The bill amends the "Benefit Determination and Utilization Review Act" and the "Rhode Island Health Care Reform Act of 2004 — Health Insurance Oversight" to enhance procedural requirements for healthcare entities and utilization review agents. Key insertions include the stipulation that adverse benefit determinations must be made by licensed practitioners with the same licensure as the ordering provider, and the prohibition of retrospective denial of authorization for healthcare services if prior approval was obtained, unless based on inaccurate information. The bill also introduces a new section on step therapy exceptions, requiring insurers to grant exceptions under specific conditions and mandating an accessible online process for submitting requests. Additionally, the health insurance commissioner is tasked with conducting public meetings, making recommendations on healthcare insurance regulations, and establishing a consumer advisory council to address health insurance concerns. Furthermore, the bill grants the office of the health insurance commissioner oversight and enforcement authority over specific requirements, including information disclosure and appeals procedures, while limiting step therapy protocols. It mandates detailed assessments and reporting requirements for social and human service programs, focusing on transparency and public engagement. The bill emphasizes the need for improved communication between health plans, providers, and patients, and aims to streamline healthcare administration processes. The provisions of this act will take effect upon passage, with a focus on ensuring that patients receive medically necessary care and enhancing the overall efficiency of healthcare services in Rhode Island.

Statutes affected:
5119: 27-18.9-5, 42-14.5-3