AN ACT RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES -- REGULATE HEALTH INSURANCE PRIOR AUTHORIZATION REQUIREMENTS FOR REHABILITATIVE AND HABILITATIVE SERVICES ACT (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.)

S2561

2026 -- S 2561
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LC003402
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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 --
REGULATE HEALTH INSURANCE PRIOR AUTHORIZATION REQUIREMENTS FOR
REHABILITATIVE AND HABILITATIVE SERVICES ACT

Introduced By:
Senators Mack, Lauria, Urso, Murray, Ujifusa, Valverde, Dimitri, and
DiMario

Date Introduced:
February 13, 2026

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

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

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 under this section within twenty-four (24)
3
hours. If an individual or group health insurance plan requires more information to make a decision
4
on the prior authorization request, the individual or group health insurance plan shall notify the
5
patient and the provider within twenty-four (24) hours of the initial request with the information
6
that is needed to complete the prior authorization request including, but not limited to, the specific
7
tests and measures needed from the patient and provider. An individual or group health insurance
8
plan shall make a decision on the prior authorization request within twenty-four (24) hours of
9
receiving the requested information.
10

(d) With regard to circumstances in which a prior authorization for covered services under
11
this section is deemed to be approved by an individual or group health insurance plan, a prior
12
authorization is deemed to be approved if an individual or group health insurance plan:
13

(1) Fails to timely answer a prior authorization request in accordance with subsection (c)
14
of this section, including due to a failure of the individual or group health insurance plan’s prior
15
authorization platform or process; or
16

(2) Informs a provider that prior authorization is not required orally, via an online platform
17
or program, through the patient's health plan documents or by any other means.
18

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

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

(g) Nothing in this section is intended to prohibit an individual or group health insurance
29
plan from performing a retrospective medical necessity review.
30
SECTION 2. Chapter 27-19 of the General Laws entitled " Nonprofit Hospital Service
31
Corporations " is hereby amended by adding thereto the following section:
32

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

33

(a) An individual or group health insurance plan shall not require prior authorization for
34
rehabilitative or habilitative services, including, but not limited to, physical therapy or occupational

LC003402 - Page 2 of 8
1
therapy services for the first twelve (12) visits of each new episode of care. For purposes of this
2
section, "new episode of care" means treatment for a new or recurring condition for which an
3
insured has not been treated by the provider within the previous ninety (90) days. After the twelve
4
(12) visits of each new episode of care, an individual or group health insurance plan shall not require
5
prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever
6
time period is longer.
7

(b) An individual or group health insurance plan shall not require prior authorization for
8
physical medicine or rehabilitation services provided to patients with chronic pain for the first
9
ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic
10
management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an
11
individual or group health insurance plan shall not require prior authorization more frequently than
12
every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this
13
subsection, "chronic pain" means pain that persists or recurs for more than three (3) months.
14

(c) An individual or group health insurance plan shall respond to a prior authorization
15
request for services or visits in an ongoing plan of care under this section within twenty-four (24)
16
hours. If an individual or group health insurance plan requires more information to make a decision
17
on the prior authorization request, the individual or group health insurance plan shall notify the
18
patient and the provider within twenty-four (24) hours of the initial request with the information
19
that is needed to complete the prior authorization request including, but not limited to, the specific
20
tests and measures needed from the patient and provider. An individual or group health insurance
21
plan shall make a decision on the prior authorization request within twenty-four (24) hours of
22
receiving the requested information.
23

(d) With regard to circumstances in which a prior authorization for covered services under
24
this section is deemed to be approved by an individual or group health insurance plan, a prior
25
authorization is deemed to be approved if an individual or group health insurance plan:
26

(1) Fails to timely answer a prior authorization request in accordance with subsection (c)
27
of this section, including due to a failure of the individual or group health insurance plan’s prior
28
authorization platform or process; or
29

(2) Informs a provider that prior authorization is not required orally, via an online platform
30
or program, through the patient's health plan documents or by any other means.
31

