The bill amends Section 27-18.9-5 of the General Laws to introduce new procedural requirements for insurers regarding benefit determinations and utilization reviews. It establishes a new section on step therapy exceptions, which mandates that insurers grant immediate coverage for prescribed treatments under specific circumstances, including when a step therapy protocol is contraindicated, ineffective, or would delay necessary care. Insurers are required to create a clear process for healthcare professionals to submit exception requests online and must approve or deny these requests within specified timeframes. If no determination is made within these timeframes, the request is presumed granted. Additionally, the bill ensures that individuals reviewing exception requests are healthcare professionals with relevant expertise.

The bill also amends Section 42-14.5-3 to enhance the powers and duties of the health insurance commissioner, granting oversight and enforcement authority over the requirements of this chapter. This includes the ability to require disclosure of information, clarify appeals procedures, limit step therapy protocol use, and impose penalties for noncompliance. The commissioner is tasked with ensuring the delivery of medically necessary care and will have the authority to analyze the use of step therapy protocols to prevent delays in care. The act takes effect upon passage.

Statutes affected:
116: 27-18.9-5, 42-14.5-3