2025 -- H 5623

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LC001281

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2025

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A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

     Introduced By: Representatives McGaw, Potter, Boylan, Speakman, Casimiro,
DeSimone, Tanzi, Donovan, Cotter, and Giraldo

     Date Introduced: February 26, 2025

     Referred To: House 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:

     27-18-95. Prior authorization restrictions for rehabilitative and habilitative services.

     (a) An individual or group health insurance plan shall not require prior authorization for

rehabilitative or habilitative services including, but not limited to, physical therapy or occupational

therapy services for the first twelve (12) visits of each new episode of care. After the twelve (12)

visits of each new episode of care, an individual or group health insurance plan may not require

prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever

time period is longer. For purposes of this section, "new episode of care" means treatment for a

new or recurring condition for which an insured has not been treated by the provider within the

previous ninety (90) days.

     (b) An individual or group health insurance plan shall not require prior authorization for

physical medicine or rehabilitation services provided to patients with chronic pain for the first

ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic

management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an

individual or group health insurance plan may not require prior authorization more frequently than

every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this

subsection, "chronic pain" means pain that persists or recurs for more than three (3) months.

     (c) An individual or group health insurance plan shall respond to a prior authorization

request for services or visits in an ongoing plan of care for rehabilitative or habilitative services

within twenty-four (24) hours. If an individual or group health insurance plan requires more

information to render a decision on the prior authorization request, the individual or group health

insurance plan shall notify the patient and the provider within twenty-four (24) hours of the initial

request with the information that is needed to complete the prior authorization request including,

but not limited to, the specific tests and measures needed from the patient and provider. An

individual or group health insurance plan shall render a decision on the prior authorization request

within twenty-four (24) hours of receiving the requested information.

     (d) A prior authorization for rehabilitative or habilitative services is deemed to be approved

if an individual or group health insurance plan:

     (1) Fails to timely answer a prior authorization request in accordance with subsection (c)

of this section, including due to a failure of the individual or group health insurance plan’s prior

authorization platform or process; or

     (2) Informs a provider that prior authorization is not required orally, via an online platform

or program, through the patient's health plan documents or by any other means.

     (e) An individual or group health insurance plan shall provide a procedure for providers

and insureds to obtain retroactive authorization for rehabilitative or habilitative services that are

medically necessary covered benefits. An individual or group health insurance plan shall not deny

coverage for medically necessary services for failure to obtain a prior authorization, if a medical

necessity determination can be made after the rehabilitative or habilitative services have been

provided and the services would have been covered benefits if prior authorization had been

obtained.

     (f) An individual or group health insurance plan’s failure to approve a prior authorization

for all rehabilitative or habilitative services or visits in a plan of care is subject to the same appeal

rights as a denial under the health insurance commissioner’s rule regarding health plan

accountability and the provider's network agreement with the carrier, if any.

     (g) Nothing in this section shall be construed to prohibit an individual or group health

insurance plan from performing a retrospective medical necessity review.

     SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service

Corporations" is hereby amended by adding thereto the following section:

     27-19-87. Prior authorization restrictions for rehabilitative and habilitative services.

     (a) An individual or group health insurance plan shall not require prior authorization for

rehabilitative or habilitative services including, but not limited to, physical therapy or occupational

therapy services for the first twelve (12) visits of each new episode of care. After the twelve (12)

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visits of each new episode of care, an individual or group health insurance plan may not require

prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever

time period is longer. For purposes of this section, "new episode of care" means treatment for a

new or recurring condition for which an insured has not been treated by the provider within the

previous ninety (90) days.

     (b) An individual or group health insurance plan shall not require prior authorization for

physical medicine or rehabilitation services provided to patients with chronic pain for the first

ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic

management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an

individual or group health insurance plan may not require prior authorization more frequently than

every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this

subsection, "chronic pain" means pain that persists or recurs for more than three (3) months.

