RI 2026 S2386: Insurance - Accident and Sickness Insurance Policies

Plain-English Summary

This legislation requires health insurance companies and the state Medicaid program to pay pharmacists for providing specific medical services. These services include evaluating patients, managing medication therapies, administering immunizations and other medications, and ordering lab tests. The bill mandates that if an insurance plan covers these services when performed by a doctor or nurse, they must also cover them when performed by a pharmacist. Additionally, insurance plans must include an adequate number of pharmacists in their medical provider networks. The law takes effect in 2027 and is set to expire in 2031 unless lawmakers extend it.

For younger readers

This new rule says that health insurance companies must pay pharmacists for doing certain jobs that doctors usually do. These jobs include giving shots to stop people from getting sick, checking if medicines are working right, and ordering tests. Usually, insurance pays doctors for this work, but now they have to pay pharmacists too if the pharmacist does the job. This helps people get care at the pharmacy instead of always going to a doctor's office. The rule starts in 2027 and will end in 2031 unless the government decides to keep it.

Who & Where It Applies

Impacted groups

PharmacistsHealth Insurance CompaniesMedicaid RecipientsPatientsDoctors

Impacted communities

All

Constitutional & Fiscal Check

None Likely

Estimated cost

Amount unknown

Estimated revenue

None

Bill Analysis

Both viewpoints

For Progressives

Increases healthcare accessibility for underserved and low-income communities by allowing pharmacists to provide compensable medical services, reducing barriers to essential care like immunizations and clinical testing.
Strengthens the social safety net by mandating Medicaid coverage for these expanded services, ensuring that the most vulnerable populations have more flexible options for receiving medical attention.
Empowers healthcare workers by formally recognizing the value of labor provided by pharmacists, potentially elevating their professional standing and ensuring they are compensated fairly for medical services they are qualified to perform.
Includes a sunset clause that expires in 2031, which fails to provide permanent systemic reform and creates future uncertainty for patients who may come to rely on these expanded access points.
Risk that private insurance companies may use the expansion of provider networks as a justification to raise premiums or deductibles, ultimately passing the cost burden onto working-class families.
Could potentially fragment care by encouraging reliance on retail pharmacy chains for medical services rather than fostering long-term, holistic relationships with primary care physicians in community health settings.

For Conservatives

Promotes free market competition in the healthcare sector by breaking the monopoly physicians hold over certain routine services, allowing pharmacists to compete for patients and reimbursement.
Encourages efficiency and consumer choice by allowing individuals to utilize pharmacists for routine medical needs, potentially reducing congestion and costs associated with doctor's offices and emergency rooms.
Leverages the existing private sector workforce of pharmacists to deliver care without creating new government agencies or hiring new public employees.
Imposes heavy government mandates on private businesses by dictating which providers insurance companies must include in their networks and what services they are legally required to cover.
Expands the scope and potential cost of the state Medicaid program, likely increasing the burden on taxpayers to fund reimbursements for a wider range of providers.
Interferes with the freedom of contract by forcing insurers to reimburse pharmacists for services, rather than allowing reimbursement rates and network inclusion to be determined by private negotiation and market forces.

Votes

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Full Bill Text

Changes to existing Rhode Island law · 149 additions

SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness Insurance Policies" is hereby amended by adding thereto the following section: 27-18-96. Coverage for pharmacists' services.

(a) Every group health insurance contract, or every group hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery, or renewed in this state, by any health insurance carrier, on or after January 1, 2027, shall provide coverage for the services within the lawful scope of the "practice of pharmacy" defined in § 5-19.1-2, and pharmacists' services provided under a "collaborative practice agreement" defined in § 5-19.2-2, if the plan would have provided coverage if the service had been performed by a physician, advanced practice nurse, or physician assistant. No nonprofit medical service corporation may require supervision, signature, or referral by any other healthcare provider as a condition of reimbursement to a pharmacist; provided that, no nonprofit medical service corporation may be required to pay for duplicative services actually rendered by both a pharmacist and any other healthcare provider. The following services shall qualify as being eligible for payment and reimbursement to a pharmacist, unless paid by another mechanism, include:

(1) Evaluation and management of a patient, which requires a medically appropriate history and/or examination and medical decision making;

(2) Medication therapy management review;

(3) Immunization education and administration;

(4) Administration of medications; and

(5) Ordering and evaluation of clinical laboratory tests.

