The bill amends Section 27-18.9-5 of the General Laws to introduce new procedural requirements for benefit determinations and utilization reviews in healthcare. It establishes a new subsection on step therapy exceptions, detailing conditions under which insurers must grant immediate coverage for prescribed treatments, including situations where the required step is contraindicated, ineffective, or will delay necessary care. Insurers are required to create a clear process for healthcare professionals to submit exception requests electronically and must approve or deny these requests within specified timeframes. The bill also mandates that while a step therapy exception request is pending, insurers must provide uninterrupted coverage of the prescribed treatment without increased cost-sharing.

Additionally, the bill 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, including the ability to require disclosure of information and impose penalties for noncompliance. The commissioner is also tasked with evaluating whether step therapy protocols delay or deny medically necessary care, and insurers must provide relevant data for this evaluation. The bill emphasizes the need for continuity of care and establishes limitations on the number of required steps and the duration of step therapy protocols.

This act would take effect upon passage.

Statutes affected:
2468: 27-18.9-5, 42-14.5-3