The "Rhode Island Prior Authorization Reform Act of 2025" establishes a three-year pilot program that prohibits insurers from imposing prior authorization requirements for any admission, item, service, treatment, or procedure ordered by an in-network primary care provider, with the exception of prescription drugs. Insurers are required to submit annual reports on the program's implementation to the governor, the speaker of the house of representatives, the president of the senate, and the office of the health insurance commissioner. The program is set to expire on October 1, 2028, unless extended by the General Assembly.

The bill also updates definitions within the Benefit Determination and Utilization Review Act to clarify the roles of various stakeholders, including the definitions of "insurer," "primary care provider," and "prior authorization." Additionally, it outlines new responsibilities for the Office of the Health Insurance Commissioner (OHIC), including ensuring that insurers minimize administrative burdens that may delay medically necessary care and conducting analyses related to the prior authorization process.

Furthermore, the bill mandates the establishment of a payor/provider workgroup to review and make recommendations regarding the continuous improvement and simplification of prior authorization processes, the facilitation of communication and collaboration, and the assessment of improvements to access to primary care services and other quality care measures. The OHIC is also tasked with submitting recommendations and a full report to the General Assembly by July 1 of each year during the pilot program.

Statutes affected:
5120: 27-18.9-2, 42-7.2-5, 42-14.5-3
5120  SUB A: 27-18.9-2, 42-7.2-5, 42-14.5-3