(e) An individual or group health insurance plan shall provide a procedure for providers
32
and insureds to obtain retroactive authorization for services under this section that are medically
33
necessary covered benefits. An individual or group health insurance plan shall not deny coverage
34
for medically necessary services under this section only for failure to obtain a prior authorization,

LC003402 - Page 3 of 8
1
if a medical necessity determination can be made after the services have been provided and the
2
services would have been covered benefits if prior authorization had been obtained.
3

(f) An individual or group health insurance plan’s failure to approve a prior authorization
4
for all services or visits in a plan of care under this section is subject to the same appeal rights as a
5
denial under the office of the health insurance commissioner's rule or regulation regarding health
6
plan accountability and the provider's network agreement with the carrier, if any.
7

(g) Nothing in this section is intended to prohibit an individual or group health insurance
8
plan from performing a retrospective medical necessity review.
9
SECTION 3. Chapter 27-20 of the General Laws entitled " Nonprofit Medical Service
10
Corporations " is hereby amended by adding thereto the following section:
11

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

12

(a) An individual or group health insurance plan shall not require prior authorization for
13
rehabilitative or habilitative services, including, but not limited to, physical therapy or occupational
14
therapy services for the first twelve (12) visits of each new episode of care. For purposes of this
15
section, "new episode of care" means treatment for a new or recurring condition for which an
16
insured has not been treated by the provider within the previous ninety (90) days. After the twelve
17
(12) visits of each new episode of care, an individual or group health insurance plan shall not require
18
prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever
19
time period is longer.
20

(b) An individual or group health insurance plan shall not require prior authorization for
21
physical medicine or rehabilitation services provided to patients with chronic pain for the first
22
ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic
23
management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an
24
individual or group health insurance plan shall not require prior authorization more frequently than
25
every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this
26
subsection, "chronic pain" means pain that persists or recurs for more than three (3) months.
27

(c) An individual or group health insurance plan shall respond to a prior authorization
28
request for services or visits in an ongoing plan of care under this section within twenty-four (24)
29
hours. If an individual or group health insurance plan requires more information to make a decision
30
on the prior authorization request, the individual or group health insurance plan shall notify the
31
patient and the provider within twenty-four (24) hours of the initial request with the information
32
that is needed to complete the prior authorization request including, but not limited to, the specific
33
tests and measures needed from the patient and provider. An individual or group health insurance
34
plan shall make a decision on the prior authorization request within twenty-four (24) hours of

LC003402 - Page 4 of 8
1
receiving the requested information.
2

(d) With regard to circumstances in which a prior authorization for covered services under
3
this section is deemed to be approved by an individual or group health insurance plan, a prior
4
authorization is deemed to be approved if an individual or group health insurance plan:
5

(1) Fails to timely answer a prior authorization request in accordance with subsection (c)
6
of this section, including due to a failure of the individual or group health insurance plan’s prior
7
authorization platform or process; or
8

(2) Informs a provider that prior authorization is not required orally, via an online platform
9
or program, through the patient's health plan documents or by any other means.
10

(e) An individual or group health insurance plan shall provide a procedure for providers
11
and insureds to obtain retroactive authorization for services under this section that are medically
12
necessary covered benefits. An individual or group health insurance plan shall not deny coverage
13
for medically necessary services under this section only for failure to obtain a prior authorization,
14
if a medical necessity determination can be made after the services have been provided and the
15
services would have been covered benefits if prior authorization had been obtained.
16

(f) An individual or group health insurance plan’s failure to approve a prior authorization
17
for all services or visits in a plan of care under this section is subject to the same appeal rights as a
18
denial under the office of the health insurance commissioner's rule or regulation regarding health
19
plan accountability and the provider's network agreement with the carrier, if any.
20

(g) Nothing in this section is intended to prohibit an individual or group health insurance
21
plan from performing a retrospective medical necessity review.
22
SECTION 4. Chapter 27-41 of the General Laws entitled " Health Maintenance
23
Organizations " is hereby amended by adding thereto the following section:
24

