AN ACT RELATING TO INSURANCE -- BENEFIT DETERMINATION AND UTILIZATION REVIEW ACT

2025 Regular Session Introduced by Joseph Solomon

Presumes provider-authorized care is medically necessary; insurers must justify any denial.

04/01/2025 Committee recommended measure be held for further study

Summary — HB 5862

Title: AN ACT RELATING TO INSURANCE — Benefit Determination and Utilization Review Act
Status: Committee recommended measure be held for further study (04/01/2025)
Introduced: Feb 28, 2025 (House); scheduled hearing Mar 28, 2025; referred to House Health & Human Services
Effective date: Upon passage (per bill text)

Note: The legislative record provided contains an unrelated House bill (a Michigan sales‑tax amendment) that shares the same bill number in a different jurisdiction. The summary below addresses the insurance/Benefit Determination and Utilization Review Act language (Rhode Island, LC002314 / HB 5862).

Main purpose and intent

The bill amends the state’s Benefit Determination and Utilization Review Act by adding a new section (27‑18.9‑16) establishing a legal presumption that any health care service or procedure authorized by a provider for a patient is “medically necessary.” Under the bill, if an insurer denies such an authorized service, the insurer bears the burden of providing justification for the denial.

Key provisions

Adds Section 27‑18.9‑16 to the General Laws:

Creates a presumption that any healthcare service or procedure authorized by a provider for a patient is medically necessary.
Imposes a duty on the insurance company to provide justification when it denies a provider‑authorized service or procedure.

Effective upon passage.

Who would be affected

Patients: could face fewer denials or faster dispute resolution when services already authorized by a provider.

Health care providers: benefit from a presumption that their authorizations reflect medical necessity, potentially reducing administrative appeals.

Insurers and managed care organizations: must document and justify denials of provider‑authorized services; potentially greater administrative, documentation, and review burdens.

State regulators and courts: may see increased complaints, administrative appeals, or litigation to define the scope of “justification” and the presumption’s application.

Employers/self‑funded plans: applicability may be limited by ERISA (federal preemption) for self‑insured employer plans — such plans might not be subject to state insurance mandates.

Potential impacts and issues

Practical effect: shifts evidentiary burden to insurers for denials of provider‑authorized care; could reduce overturn rates on appeal but may increase insurer documentation requirements.

Ambiguities: the bill does not define what constitutes adequate “justification” for a denial or the standard of proof; this may prompt rulemaking, regulatory guidance, or litigation to clarify implementation.

Federal preemption: self‑insured (ERISA) plans may be exempt, limiting reach.

Fiscal/administrative: insurers may incur increased compliance costs; patients and providers may experience faster resolution of authorization disputes.

Procedural/timeline notes

Introduced in the House and referred to House Health & Human Services (Feb 28, 2025).

Public hearing scheduled Mar 28, 2025.

Committee recommended measure be held for further study (04/01/2025) — no further action reported as of that date.

If you’d like, I can draft a one‑page fact sheet for stakeholders (insurers, providers, patients) or analyze likely legal challenges (e.g., ERISA preemption and interpreting “justification”).