AN ACT RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES (Limits prior authorization requirements for rehabilitative and habilitative services. Also prohibits prior authorization for the first twelve (12) visits of a new episode of care and for ninety (90) days following a chronic pain diagnosis.)

H7347

2026 -- H 7347
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LC004486
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STATE OF RHODE ISLAND
IN GENERAL ASSEMBLY
JANUARY SESSION, A.D. 2026
____________
A N A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

Introduced By:
Representatives McGaw, Fogarty, Carson, Potter, Fellela, Furtado,
Morales, Messier, Donovan, and Boylan

Date Introduced:
January 28, 2026

Referred To:
House Health & Human Services
It is enacted by the General Assembly as follows:
1
SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness Insurance
2
Policies" is hereby amended by adding thereto the following section:
3

27-18-96. Prior authorization restrictions for rehabilitative and habilitative services.
4

(a) An individual or group health insurance plan shall not require prior authorization for
5
rehabilitative or habilitative services including, but not limited to, physical therapy services for the
6
first twelve (12) visits of each new episode of care. After the twelve (12) visits of each new episode
7
of care, an individual or group health insurance plan may not require prior authorization more
8
frequently than every six (6) visits or every thirty (30) days, whichever time period is longer. For
9
purposes of this section, "new episode of care" means treatment for a new or recurring condition
10
for which an insured has not been treated by the provider within the previous ninety (90) days.
11

(b) An individual or group health insurance plan shall not require prior authorization for
12
physical medicine or rehabilitation services provided to patients with chronic pain for the first
13
ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic
14
management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an
15
individual or group health insurance plan may not require prior authorization more frequently than
16
every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this
17
subsection, "chronic pain" means pain that persists or recurs for more than three (3) months.
18

(c) An individual or group health insurance plan shall respond to a prior authorization
19
request for services or visits in an ongoing plan of care for rehabilitative or habilitative services

1
within twenty-four (24) hours. If an individual or group health insurance plan requires more
2
information to render a decision on the prior authorization request, the individual or group health
3
insurance plan shall notify the patient and the provider within twenty-four (24) hours of the initial
4
request with the information that is needed to complete the prior authorization request including,
5
but not limited to, the specific tests and measures needed from the patient and provider. An
6
individual or group health insurance plan shall render a decision on the prior authorization request
7
within twenty-four (24) hours of receiving the requested information.
8

(d) A prior authorization for rehabilitative or habilitative services is deemed to be approved
9
if an individual or group health insurance plan:
10

(1) Fails to timely answer a prior authorization request in accordance with subsection (c)
11
of this section, including due to a failure of the individual or group health insurance plan’s prior
12
authorization platform or process; or
13

(2) Informs a provider that prior authorization is not required orally, via an online platform
14
or program, through the patient's health plan documents or by any other means.
15

(e) An individual or group health insurance plan shall provide a procedure for providers
16
and insureds to obtain retroactive authorization for rehabilitative or habilitative services that are
17
medically necessary covered benefits. An individual or group health insurance plan shall not deny
18
coverage for medically necessary services for failure to obtain a prior authorization, if a medical
19
necessity determination can be made after the rehabilitative or habilitative services have been
20
provided and the services would have been covered benefits if prior authorization had been
21
obtained.
22

(f) An individual or group health insurance plan’s failure to approve a prior authorization
23
for all rehabilitative or habilitative services or visits in a plan of care is subject to the same appeal
24
rights as a denial under the health insurance commissioner’s rule regarding health plan
25
accountability and the provider's network agreement with the carrier, if any.
26

(g) Nothing in this section shall be construed to prohibit an individual or group health
27
insurance plan from performing a retrospective medical necessity review.
28
SECTION 2. Chapter 27-19 of the General Laws entitled " Nonprofit Hospital Service
29
Corporations " is hereby amended by adding thereto the following section:
30

27-19-88. Prior authorization restrictions for rehabilitative and habilitative services.
31

(a) An individual or group health insurance plan shall not require prior authorization for
32
rehabilitative or habilitative services including, but not limited to, physical therapy services for the
33
first twelve (12) visits of each new episode of care. After the twelve (12) visits of each new episode
34
of care, an individual or group health insurance plan may not require prior authorization more

LC004486 - Page 2 of 7
1
frequently than every six (6) visits or every thirty (30) days, whichever time period is longer. For
2
purposes of this section, "new episode of care" means treatment for a new or recurring condition
3
for which an insured has not been treated by the provider within the previous ninety (90) days.
4

