Bill
HB 5626
Rhode Island bill requires private health plans to cover FDA-approved contraceptives and related services with no cost-sharing, including up to a 12-month supply.
AN ACT RELATING TO INSURANCE — ACCIDENT AND SICKNESS INSURANCE POLICIES
Status snapshot
- Introduced (sponsor list): Representatives Speakman, Knight, Boylan, Donovan, Fogarty, Spears, Cotter, Carson, Tanzi, and Alzate.
- Key code sections added: R.I. Gen. Laws §§ 27-18-57.1 and 27-20-43.1.
- Legislative actions: filed 03/14/2025; referred to House Health & Human Services (02/26/2025); scheduled for hearing 02/28/2025; committee postponed at sponsor request 03/04/2025; read first time 04/07/2025 and referred to subcommittee on Workforce. Current status: committee postponed at sponsor request (03/04/2025).
Purpose
- To require most health insurance plans issued, delivered, or renewed in Rhode Island to cover FDA‑approved contraceptive drugs, devices, products and related services without cost‑sharing, subject to specified exceptions and limits.
Key provisions
- Scope: Applies to accident & sickness policies and nonprofit medical service corporation plans; excludes supplemental Medicare or other governmental-program supplemental contracts.
- Covered items and services:
- FDA‑approved contraceptive drugs, devices and products (with specific exceptions noted below).
- FDA‑approved emergency contraception available over‑the‑counter (whether with prescription or as current law allows).
- Voluntary female sterilization procedures.
- Patient education, counseling, and follow‑up services (management of side effects, adherence counseling, insertion/removal).
- Therapeutic equivalents and formulary rules:
- “Therapeutic equivalent” defined consistent with FDA pharmaceutical equivalence and FDA therapeutic equivalence codes.
- If therapeutic equivalents exist, the state insurance office need only require at least one be on the formulary and covered without cost‑sharing.
- Insurers may cover more than one equivalent and may impose cost‑sharing on additional equivalents so long as at least one option per method is available without cost‑sharing.
- If a provider makes a medical determination recommending a specific FDA‑approved contraceptive for an individual, that prescribed contraceptive must be covered without cost‑sharing, regardless of equivalence status.
- Dispensing limits:
- First dispensing: up to a 3‑month supply.
- Subsequent dispensings: up to a 12‑month supply (may be dispensed all at once or over the 12 months). An insured may not receive more than one 12‑month prescription dispensing in a single plan year.
- Cost-sharing and management:
- Coverage under this section shall not be subject to deductible, coinsurance, copayment, or other cost‑sharing, except as required by federal law.
- Reasonable medical management is allowed within a method category (per FDA categories), but not across different types of contraceptive methods.
- Additional rules:
- Benefits extend equally to a covered enrollee’s covered spouse and dependents.
- Coverage cannot be construed to exclude contraceptives when prescribed for non‑contraceptive medical reasons (e.g., ovarian cancer risk reduction, menopause symptoms, or when necessary to preserve life/health).
- Insurers are not required to cover experimental or investigational treatments.
- The Office of the Health Insurance Commissioner is charged with ensuring plan compliance.
Who is affected
- Individuals covered by private health insurance and nonprofit medical service corporation plans in Rhode Island (not including Medicare supplemental or other government supplemental plans).
- Insurers and plan administrators (must update formularies, dispensing policies, and cost‑sharing rules).
- Health care providers and pharmacists (changes to prescribing/dispensing practices, potential for 12‑month supplies).
- State regulators (enforcement and oversight responsibilities for compliance).
Potential impacts and considerations
- Increases access to contraception and reduces out‑of‑pocket costs for covered individuals, including coverage for 12‑month supplies and OTC emergency contraception.
- Gives providers authority to secure no‑cost options for patients via medical determination for specific products.
- May affect insurer formulary design and drug‑supply/distribution practices; allows some formulary flexibility by requiring only one no‑cost therapeutic equivalent per method.
- Administrative oversight required by the Office of the Health Insurance Commissioner to ensure compliance and to interpret permissible medical management practices.
Compiled from official sources — confirm details with the bill’s official record.
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