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S2109aaHealth Insurance

Insurance - Benefit Determination and Utilization Review Act

This bill stops insurers from requiring prior approval for certain addiction medications and prevents reversing previously approved healthcare coverage.

Introduced37 Yea0 Nay1 Not voting
Population
Affected
65
Email Legislator
Introduced Jan 16, 2026Committee Senate Health & Human Services

Plain-English Summary

This bill prevents health insurance companies from denying coverage for a healthcare service after it has been provided, as long as the service was approved beforehand and no fraudulent or inaccurate information was given. It also bans insurers from requiring prior approval for prescription medications used to treat alcohol or opioid use disorders, such as methadone, buprenorphine, or naltrexone, starting in 2027. Additionally, the bill requires Medicaid managed care organizations to use specific medical necessity criteria chosen by the state's Executive Office of Health and Human Services when reviewing benefit claims.

For younger readers

Imagine you ask your parents if you can buy a toy, and they say yes. But after you buy it, they refuse to pay for it. This bill stops health insurance companies from doing that to doctors and patients if they already said yes to a treatment. It also says that starting in a few years, insurance companies can't make people wait for special permission to get medicine that helps them stop drinking alcohol or taking harmful drugs. Finally, it makes sure the state’s health program for people who need extra help follows strict rules.

Who & Where It Applies

Impacted groups
Health insurance companiesHealthcare providersMedicaid recipientsIndividuals with substance use disordersPharmacists
Impacted communities
All

Constitutional & Fiscal Check

None Likely. The bill regulates insurance contracts and Medicaid administration, which falls well within the state's established regulatory authority over public health and the business of insurance. It does not appear to infringe upon free speech, due process, or protection from unreasonable searches and seizures.

Estimated cost
Amount unknown
Estimated revenue
None

Bill Analysis

Both viewpoints
For Progressives
  • Removes barriers to life-saving addiction treatments by eliminating prior authorization for opioid and alcohol use disorder medications, ensuring vulnerable individuals get immediate help.
  • Protects patients and healthcare providers from predatory insurance practices by prohibiting retrospective denials of previously approved care, strengthening the healthcare safety net.
  • Standardizes Medicaid utilization reviews by requiring managed care organizations to use state-selected medical necessity criteria, ensuring fairer, more consistent healthcare access for low-income populations.
  • The elimination of prior authorizations for addiction medications does not take effect until January 1, 2027, delaying critical access to treatment during an ongoing opioid crisis.
  • The bill only addresses prior authorization for specific medications, missing an opportunity to comprehensively reform utilization management for all mental health and substance abuse treatments.
  • By focusing heavily on private insurance and Medicaid managed care, it may not adequately protect uninsured or undocumented individuals who struggle the most to access addiction treatment.
For Conservatives
  • Reduces administrative burdens and red tape for healthcare providers by stopping insurance companies from retroactively denying approved claims, streamlining business operations.
  • Holds individuals and providers accountable by maintaining the right for insurers to deny claims if the original approval was based on fraudulent or misrepresented information.
  • Streamlines Medicaid oversight by ensuring managed care organizations use a single, standardized set of criteria, potentially reducing government waste and inefficiencies in the state system.
  • Restricts the freedom of private insurance companies to manage their own risk and control costs by banning them from requiring prior authorizations on specific medications.
  • Imposes strict government mandates on private healthcare contracts, forcing insurers to adhere to state-dictated rules on how they conduct utilization reviews.
  • By standardizing Medicaid criteria through a central state office, the bill removes flexibility from private managed care organizations that might otherwise implement more stringent cost-saving measures.

Votes

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Full Bill Text

2 versions
Changes to existing Rhode Island law · 18 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. Utilization review decisions for the treatment of alcohol or substance use disorder.

(a) A utilization review decision shall not retrospectively deny coverage for healthcare service provided to a covered person, when prior approval has been obtained from the insurer or its designee for those services, unless the approval was based upon fraudulent, materially inaccurate, or misrepresented information submitted by the covered person, authorized person, or the provider.

(b) For health benefit plans issued or renewed on or after January 1, 2027, an insurer or shall not require or conduct a prospective or concurrent review for a prescription medicine:

(1) That is used for the treatment of alcohol or opioid use disorder; (2) That contains methadone, buprenorphine or naltrexone; or

(3) That was approved before January 1, 2027, by the United States Food and Drug Administration for the management of alcohol or opioid use disorder, or the mitigation of opioid withdrawal symptoms.

SECTION 2. Chapter 40-8 of the General Laws entitled "Medical Assistance" is hereby amended by adding thereto the following section: 40-8-33. Utilization reviews for Medicaid benefits. In conducting utilization reviews for Medicaid benefits, each Medicaid managed care organization shall use the medical necessity criteria selected by the executive office of health and human services for making determinations of medical necessity and clinical appropriateness pursuant to the utilization review plan.

SECTION 3. This act shall take effect upon passage.