(b) An individual or group health insurance plan shall not require prior authorization for
5
physical medicine or rehabilitation services provided to patients with chronic pain for the first
6
ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic
7
management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an
8
individual or group health insurance plan may not require prior authorization more frequently than
9
every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this
10
subsection, "chronic pain" means pain that persists or recurs for more than three (3) months.
11

(c) An individual or group health insurance plan shall respond to a prior authorization
12
request for services or visits in an ongoing plan of care for rehabilitative or habilitative services
13
within twenty-four (24) hours. If an individual or group health insurance plan requires more
14
information to render a decision on the prior authorization request, the individual or group health
15
insurance plan shall notify the patient and the provider within twenty-four (24) hours of the initial
16
request with the information that is needed to complete the prior authorization request including,
17
but not limited to, the specific tests and measures needed from the patient and provider. An
18
individual or group health insurance plan shall render a decision on the prior authorization request
19
within twenty-four (24) hours of receiving the requested information.
20

(d) A prior authorization for rehabilitative or habilitative services is deemed to be approved
21
if an individual or group health insurance plan:
22

(1) Fails to timely answer a prior authorization request in accordance with subsection (c)
23
of this section, including due to a failure of the individual or group health insurance plan’s prior
24
authorization platform or process; or
25

(2) Informs a provider that prior authorization is not required orally, via an online platform
26
or program, through the patient's health plan documents or by any other means.
27

(e) An individual or group health insurance plan shall provide a procedure for providers
28
and insureds to obtain retroactive authorization for rehabilitative or habilitative services that are
29
medically necessary covered benefits. An individual or group health insurance plan shall not deny
30
coverage for medically necessary services for failure to obtain a prior authorization, if a medical
31
necessity determination can be made after the rehabilitative or habilitative services have been
32
provided and the services would have been covered benefits if prior authorization had been
33
obtained.
34

(f) An individual or group health insurance plan’s failure to approve a prior authorization

LC004486 - Page 3 of 7
1
for all rehabilitative or habilitative services or visits in a plan of care is subject to the same appeal
2
rights as a denial under the health insurance commissioner’s rule regarding health plan
3
accountability and the provider's network agreement with the carrier, if any.
4

(g) Nothing in this section shall be construed to prohibit an individual or group health
5
insurance plan from performing a retrospective medical necessity review.
6
SECTION 3. Chapter 27-20 of the General Laws entitled " Nonprofit Medical Service
7
Corporations " is hereby amended by adding thereto the following section:
8

27-20-84. Prior authorization restrictions for rehabilitative and habilitative services.
9

(a) An individual or group health insurance plan shall not require prior authorization for
10
rehabilitative or habilitative services including, but not limited to, physical therapy services for the
11
first twelve (12) visits of each new episode of care. After the twelve (12) visits of each new episode
12
of care, an individual or group health insurance plan may not require prior authorization more
13
frequently than every six (6) visits or every thirty (30) days, whichever time period is longer. For
14
purposes of this section, "new episode of care" means treatment for a new or recurring condition
15
for which an insured has not been treated by the provider within the previous ninety (90) days.
16

(b) An individual or group health insurance plan shall not require prior authorization for
17
physical medicine or rehabilitation services provided to patients with chronic pain for the first
18
ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic
19
management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an
20
individual or group health insurance plan may not require prior authorization more frequently than
21
every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this
22
subsection, "chronic pain" means pain that persists or recurs for more than three (3) months.
23

(c) An individual or group health insurance plan shall respond to a prior authorization
24
request for services or visits in an ongoing plan of care for rehabilitative or habilitative services
25
within twenty-four (24) hours. If an individual or group health insurance plan requires more
26
information to render a decision on the prior authorization request, the individual or group health
27
insurance plan shall notify the patient and the provider within twenty-four (24) hours of the initial
28
request with the information that is needed to complete the prior authorization request including,
29
but not limited to, the specific tests and measures needed from the patient and provider. An
30
individual or group health insurance plan shall render a decision on the prior authorization request
31
within twenty-four (24) hours of receiving the requested information.
32

(d) A prior authorization for rehabilitative or habilitative services is deemed to be approved
33
if an individual or group health insurance plan:
34

(1) Fails to timely answer a prior authorization request in accordance with subsection (c)

LC004486 - Page 4 of 7
1
of this section, including due to a failure of the individual or group health insurance plan’s prior
2
authorization platform or process; or
3

(2) Informs a provider that prior authorization is not required orally, via an online platform
4
or program, through the patient's health plan documents or by any other means.
5

