The bill amends Section 27-18.9-2 of the General Laws in the "Benefit Determination and Utilization Review Act" to introduce new definitions and clarify existing terms related to healthcare services and benefit determinations. Key insertions include the definition of "insurer" specifically for the purposes of § 27-18.9-16, which encompasses all licensed insurance companies in the state. The bill also distinguishes between administrative and non-administrative adverse benefit determinations and provides detailed definitions for terms such as "appeal," "authorization," and "healthcare entity." Additionally, it outlines the roles of authorized representatives and the processes for internal appeals and external reviews, emphasizing the importance of medical judgment in determining the necessity of healthcare services.

Moreover, the bill enhances the authority of the Secretary of the Executive Office of Health and Human Services (EOHHS) in coordinating healthcare benefits and human services, particularly regarding Medicaid. It mandates the Secretary to conduct biennial reviews of Medicaid eligibility criteria and prepare annual overviews of Medicaid expenditures. The bill also introduces provisions to streamline prior authorization processes, prohibiting insurers from imposing such requirements for services ordered by primary care providers, with exceptions for controlled substances. Starting January 1, 2026, a standardized prior authorization form must be used, and the bill aims to improve healthcare delivery efficiency while ensuring transparency and accountability in health insurance practices.

Statutes affected:
6317: 27-18.9-2, 42-7.2-5, 42-14.5-3