Rhode Island Senate Bill S0053

Rhode Island 2025 Regular Session

• Introduced: 1/23/25
• Refer: 1/23/25

Caption

Provides an insurer would not impose prior authorization requirements for any service ordered by an in-network primary care provider.

Summary

S0053, titled the “Rhode Island Prior Authorization Reform Act of 2025,” would substantially limit prior authorization in health insurance when a service is ordered by an in-network primary care provider. Under the bill, insurers generally could not require prior authorization for any admission, item, service, treatment, or procedure ordered by a PCP, although prescription drugs would remain subject to prior authorization. The bill also defines and reorganizes a number of utilization review and appeal terms within Rhode Island’s Benefit Determination and Utilization Review Act. Beyond the new PCP exception, the bill makes conforming and related changes to the duties of the Executive Office of Health and Human Services and the health insurance commissioner. Those provisions emphasize reducing administrative burden, improving transparency in utilization review, and directing insurers toward more streamlined prior authorization processes, including electronic standards, continuity of care protections, and clearer disclosure of requirements and appeal processes. The act is scheduled to take effect on July 1, 2026.

Impact

The bill would amend Chapter 27-18.9 of the General Laws by adding a new section prohibiting prior authorization for most services ordered by an in-network primary care provider, while preserving prior authorization for prescription drugs. It also revises definitions used in utilization review and updates related oversight language in Title 42, especially the duties of EOHHS and the health insurance commissioner, to support enforcement and administrative simplification. In practical terms, the bill would affect insurers, pharmacy benefit managers, primary care providers, and patients by reducing utilization-review hurdles for PCP-ordered care and potentially increasing access to timely treatment.

Sentiment

The bill appears to be generally favorable to patients and providers who support reducing administrative barriers in health care, especially around prior authorization. The caption and text frame the measure as reform aimed at making medically necessary care easier to obtain and less delayed by insurer review processes. No committee transcript or vote record was provided, so there is no recorded opposition or formal vote history to indicate broader legislative sentiment beyond the bill’s pro-reform structure.

Contention

The main point of contention is the scope of the prior authorization ban. Supporters are likely to favor the broad exemption for services ordered by in-network primary care providers, while insurers may object that the restriction limits utilization management and could increase costs or reduce oversight of medical necessity. The bill also preserves prior authorization for prescription drugs, which suggests a compromise point and a likely area of debate over whether drug coverage should be treated differently from other services. Additional tension may arise over the bill’s broader administrative mandates on insurers and the health insurance commissioner, including enforcement and process-standardization requirements.