The "Rhode Island Prior Authorization Reform Act of 2025" amends Section 27-18.9-2 of the General Laws to enhance the Benefit Determination and Utilization Review Act by introducing new definitions, including "adverse benefit determination," which clarifies the types of decisions made regarding healthcare service authorizations. The bill aims to streamline the healthcare authorization process by providing detailed definitions for terms such as "appeal," "authorization," and "beneficiary." Notably, it prohibits insurers from imposing prior authorization requirements for services ordered by primary care providers, with specific exceptions for brand-name prescription drugs and controlled substances. This reform is designed to improve access to necessary healthcare services and enhance the overall patient experience in Rhode Island.

In addition to the new definitions, the bill emphasizes the responsibilities of the Secretary of the Office of Health and Human Services in overseeing Medicaid programs and ensuring compliance with state and federal laws. The Secretary is tasked with reviewing changes to the Medicaid section 1115 demonstration waiver, preparing annual reports on Medicaid expenditures, and directing the development of Medicaid policies. The bill also mandates a comprehensive analysis of the small-employer health insurance market and establishes a workgroup to streamline healthcare administration processes. Overall, the act seeks to improve healthcare services, transparency, and patient care while minimizing administrative burdens on healthcare providers.

Statutes affected:
168: 27-18.9-2, 42-7.2-5, 42-14.5-3