H 7942Health Insurance

Insurance - Benefit Determination and Utilization Review Act

This bill mandates that treatments ordered by doctors are presumed medically necessary unless an insurer proves otherwise.

Held for study

Population
Affected

Email Legislator

Introduced Feb 27, 2026Committee House Health & Human Services

Plain-English Summary

This legislation changes the rules for how health insurance companies handle claims. Under this bill, if a healthcare provider (like a doctor) authorizes a specific service or procedure for a patient, it is automatically assumed to be medically necessary. If an insurance company wants to deny coverage for that treatment, the burden of proof shifts to them. The insurance company becomes legally required to provide a specific justification explaining why they are denying the service that the doctor ordered.

For younger readers

When you go to the doctor, sometimes they say you need a special test or medicine to get better. Right now, insurance companies can sometimes say "no" and refuse to pay for it. This new rule says that if your doctor thinks you need something, the insurance company has to assume the doctor is right. If the insurance company doesn't want to pay, they have to work much harder to explain exactly why they think the doctor is wrong. It helps make sure you get the care your doctor orders.

Who & Where It Applies

Impacted groups

Patients/PolicyholdersDoctors and Healthcare ProvidersHealth Insurance CompaniesEmployers providing health benefitsHospital Administrators

Impacted communities

All

Constitutional & Fiscal Check

None Likely

Estimated cost

Amount unknown

Estimated revenue

None

Bill Analysis

Both viewpoints

For Progressives

Shifts power away from profit-driven insurance corporations and back to medical professionals and patients, ensuring that care decisions are based on health needs rather than corporate bottom lines.
Increases access to healthcare for vulnerable populations by removing arbitrary administrative barriers and denials that often prevent poor and disadvantaged individuals from receiving necessary treatment.
Strengthens the social safety net by mandating transparency, forcing insurers to justify denials and hindering their ability to withhold coverage for essential services to boost profits.
Could potentially lead to increased insurance premiums if insurers pass the costs of broader coverage and compliance onto working-class families who are already struggling with the cost of living.
Lacks specific enforcement mechanisms or penalties in the text, which might allow large insurance corporations to bypass the intent of the law by providing vague "rubber stamp" justifications for denials.
The presumption of necessity could theoretically be exploited by profit-seeking healthcare providers to order unnecessary tests, diverting resources within the healthcare system that could be better used for public health initiatives.

For Conservatives

Protects the sanctity of the doctor-patient relationship by preventing distant corporate bureaucrats from interfering with medical decisions made by qualified professionals.
Enforces contractual honesty and transparency by requiring insurance companies to provide clear reasons for their actions, rather than arbitrarily denying services consumers have paid for.
Reduces the administrative burden and red tape that doctors face when fighting for approval, allowing private practitioners to focus on their patients rather than paperwork.
Represents government interference in the free market by dictating the terms of private contracts between insurance companies and healthcare providers.
Will likely result in higher insurance premiums for businesses and families, as insurers will be forced to cover more procedures, driving up overall healthcare spending.
Removes necessary checks and balances on spending, potentially encouraging fraud and waste by automatically presuming that every procedure ordered by a provider is necessary effectively writing a blank check.

Votes

Loading votes...

Full Bill Text

Changes to existing Rhode Island law · 5 additions

SECTION 1. Chapter 27-18.9 of the General Laws entitled "Benefit Determination and Utilization Review Act" is hereby amended by adding thereto the following section: 27-18.9-17. Medically necessary treatment -- Justification for denial. Any healthcare service or procedure authorized by a provider to a patient shall create a presumption that the healthcare service or procedure is medically necessary and it shall be the duty of the insurance company to provide justification for any denial of such healthcare service or procedure.

SECTION 2. This act shall take effect upon passage.