Bill > S0485

This bill limits prior authorization requirements for rehabilitative and habilitative services across different types of health insurance plans in Rhode Island. Specifically, the bill mandates that health insurance plans cannot require prior authorization for the first twelve visits of a new episode of care for services like physical or occupational therapy, where a "new episode of care" means treatment for a condition not addressed in the previous 90 days. Additionally, the bill prohibits prior authorization for physical medicine or rehabilitation services for patients with chronic pain (defined as pain persisting over three months) during the first 90 days following diagnosis. The bill also establishes strict timelines for insurance plan responses to prior authorization requests, requiring a response within 24 hours and providing clear guidelines for what constitutes an approved authorization. If an insurance plan fails to respond in a timely manner or provides conflicting information about authorization requirements, the prior authorization is considered automatically approved. The bill further ensures that patients cannot be denied coverage for medically necessary services solely due to a lack of prior authorization and maintains the insurance plans' ability to conduct retrospective medical necessity reviews. The provisions will take effect on January 1, 2026, and apply to individual and group health insurance plans, nonprofit hospital service corporations, nonprofit medical service corporations, and health maintenance organizations.

Health and Social Services

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