(b) The health plan shall include an adequate number of pharmacists in its network of participating medical providers. The participation of pharmacies in the plan network's drug benefit shall not satisfy the requirement that plans include pharmacists in their networks of participating medical providers.

(c) The healthcare benefits outlined in this section apply only to services delivered within the health insurer's provider network; provided that, all health insurers shall be required to provide coverage for those benefits required by the provisions of this section outside of the health insurer's provider network where it can be established that the required services are not available from a provider in the health insurer's network.

(d) The provisions of this section shall sunset and expire on January 1, 2031, unless extended by the general assembly.

SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service Corporations" is hereby amended by adding thereto the following section: 27-19-88. Coverage for pharmacists' services.

(a) Every group health insurance contract, or every group hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery, or renewed in this state, by any health insurance carrier, on or after January 1, 2027, shall provide coverage for the services within the lawful scope of the "practice of pharmacy" defined in § 5-19.1-2, and pharmacists' services provided under a "collaborative practice agreement" defined in § 5-19.2-2, if the plan would have provided coverage if the service had been performed by a physician, advanced practice nurse, or physician assistant. No nonprofit medical service corporation may require supervision, signature, or referral by any other healthcare provider as a condition of reimbursement to a pharmacist; provided that, no nonprofit medical service corporation may be required to pay for duplicative services actually rendered by both a pharmacist and any other healthcare provider. The following services shall qualify as being eligible for payment and reimbursement to a pharmacist, unless paid by another mechanism, include:

(1) Evaluation and management of a patient, which requires a medically appropriate history and/or examination and medical decision making;

(2) Medication therapy management review;

(3) Immunization education and administration;

(4) Administration of medications; and

(5) Ordering and evaluation of clinical laboratory tests.

(b) The health plan shall include an adequate number of pharmacists in its network of participating medical providers. The participation of pharmacies in the plan network's drug benefit shall not satisfy the requirement that plans include pharmacists in their networks of participating medical providers.

(c) The healthcare benefits outlined in this section apply only to services delivered within the health insurer's provider network; provided that, all health insurers shall be required to provide coverage for those benefits required by the provisions of this section outside of the health insurer's provider network where it can be established that the required services are not available from a provider in the health insurer's network.

(d) The provisions of this section shall sunset and expire on January 1, 2031, unless extended by the general assembly.

SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service Corporations" is hereby amended by adding thereto the following section: 27-20-84. Coverage for pharmacists' services.

(a) Every group health insurance contract, or every group hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery, or renewed in this state, by any health insurance carrier, on or after January 1, 2027, shall provide coverage for the services within the lawful scope of the "practice of pharmacy" defined in § 5-19.1-2, and pharmacists' services provided under a "collaborative practice agreement" defined in § 5-19.2-2, if the plan would have provided coverage if the service had been performed by a physician, advanced practice nurse, or physician assistant. No nonprofit medical service corporation may require supervision, signature, or referral by any other healthcare provider as a condition of reimbursement to a pharmacist; provided that, no nonprofit medical service corporation may be required to pay for duplicative services actually rendered by both a pharmacist and any other healthcare provider. The following services shall qualify as being eligible for payment and reimbursement to a pharmacist, unless paid by another mechanism, include:

(1) Evaluation and management of a patient, which requires a medically appropriate history and/or examination and medical decision making;

(2) Medication therapy management review;

(3) Immunization education and administration;

(4) Administration of medications; and

(5) Ordering and evaluation of clinical laboratory tests.

(b) The health plan shall include an adequate number of pharmacists in its network of participating medical providers. The participation of pharmacies in the plan network's drug benefit shall not satisfy the requirement that plans include pharmacists in their networks of participating medical providers.

