RELATING TO INSURANCE -- BENEFIT DETERMINATION AND UTILIZATION, REVIEW ACT
Summary
S2468 amends Rhode Island’s Benefit Determination and Utilization Review Act to place new limits on insurer step therapy protocols and to strengthen utilization review procedures. The bill requires insurers to grant exceptions to step therapy when the required step is contraindicated, ineffective, likely to delay medically necessary care, or would disrupt a patient’s stable treatment, and it sets expedited timelines for insurers to act on exception requests. It also requires insurers to maintain an accessible electronic exception process, use qualified clinical reviewers with expertise in the relevant condition, and preserve coverage while an exception request or appeal is pending.
The bill also revises utilization review rules for adverse benefit determinations. For certain non-administrative adverse determinations, the decision must be made and signed by a licensed practitioner with the same licensure status as the ordering provider, and insurers are restricted from retrospectively denying previously authorized care except in limited circumstances such as inaccurate material information or failure to follow the approved plan of care. In addition, the bill directs the Office of the Health Insurance Commissioner to receive data and documents needed to evaluate whether step therapy delays or denies medically necessary care, and it expands the commissioner’s oversight and enforcement authority over these requirements.
Impact
The bill would amend sections of title 27 governing benefit determinations and health insurance oversight, primarily by adding new statutory protections for patients and prescribing providers in the step therapy and prior authorization process. It would require insurers to modify internal review procedures, exception workflows, and clinical review staffing, while also increasing reporting obligations to the Office of the Health Insurance Commissioner. Covered persons, healthcare professionals, and insurers would all be affected, with the most direct impact on prescription drug coverage, treatment continuity, and utilization management practices.
Sentiment
The overall sentiment reflected in the bill text is strongly supportive of patient access to medically necessary care and skeptical of insurer utilization controls that delay treatment. The explanation accompanying the bill frames it as a consumer-protection measure that limits step therapy and improves transparency and oversight. No committee transcript or vote record was provided, so there is no recorded opposition or support beyond the bill’s stated purpose and structure.
Contention
The main point of contention is likely to be the balance between insurer cost-control tools and provider/patient access to treatment. Supporters would emphasize that step therapy can delay care, disrupt stable treatment, and create unnecessary administrative barriers, while insurers may object to the presumption of approval, shortened response deadlines, limits on the number and duration of required steps, and the prohibition on retrospective denials in many cases. Another likely issue is the bill’s requirement that clinical reviewers have expertise matching the condition at issue, which could increase administrative burden and compliance costs for insurers.