2024 -- S 2086 AS AMENDED

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LC004126

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2024

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A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

     Introduced By: Senators Ujifusa, Miller, Valverde, DiMario, Gu, Acosta, Mack, Gallo,

     Date Introduced: January 12, 2024

     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

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 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 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

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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 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:

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     (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 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,

LC004126 - Page 4 of 6

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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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

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     This act would prevent healthcare entities from refusing to authorize, approve, or pay a

participating provider for providing covered clinician-administered drugs and related services to

covered persons. This act would also prevent healthcare entities from imposing coverage or benefits

limitations, or require an enrollee to pay an additional fee, higher copay, higher coinsurance, second

copay, second coinsurance, or other penalty when obtaining clinician-administered drugs from a

healthcare provider. It would prohibit interference with the patient's right to choose to obtain a

clinician-administered drug from their provider or pharmacy of choice.

     This act would take effect upon passage.

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