(c) The healthcare benefits outlined in this section apply only to services delivered within the health insurer's provider network; provided that, all health insurers shall be required to provide coverage for those benefits required by the provisions of this section outside of the health insurer's provider network where it can be established that the required services are not available from a provider in the health insurer's network.

(d) The provisions of this section shall sunset and expire on January 1, 2031, unless extended by the general assembly.

SECTION 4. Chapter 27-41 of the General Laws entitled "Health Maintenance Organizations" is hereby amended by adding thereto the following section: 27-41-101. Coverage for pharmacists' services.

(a) Every group health insurance contract, or every group hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery, or renewed in this state, by any health insurance carrier, on or after January 1, 2027, shall provide coverage for the services within the lawful scope of the "practice of pharmacy" defined in § 5-19.1-2, and pharmacists' services provided under a "collaborative practice agreement" defined in § 5-19.2-2, if the plan would have provided coverage if the service had been performed by a physician, advanced practice nurse, or physician assistant. No nonprofit medical service corporation may require supervision, signature, or referral by any other healthcare provider as a condition of reimbursement to a pharmacist; provided that, no nonprofit medical service corporation may be required to pay for duplicative services actually rendered by both a pharmacist and any other healthcare provider. The following services shall qualify as being eligible for payment and reimbursement to a pharmacist, unless paid by another mechanism, include:

(1) Evaluation and management of a patient, which requires a medically appropriate history and/or examination and medical decision making;

(2) Medication therapy management review;

(3) Immunization education and administration;

(4) Administration of medications; and

(5) Ordering and evaluation of clinical laboratory tests.

(b) The health plan shall include an adequate number of pharmacists in its network of participating medical providers. The participation of pharmacies in the plan network's drug benefit shall not satisfy the requirement that plans include pharmacists in their networks of participating medical providers.

(c) The healthcare benefits outlined in this section apply only to services delivered within the health insurer's provider network; provided that, all health insurers shall be required to provide coverage for those benefits required by the provisions of this section outside of the health insurer's provider network where it can be established that the required services are not available from a provider in the health insurer's network.

(d) The provisions of this section shall sunset and expire on January 1, 2031, unless extended by the general assembly.

SECTION 5. Chapter 40-8 of the General Laws entitled "Medical Assistance" is hereby amended by adding thereto the following section: 40-8-33. Coverage for pharmacists' services.

(a) The executive office of health and human services is directed and authorized to establish coverage for the services within the lawful scope of the "practice of pharmacy" defined in § 5-19.1- 2, and pharmacists' services provided under a "collaborative practice agreement" defined in § 5- 19.2-2, if the plan would have provided coverage if the service had been performed by a physician, advanced practice nurse, or physician assistant. The following services would qualify as being eligible for payment and reimbursement to a pharmacist, unless paid by another mechanism, include:

(1) Evaluation and management of a patient, which requires a medically appropriate history and/or examination and medical decision making;

(2) Medication therapy management review;

(3) Immunization education and administration;

(4) Administration of medications; and

(5) Ordering and evaluation of clinical laboratory tests.

(b) The health plan shall include pharmacists in its network of participating medical providers. The participation of pharmacies in the plan network's drug benefit shall not satisfy the requirement that plans include pharmacists in their networks of participating medical providers.

(c) The healthcare benefits outlined in this section apply only to services delivered within the health insurer's provider network; provided that, all health insurers shall be required to provide coverage for those benefits required by the provisions of this section outside of the health insurer's provider network where it can be established that the required services are not available from a provider in the health insurer's network.

(d) The executive office of health and department of human services shall apply to the United States department of health and human services for any amendment to the state Medicaid plan or for any Medicaid waiver as necessary to implement this section. The executive office of health and human services shall submit the Medicaid state plan amendment not later than September 1, 2026.

(e) The provisions of this section shall sunset and expire on January 1, 2031, unless extended by the general assembly.

SECTION 6. This act shall take effect on January 1, 2027, and unless extended by the general assembly, shall expire on January 1, 2031.