     (c) An individual or group health insurance plan shall respond to a prior authorization

request for services or visits in an ongoing plan of care for rehabilitative or habilitative services

within twenty-four (24) hours. If an individual or group health insurance plan requires more

information to render a decision on the prior authorization request, the individual or group health

insurance plan shall notify the patient and the provider within twenty-four (24) hours of the initial

request with the information that is needed to complete the prior authorization request including,

but not limited to, the specific tests and measures needed from the patient and provider. An

individual or group health insurance plan shall render a decision on the prior authorization request

within twenty-four (24) hours of receiving the requested information.

     (d) A prior authorization for rehabilitative or habilitative services is deemed to be approved

if an individual or group health insurance plan:

     (1) Fails to timely answer a prior authorization request in accordance with subsection (c)

of this section, including due to a failure of the individual or group health insurance plan’s prior

authorization platform or process; or

     (2) Informs a provider that prior authorization is not required orally, via an online platform

or program, through the patient's health plan documents or by any other means.

     (e) An individual or group health insurance plan shall provide a procedure for providers

and insureds to obtain retroactive authorization for rehabilitative or habilitative services that are

medically necessary covered benefits. An individual or group health insurance plan shall not deny

coverage for medically necessary services for failure to obtain a prior authorization, if a medical

necessity determination can be made after the rehabilitative or habilitative services have been

provided and the services would have been covered benefits if prior authorization had been

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obtained.

     (f) An individual or group health insurance plan’s failure to approve a prior authorization

for all rehabilitative or habilitative services or visits in a plan of care is subject to the same appeal

rights as a denial under the health insurance commissioner’s rule regarding health plan

accountability and the provider's network agreement with the carrier, if any.

     (g) Nothing in this section shall be construed to prohibit an individual or group health

insurance plan from performing a retrospective medical necessity review.

     SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service

Corporations" is hereby amended by adding thereto the following section:

     27-20-83. Prior authorization restrictions for rehabilitative and habilitative services.

     (a) An individual or group health insurance plan shall not require prior authorization for

rehabilitative or habilitative services including, but not limited to, physical therapy or occupational

therapy services for the first twelve (12) visits of each new episode of care. After the twelve (12)

visits of each new episode of care, an individual or group health insurance plan may not require

prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever

time period is longer. For purposes of this section, "new episode of care" means treatment for a

new or recurring condition for which an insured has not been treated by the provider within the

previous ninety (90) days.

     (b) An individual or group health insurance plan shall not require prior authorization for

physical medicine or rehabilitation services provided to patients with chronic pain for the first

ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic

management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an

individual or group health insurance plan may not require prior authorization more frequently than

every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this

subsection, "chronic pain" means pain that persists or recurs for more than three (3) months.

     (c) An individual or group health insurance plan shall respond to a prior authorization

request for services or visits in an ongoing plan of care for rehabilitative or habilitative services

within twenty-four (24) hours. If an individual or group health insurance plan requires more

information to render a decision on the prior authorization request, the individual or group health

insurance plan shall notify the patient and the provider within twenty-four (24) hours of the initial

request with the information that is needed to complete the prior authorization request including,

but not limited to, the specific tests and measures needed from the patient and provider. An

individual or group health insurance plan shall render a decision on the prior authorization request

within twenty-four (24) hours of receiving the requested information.

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     (d) A prior authorization for rehabilitative or habilitative services is deemed to be approved

if an individual or group health insurance plan:

     (1) Fails to timely answer a prior authorization request in accordance with subsection (c)

of this section, including due to a failure of the individual or group health insurance plan’s prior

authorization platform or process; or

     (2) Informs a provider that prior authorization is not required orally, via an online platform

or program, through the patient's health plan documents or by any other means.

     (e) An individual or group health insurance plan shall provide a procedure for providers

and insureds to obtain retroactive authorization for rehabilitative or habilitative services that are

medically necessary covered benefits. An individual or group health insurance plan shall not deny

coverage for medically necessary services for failure to obtain a prior authorization, if a medical

necessity determination can be made after the rehabilitative or habilitative services have been

provided and the services would have been covered benefits if prior authorization had been

obtained.