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

25

(a) An individual or group health insurance plan shall not require prior authorization for
26
rehabilitative or habilitative services, including, but not limited to, physical therapy or occupational
27
therapy services for the first twelve (12) visits of each new episode of care. For purposes of this
28
section, "new episode of care" means treatment for a new or recurring condition for which an
29
insured has not been treated by the provider within the previous ninety (90) days. After the twelve
30
(12) visits of each new episode of care, an individual or group health insurance plan shall not require
31
prior authorization more frequently than every six (6) visits or every thirty (30) days, whichever
32
time period is longer.
33

(b) An individual or group health insurance plan shall not require prior authorization for
34
physical medicine or rehabilitation services provided to patients with chronic pain for the first

LC003402 - Page 5 of 8
1
ninety (90) days following diagnosis in order to provide the necessary nonpharmacologic
2
management of the pain. After the first ninety (90) days following a chronic pain diagnosis, an
3
individual or group health insurance plan shall not require prior authorization more frequently than
4
every six (6) visits or every thirty (30) days, whichever time period is longer. For purposes of this
5
subsection, "chronic pain" means pain that persists or recurs for more than three (3) months.
6

(c) An individual or group health insurance plan shall respond to a prior authorization
7
request for services or visits in an ongoing plan of care under this section within twenty-four (24)
8
hours. If an individual or group health insurance plan requires more information to make a decision
9
on the prior authorization request, the individual or group health insurance plan shall notify the
10
patient and the provider within twenty-four (24) hours of the initial request with the information
11
that is needed to complete the prior authorization request including, but not limited to, the specific
12
tests and measures needed from the patient and provider. An individual or group health insurance
13
plan shall make a decision on the prior authorization request within twenty-four (24) hours of
14
receiving the requested information.
15

(d) With regard to circumstances in which a prior authorization for covered services under
16
this section is deemed to be approved by an individual or group health insurance plan, a prior
17
authorization is deemed to be approved if an individual or group health insurance plan:
18

(1) Fails to timely answer a prior authorization request in accordance with subsection (c)
19
of this section, including due to a failure of the individual or group health insurance plan’s prior
20
authorization platform or process; or
21

(2) Informs a provider that prior authorization is not required orally, via an online platform
22
or program, through the patient's health plan documents or by any other means.
23

(e) An individual or group health insurance plan shall provide a procedure for providers
24
and insureds to obtain retroactive authorization for services under this section that are medically
25
necessary covered benefits. An individual or group health insurance plan shall not deny coverage
26
for medically necessary services under this section only for failure to obtain a prior authorization,
27
if a medical necessity determination can be made after the services have been provided and the
28
services would have been covered benefits if prior authorization had been obtained.
29

(f) An individual or group health insurance plan’s failure to approve a prior authorization
30
for all services or visits in a plan of care under this section is subject to the same appeal rights as a
31
denial under the office of the health insurance commissioner's rule or regulation regarding health
32
plan accountability and the provider's network agreement with the carrier, if any.
33

(g) Nothing in this section is intended to prohibit an individual or group health insurance
34
plan from performing a retrospective medical necessity review.

LC003402 - Page 6 of 8
1
SECTION 2. This act shall take effect on January 1, 2027.
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LC003402
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LC003402 - Page 7 of 8
EXPLANATION
BY THE LEGISLATIVE COUNCIL
OF
A N A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES --
REGULATE HEALTH INSURANCE PRIOR AUTHORIZATION REQUIREMENTS FOR
REHABILITATIVE AND HABILITATIVE SERVICES ACT
***
1
This act would limit prior authorization requirements for rehabilitative and habilitative
2
services. This act would prohibit prior authorization for the first twelve (12) visits of a new episode
3
of care and for ninety (90) days following a chronic pain diagnosis. This act would also require that
4
insurers must respond to requests within twenty-four (24) hours, and delays result in automatic
5
approval. This act would further allow retroactive authorization for medically necessary services
6
and provides appeal rights for denied requests.
7
This act would take effect on January 1, 2027.
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LC003402
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LC003402 - Page 8 of 8