The bill amends Section 27-18.9-5 of the General Laws to introduce new procedural requirements for insurers concerning benefit determinations and utilization reviews. It establishes a new section on step therapy exceptions, which requires insurers to grant immediate coverage exceptions when specific conditions are met, such as when a prescribed treatment is contraindicated, has been ineffective, or will disrupt a patient's current effective drug regimen. Insurers must also create a clear and accessible process for healthcare professionals to submit exception requests online and must approve or deny these requests within specified time frames. If no determination is made within these time frames, the request is presumed granted. Additionally, individuals reviewing exception requests must be 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 new requirements. The commissioner is empowered to require disclosure of information, clarify appeals procedures, limit the use of step therapy protocols, and impose penalties for noncompliance. Overall, the bill aims to improve the process for obtaining necessary medical care and ensure compliance with the new regulations.

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