     (f) An individual or group health insurance plan’s failure to approve a prior authorization

for all rehabilitative or habilitative services or visits in a plan of care is subject to the same appeal

rights as a denial under the health insurance commissioner’s rule regarding health plan

accountability and the provider's network agreement with the carrier, if any.

     (g) Nothing in this section shall be construed to prohibit an individual or group health

insurance plan from performing a retrospective medical necessity review.

     SECTION 4. Chapter 27-41 of the General Laws entitled "Health Maintenance

Organizations" is hereby amended by adding thereto the following section:

     27-41-100. Prior authorization restrictions for rehabilitative and habilitative services.

     (a) An individual or group health insurance plan shall not require prior authorization for

rehabilitative or habilitative services including, but not limited to, physical therapy or occupational

therapy services for the first twelve (12) visits of each new episode of care. After the twelve (12)

visits of each new episode of care, an individual or group health insurance plan may not require

prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever

time period is longer. For purposes of this section, "new episode of care" means treatment for a

new or recurring condition for which an insured has not been treated by the provider within the

previous ninety (90) days.

     (b) An individual or group health insurance plan shall not require prior authorization for

physical medicine or rehabilitation services provided to patients with chronic pain for the first

ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic

LC001281 - Page 5 of 8

management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an

individual or group health insurance plan may not require prior authorization more frequently than

every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this

subsection, "chronic pain" means pain that persists or recurs for more than three (3) months.

     (c) An individual or group health insurance plan shall respond to a prior authorization

request for services or visits in an ongoing plan of care for rehabilitative or habilitative services

within twenty-four (24) hours. If an individual or group health insurance plan requires more

information to render a decision on the prior authorization request, the individual or group health

insurance plan shall notify the patient and the provider within twenty-four (24) hours of the initial

request with the information that is needed to complete the prior authorization request including,

but not limited to, the specific tests and measures needed from the patient and provider. An

individual or group health insurance plan shall render a decision on the prior authorization request

within twenty-four (24) hours of receiving the requested information.

     (d) A prior authorization for rehabilitative or habilitative services is deemed to be approved

if an individual or group health insurance plan:

     (1) Fails to timely answer a prior authorization request in accordance with subsection (c)

of this section, including due to a failure of the individual or group health insurance plan’s prior

authorization platform or process; or

     (2) Informs a provider that prior authorization is not required orally, via an online platform

or program, through the patient's health plan documents or by any other means.

     (e) An individual or group health insurance plan shall provide a procedure for providers

and insureds to obtain retroactive authorization for rehabilitative or habilitative services that are

medically necessary covered benefits. An individual or group health insurance plan shall not deny

coverage for medically necessary services for failure to obtain a prior authorization, if a medical

necessity determination can be made after the rehabilitative or habilitative services have been

provided and the services would have been covered benefits if prior authorization had been

obtained.

     (f) An individual or group health insurance plan’s failure to approve a prior authorization

for all rehabilitative or habilitative services or visits in a plan of care is subject to the same appeal

rights as a denial under the health insurance commissioner’s rule regarding health plan

accountability and the provider's network agreement with the carrier, if any.

     (g) Nothing in this section shall be construed to prohibit an individual or group health

insurance plan from performing a retrospective medical necessity review.

LC001281 - Page 6 of 8

     SECTION 5. This act shall take effect on January 1, 2026

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

***

     This act would prohibit health insurance plans from requiring prior authorization for a new

episode of rehabilitative care for twelve (12) visits, or from requiring prior authorization for

rehabilitative care for chronic pain for ninety (90) days. This act would further mandate that where

prior authorization is required, the health insurance plan would respond within twenty-four (24)

hours. In addition, this act would require health insurance plans to provide a procedure for providers

and insureds to obtain retroactive authorization for services that are medically necessary covered

benefits.

     This act would take effect on January 1, 2026

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