The bill amends Chapter 27-18.9 of the General Laws, known as the "Benefit Determination and Utilization Review Act," by adding a new section, 27-18.9-17, which outlines specific provisions regarding utilization review decisions. It stipulates that a utilization review decision shall not retrospectively deny coverage for healthcare services provided to a covered person if prior approval was obtained from the insurer or its designee, unless the approval was based upon fraudulent, materially inaccurate, or misrepresented information submitted by the covered person, authorized person, or the provider.

Additionally, for health benefit plans issued or renewed on or after January 1, 2027, insurers are prohibited from requiring or conducting a prospective or concurrent review for prescription medications that are used in the treatment of alcohol or opioid use disorder, that contain Methadone, Buprenorphine, or Naltrexone, or that were approved by the United States Food and Drug Administration for the mitigation of opioid withdrawal symptoms before January 1, 2027.

Furthermore, the bill mandates that in conducting utilization reviews for Medicaid benefits, each Medicaid managed care organization shall use the medical necessity criteria selected by the Rhode Island division of insurance for making determinations of medical necessity and clinical appropriateness pursuant to the utilization review plan. This act will take effect upon passage.