The bill amends the "Benefit Determination and Utilization Review Act" and the "Rhode Island Health Care Reform Act of 2004 Health Insurance Oversight" to enhance the procedures for healthcare entities and utilization review agents, and to detail the powers and duties of the health insurance commissioner. It introduces requirements for adverse benefit determinations to be made by a licensed practitioner with the same licensure as the ordering provider and prohibits retrospective denial of authorization for services if prior approval was obtained, except under specific circumstances. The bill also mandates insurers to grant exceptions to step therapy protocols under certain conditions and outlines a clear process for submitting exception requests with defined time frames for insurer responses. Additionally, it requires the health insurance commissioner to conduct quarterly public meetings, provide recommendations to the governor and legislative finance committees, and establish a consumer/business/labor/medical advisory council to address health insurance concerns. The bill further requires the creation of a subcommittee to report on healthcare administration aspects, including fee schedule disclosures and standardized provider application processes. It mandates the establishment of a consistent standard for electronic eligibility and coverage verification, the development of guidelines for coding policies, and the improvement of the prior authorization process. The bill emphasizes continuity of care and the establishment of guidelines to streamline healthcare administration. It also outlines various responsibilities for the Office of the Health Insurance Commissioner (OHIC), including monitoring compliance with federal and state laws, reporting on hospital payment variation, and the impact of mandated healthcare benefits on insurance costs. The bill does not include any text marked with or , indicating that it adds new requirements and tasks without directly modifying existing legal language. It also grants the OHIC new oversight and enforcement authority, including the power to impose fines for noncompliance, and aims to limit the use of step therapy by insurers. The act would take effect immediately upon passage.

Statutes affected:
2611: 27-18.9-5, 42-14.5-3