The bill amends Section 27-18.9-5 of the General Laws to introduce new procedural requirements for benefit determinations and utilization reviews in healthcare. It establishes that when an insurer uses a step therapy protocol to deny or restrict coverage of a prescription drug, therapy, medical test, or other service prescribed by a healthcare professional, the insurer must grant an exception for immediate coverage under specific conditions, including if the required step is contraindicated, has been tried and found ineffective, is expected to be ineffective, will delay or prevent medically necessary care, or will disrupt the patient's current effective drug regimen.

The bill mandates that insurers create a clear and accessible process for healthcare professionals to submit exception requests online and requires insurers to approve or deny these requests within seventy-two hours, or within twenty-four hours for urgent requests. If no determination is made within these time frames, the request is presumed granted. Additionally, it stipulates that individuals reviewing or discussing exceptions must be healthcare professionals with relevant expertise.

The bill also requires insurers to provide the Office of Health Insurance Commissioner with information regarding their use of step therapy protocols to allow for analysis of whether these protocols have delayed or denied medically necessary care. Furthermore, it grants the Office of Health Insurance Commissioner oversight and enforcement authority over the requirements of Section 27-18.9-5, including the power to require disclosure of information, clarify appeals procedures, limit step therapy protocol use, and impose penalties for noncompliance.

The act will take effect upon passage.

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