |
(j) To monitor the adequacy of each health plan’s compliance with the provisions of the |
federal Mental Health Parity Act, including a review of related claims processing and |
reimbursement procedures. Findings, recommendations, and assessments shall be made available |
to the public. |
(k) To monitor the transition from fee-for-service and toward global and other alternative |
payment methodologies for the payment for healthcare services. Alternative payment |
methodologies should be assessed for their likelihood to promote access to affordable health |
insurance, health outcomes, and performance. |
(l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital |
payment variation, including findings and recommendations, subject to available resources. |
(m) Notwithstanding any provision of the general or public laws or regulation to the |
contrary, provide a report with findings and recommendations to the president of the senate and the |
speaker of the house, on or before April 1, 2014, including, but not limited to, the following |
information: |
(1) The impact of the current, mandated healthcare benefits as defined in §§ 27-18-48.1, |
27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41 of title 27, and §§ 27- |
18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health |
insurance for fully insured employers, subject to available resources; |
(2) Current provider and insurer mandates that are unnecessary and/or duplicative due to |
the existing standards of care and/or delivery of services in the healthcare system; |
(3) A state-by-state comparison of health insurance mandates and the extent to which |
Rhode Island mandates exceed other states benefits; and |
(4) Recommendations for amendments to existing mandated benefits based on the findings |
in (m)(1), (m)(2), and (m)(3) above. |
(n) On or before July 1, 2014, the office of the health insurance commissioner, in |
collaboration with the director of health and lieutenant governor’s office, shall submit a report to |
the general assembly and the governor to inform the design of accountable care organizations |
(ACOs) in Rhode Island as unique structures for comprehensive healthcare delivery and value- |
based payment arrangements, that shall include, but not be limited to: |
(1) Utilization review; |
(2) Contracting; and |
(3) Licensing and regulation. |
(o) On or before February 3, 2015, the office of the health insurance commissioner shall |
submit a report to the general assembly and the governor that describes, analyzes, and proposes |
recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard |
to patients with mental health and substance use disorders. |
(p) To work to ensure the health insurance coverage of behavioral health care under the |
same terms and conditions as other health care, and to integrate behavioral health parity |
requirements into the office of the health insurance commissioner insurance oversight and |
healthcare transformation efforts. |
(q) To work with other state agencies to seek delivery system improvements that enhance |
access to a continuum of mental health and substance use disorder treatment in the state; and |
integrate that treatment with primary and other medical care to the fullest extent possible. |
(r) To direct insurers toward policies and practices that address the behavioral health needs |
of the public and greater integration of physical and behavioral healthcare delivery. |
(s) The office of the health insurance commissioner shall conduct an analysis of the impact |
of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and |
submit a report of its findings to the general assembly on or before June 1, 2023. |
(t) To undertake the analyses, reports, and studies contained in this section: |
(1) The office shall hire the necessary staff and prepare a request for proposal for a qualified |
and competent firm or firms to undertake the following analyses, reports, and studies: |
(i) The firm shall undertake a comprehensive review of all social and human service |
programs having a contract with or licensed by the state or any subdivision of the department of |
children, youth and families (DCYF), the department of behavioral healthcare, developmental |
disabilities and hospitals (BHDDH), the department of human services (DHS), the department of |
health (DOH), and Medicaid for the purposes of: |
(A) Establishing a baseline of the eligibility factors for receiving services; |
(B) Establishing a baseline of the service offering through each agency for those |
determined eligible; |
(C) Establishing a baseline understanding of reimbursement rates for all social and human |
service programs including rates currently being paid, the date of the last increase, and a proposed |
model that the state may use to conduct future studies and analyses; |
(D) Ensuring accurate and adequate reimbursement to social and human service providers |
that facilitate the availability of high-quality services to individuals receiving home and |
community-based long-term services and supports provided by social and human service providers; |
(E) Ensuring the general assembly is provided accurate financial projections on social and |
human service program costs, demand for services, and workforce needs to ensure access to entitled |
beneficiaries and services; |
(F) Establishing a baseline and determining the relationship between state government and |
the provider network including functions, responsibilities, and duties; |
(G) Determining a set of measures and accountability standards to be used by EOHHS and |
the general assembly to measure the outcomes of the provision of services including budgetary |
reporting requirements, transparency portals, and other methods; and |
(H) Reporting the findings of human services analyses and reports to the speaker of the |
house, senate president, chairs of the house and senate finance committees, chairs of the house and |
senate health and human services committees, and the governor. |
(2) The analyses, reports, and studies required pursuant to this section shall be |
accomplished and published as follows and shall provide: |
