The bill amends Section 27-18.9-5 of the General Laws to introduce new procedural requirements for healthcare benefit determinations and utilization reviews. Key insertions include the establishment of a section titled "Administrative and non-administrative benefit determination procedural requirements," which outlines the responsibilities of healthcare entities in notifying claimants about procedural failures and requires claimants to provide specific information regarding their medical conditions and treatment requests. Additionally, a new subsection on "Step therapy exceptions" is introduced, detailing conditions under which insurers must grant exceptions to step therapy protocols that deny or restrict coverage for prescribed treatments. The bill also enhances the powers of the health insurance commissioner, mandating quarterly public meetings to discuss health insurer operations and their impact on consumers, while emphasizing transparency and accountability.

Moreover, the bill establishes a consumer/business/labor/medical advisory council to address health insurance concerns, particularly for small businesses, and mandates the creation of a workgroup to streamline healthcare administration processes. It proposes guidelines for improving the electronic eligibility and coverage verification process, ensuring claims are not automatically denied due to preauthorization issues, and enhancing communication between health plans, providers, and patients. The bill also outlines various responsibilities for the office of the health insurance commissioner, including analyzing the impact of healthcare benefits on insurance costs and ensuring compliance with mental health parity laws. Overall, the bill aims to improve procedural clarity, accountability, and access to necessary medical treatments while enhancing oversight of health insurance practices.

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