The "Rhode Island Prior Authorization Reform Act of 2025" amends the Benefit Determination and Utilization Review Act by introducing new definitions and provisions aimed at improving the healthcare authorization process. Key insertions include the definitions of "adverse benefit determination," which clarifies decisions regarding healthcare service authorizations, and the establishment of a "primary care exception" that prohibits insurers from imposing prior authorization requirements for services ordered by primary care providers (PCPs). The bill also emphasizes the role of medical judgment in determining the necessity of services, particularly for experimental treatments and non-formulary drugs, and mandates that any changes to prior authorization requirements be communicated through provider-accessible websites.

Additionally, the bill enhances the responsibilities of the secretary of the Office of Health and Human Services, requiring biennial reviews of Medicaid eligibility criteria and the submission of annual reports on Medicaid expenditures and outcomes. It aims to streamline healthcare access by eliminating fixed eligibility thresholds for assistance programs and minimizing administrative burdens that delay necessary care. The act also establishes a workgroup to improve healthcare administration processes and mandates compliance monitoring with the federal Mental Health Parity Act. Overall, the bill seeks to enhance transparency, efficiency, and accountability within Rhode Island's healthcare system while ensuring better coordination among providers, insurers, and state departments.

Statutes affected:
53: 27-18.9-2, 42-7.2-5, 42-14.5-3