(i) An assessment and detailed reporting on all social and human service program rates to |
be completed by January 1, 2023, including rates currently being paid and the date of the last |
increase; |
(ii) An assessment and detailed reporting on eligibility standards and processes of all |
mandatory and discretionary social and human service programs to be completed by January 1, |
2023; |
(iii) An assessment and detailed reporting on utilization trends from the period of January |
1, 2017, through December 31, 2021, for social and human service programs to be completed by |
January 1, 2023; |
(iv) An assessment and detailed reporting on the structure of the state government as it |
relates to the provision of services by social and human service providers including eligibility and |
functions of the provider network to be completed by January 1, 2023; |
(v) An assessment and detailed reporting on accountability standards for services for social |
and human service programs to be completed by January 1, 2023; |
(vi) An assessment and detailed reporting by April 1, 2023, on all professional licensed |
and unlicensed personnel requirements for established rates for social and human service programs |
pursuant to a contract or established fee schedule; |
(vii) An assessment and reporting on access to social and human service programs, to |
include any wait lists and length of time on wait lists, in each service category by April 1, 2023; |
(viii) An assessment and reporting of national and regional Medicaid rates in comparison |
to Rhode Island social and human service provider rates by April 1, 2023; |
(ix) An assessment and reporting on usual and customary rates paid by private insurers and |
private pay for similar social and human service providers, both nationally and regionally, by April |
1, 2023; and |
(x) Completion of the development of an assessment and review process that includes the |
following components: eligibility; scope of services; relationship of social and human service |
provider and the state; national and regional rate comparisons and accountability standards that |
result in recommended rate adjustments; and this process shall be completed by September 1, 2023, |
and conducted biennially hereafter. The biennial rate setting shall be consistent with payment |
requirements established in § 1902(a)(30)(A) of the Social Security Act, 42 U.S.C. § |
1396a(a)(30)(A), and all federal and state law, regulations, and quality and safety standards. The |
results and findings of this process shall be transparent, and public meetings shall be conducted to |
allow providers, recipients, and other interested parties an opportunity to ask questions and provide |
comment beginning in September 2023 and biennially thereafter. |
(3) In fulfillment of the responsibilities defined in subsection (t), the office of the health |
insurance commissioner shall consult with the Executive Office of Health and Human Services. |
(u) Annually, each department (namely, EOHHS, DCYF, DOH, DHS, and BHDDH) shall |
include the corresponding components of the assessment and review (i.e., eligibility; scope of |
services; relationship of social and human service provider and the state; and national and regional |
rate comparisons and accountability standards including any changes or substantive issues between |
biennial reviews) including the recommended rates from the most recent assessment and review |
with their annual budget submission to the office of management and budget and provide a detailed |
explanation and impact statement if any rate variances exist between submitted recommended |
budget and the corresponding recommended rate from the most recent assessment and review |
process starting October 1, 2023, and biennially thereafter. |
(v) The general assembly shall appropriate adequate funding as it deems necessary to |
undertake the analyses, reports, and studies contained in this section relating to the powers and |
duties of the office of the health insurance commissioner. |
(w) The office of the health insurance commissioner shall: |
(1) Ensure that insurers minimize administrative burdens that may delay medically |
necessary care, by promulgating rules and regulations and taking enforcement actions to implement |
§ 27-18.9-16; and, |
(2) Convene the payor/provider workgroup described in subsection (h) of this section, or a |
similar taskforce, comprised of members with relevant experience and expertise, to serve as a |
standing advisory steering committee (“committee”) to review and make recommendations |
regarding: |
(i) The continuous improvement and simplification of the prior authorization processes for |
medical services and prescription drugs; |
(ii) The facilitation of communication and collaboration related to volume reduction; |
(iii) The establishment of a tracking method to improve the collection of baseline data from |
commercial health insurers that does not create an administrative burden; |
(iv) The assessment of prior authorizations that have been approved, those that have been |
approved with modifications, and the utilization of MRI services in the emergency department; |
and, |
(v) The assessment of improvements to the access of primary care services and other |
quality care measures related to the elimination of prior authorizations during this program, |
including increase in staff availability to perform other office functions; increase in patient |
appointments,; and reduction in care delay. |
(3) Shall submit such recommendations of the committee with a rationale, to the governor’s |
office, speaker of the house of representatives, and the president of the senate, prior to the |
implementation of any such recommendations and subsequently shall submit a full report to the |
general assembly by July 1 of each year of the pilot program. |
SECTION 6. Should any provision of this act be found unconstitutional, preempted, or |
otherwise invalid, that provision shall be severed and such decision shall not affect the validity of |
the other parts of this act. |
SECTION 7. This act shall take effect on October 1, 2025. |
======== |
LC001207/SUB B |
======== |