(e) An individual or group health insurance plan shall provide a procedure for providers
6
and insureds to obtain retroactive authorization for rehabilitative or habilitative services that are
7
medically necessary covered benefits. An individual or group health insurance plan shall not deny
8
coverage for medically necessary services for failure to obtain a prior authorization, if a medical
9
necessity determination can be made after the rehabilitative or habilitative services have been
10
provided and the services would have been covered benefits if prior authorization had been
11
obtained.
12

(f) An individual or group health insurance plan’s failure to approve a prior authorization
13
for all rehabilitative or habilitative services or visits in a plan of care is subject to the same appeal
14
rights as a denial under the health insurance commissioner’s rule regarding health plan
15
accountability and the provider's network agreement with the carrier, if any.
16

(g) Nothing in this section shall be construed to prohibit an individual or group health
17
insurance plan from performing a retrospective medical necessity review.
18
SECTION 4. Chapter 27-41 of the General Laws entitled " Health Maintenance
19
Organizations " is hereby amended by adding thereto the following section:
20

27-41-101. Prior authorization restrictions for rehabilitative and habilitative services.
21

(a) An individual or group health insurance plan shall not require prior authorization for
22
rehabilitative or habilitative services including, but not limited to, physical therapy services for the
23
first twelve (12) visits of each new episode of care. After the twelve (12) visits of each new episode
24
of care, an individual or group health insurance plan may not require prior authorization more
25
frequently than every six (6) visits or every thirty (30) days, whichever time period is longer. For
26
purposes of this section, "new episode of care" means treatment for a new or recurring condition
27
for which an insured has not been treated by the provider within the previous ninety (90) days.
28

(b) An individual or group health insurance plan shall not require prior authorization for
29
physical medicine or rehabilitation services provided to patients with chronic pain for the first
30
ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic
31
management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an
32
individual or group health insurance plan may not require prior authorization more frequently than
33
every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this
34
subsection, "chronic pain" means pain that persists or recurs for more than three (3) months.

LC004486 - Page 5 of 7
1

(c) An individual or group health insurance plan shall respond to a prior authorization
2
request for services or visits in an ongoing plan of care for rehabilitative or habilitative services
3
within twenty-four (24) hours. If an individual or group health insurance plan requires more
4
information to render a decision on the prior authorization request, the individual or group health
5
insurance plan shall notify the patient and the provider within twenty-four (24) hours of the initial
6
request with the information that is needed to complete the prior authorization request including,
7
but not limited to, the specific tests and measures needed from the patient and provider. An
8
individual or group health insurance plan shall render a decision on the prior authorization request
9
within twenty-four (24) hours of receiving the requested information.
10

(d) A prior authorization for rehabilitative or habilitative services is deemed to be approved
11
if an individual or group health insurance plan:
12

(1) Fails to timely answer a prior authorization request in accordance with subsection (c)
13
of this section, including due to a failure of the individual or group health insurance plan’s prior
14
authorization platform or process; or
15

(2) Informs a provider that prior authorization is not required orally, via an online platform
16
or program, through the patient's health plan documents or by any other means.
17

(e) An individual or group health insurance plan shall provide a procedure for providers
18
and insureds to obtain retroactive authorization for rehabilitative or habilitative services that are
19
medically necessary covered benefits. An individual or group health insurance plan shall not deny
20
coverage for medically necessary services for failure to obtain a prior authorization, if a medical
21
necessity determination can be made after the rehabilitative or habilitative services have been
22
provided and the services would have been covered benefits if prior authorization had been
23
obtained.
24

(f) An individual or group health insurance plan’s failure to approve a prior authorization
25
for all rehabilitative or habilitative services or visits in a plan of care is subject to the same appeal
26
rights as a denial under the health insurance commissioner’s rule regarding health plan
27
accountability and the provider's network agreement with the carrier, if any.
28

(g) Nothing in this section shall be construed to prohibit an individual or group health
29
insurance plan from performing a retrospective medical necessity review.
30
SECTION 2. This act shall take effect on January 1, 2027.
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LC004486
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LC004486 - Page 6 of 7
EXPLANATION
BY THE LEGISLATIVE COUNCIL
OF
A N A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES
***
1
This act would prohibit health insurance plans from requiring prior authorization for a new
2
episode of rehabilitative care for twelve (12) visits, or from requiring prior authorization for
3
rehabilitative care for chronic pain for ninety (90) days. This act would further mandate that where
4
prior authorization is required, the health insurance plan would respond within twenty-four (24)
5
hours. In addition, this act would require health insurance plans to provide a procedure for providers
6
and insureds to obtain retroactive authorization for services that are medically necessary covered
7
benefits.
8
This act would take effect on January 1, 2027.
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LC004486
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LC004486 - Page 7 of 7