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 specific provisions regarding step therapy protocols, requiring insurers to grant exceptions for immediate coverage under certain conditions, including if the required step is contraindicated, has been tried and found ineffective, is likely to be ineffective based on the patient's clinical history, will delay or prevent medically necessary care, or will disrupt the patient's current stable and effective course of treatment. Insurers must create a clear and accessible process for healthcare professionals to submit exception requests electronically and must approve or deny these requests within specified time frames. If no determination is made within these time frames, the request is presumed granted. The bill also mandates that while a step therapy exception request or appeal 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 requirements of this chapter. This includes the power to require disclosure of information and documents, clarify or simplify appeals procedures, limit step therapy protocol use, and impose penalties for noncompliance. The commissioner is also tasked with evaluating whether step therapy protocols delay or deny medically necessary care, including the collection of utilization and outcome data as required. The act takes effect upon passage.

Statutes affected:
7539: 27-18.9-5, 42-14.5-3