The bill amends the "Benefit Determination and Utilization Review Act" to enhance procedural requirements for healthcare entities and utilization review agents. It inserts new legal language to ensure that adverse benefit determinations are made by licensed practitioners with the same licensure as the ordering provider and prohibits retrospective denial of authorization for healthcare services if prior approval was obtained, except under specific circumstances. The bill also introduces a new section on step therapy exceptions, requiring insurers to grant exceptions under certain conditions and to respond to exception requests within specified time frames. It mandates that reviewers of exceptions must be healthcare professionals with expertise in the relevant medical service. Additionally, the bill amends the "Rhode Island Health Care Reform Act of 2004 — Health Insurance Oversight" to detail the powers and duties of the health insurance commissioner, including conducting quarterly public meetings and making recommendations to the governor and legislative finance committees.

The bill also establishes a consumer/business/labor/medical advisory council to address health insurance concerns, particularly for small businesses, and a subcommittee to work on issues such as fee schedule disclosure and standardizing provider application processes. It outlines recommendations for improving the electronic eligibility and coverage verification process, preventing automatic claim denials under certain circumstances, and adopting common processes for medical management approvals. The office of the health insurance commissioner is tasked with various responsibilities and reporting requirements, including distinguishing between FDA-designated interchangeable products and proprietary versions of medications, encouraging electronic prior authorization technology, and monitoring health plan compliance with the Mental Health Parity Act. The bill includes insertions granting the office of health insurance commission new oversight and enforcement authority, but no deletions from current law are mentioned.

Statutes affected:
2611: 27-18.9-5, 42-14.5-3