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HB 7692

AN ACT RELATING TO STATE AFFAIRS AND GOVERNMENT -- OFFICE OF HEALTH AND HUMAN SERVICES

2026 Regular Session Introduced by Jennifer Boylan and 9 co-sponsors

Aims to lower Medicaid drug costs and boost transparency by restricting PBMs/MCOs practices, while empowering EOHHS to reform Medicaid, with possible PBM carve-outs or a single Med

05/05/2026 Committee recommended measure be held for further study
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Bill Summary · HB 7692

Summary of HB 7692 (Rhode Island, 2026)

Title: AN ACT RELATING TO STATE AFFAIRS AND GOVERNMENT -- OFFICE OF HEALTH AND HUMAN SERVICES

Jurisdiction: Rhode Island
Session: 2026
Introduced: February 11, 2026
Sponsors: reps Stewart, Potter, Giraldo, Tanzi, Boylan, Donovan, Speakman, Cotter, Morales, Kislak; co-sponsors listed

Status: Referred to House Finance; scheduled for hearing/consideration (as of May 1, 2026)

1) Purpose and Intent

  • The primary aim is to protect Rhode Islanders and the state Medicaid program from high prescription drug costs.
  • The bill seeks greater transparency and accountability for managed care organizations (MCOs) and their pharmacy benefit managers (PBMs) involved in the state's Medicaid program.

2) Key Provisions and Changes

  • Section 42-7.2-5 (Duties of the Secretary) is amended to expand the Secretary of the Executive Office of Health and Human Services (EOHHS) powers and responsibilities, including:

    • Coordinating administration and financing of health and human services, including Medicaid, while preserving existing powers of departments for state plan administration.
    • Acting as the governor’s chief advisor on Medicaid reform and as the state’s primary contact with federal policymakers on Medicaid issues.
    • Reviewing and coordinating changes to the Medicaid 1115 waiver and related state plan amendments that could affect services, provider payments, or benefits.
    • Directing development and implementation of Medicaid policies and systems to support integrated eligibility and coordination with HealthSource RI (the state marketplace).
    • Conducting biennial comprehensive reviews of Medicaid eligibility criteria (from 2015 onward) to ensure consistency with laws, align systems, and identify quality and access improvements.
    • Producing an annual (beginning 2020) comprehensive overview of Medicaid expenditures, outcomes, and utilization by September 15, including detailed breakdowns (titles XIX/XXI, populations, service types, providers, and Core Set measures for CMS reporting).
    • Directing service delivery reforms to improve integration, value, and outcomes; centralizing certain administrative and legal functions; and promoting workforce development, consumer-centered design, and resource optimization (purchasing power, budgets, finance, procurement, and data management).
    • Creating an assessment/coordination unit to ensure publicly funded health services are provided appropriately and timely, including rebalancing long-term services.
    • Strengthening program integrity, cost recovery, and coordination of oversight for vulnerable populations.
    • Recommending sliding-scale reductions in program eligibility tied to income (up to 450% of the federal poverty level) for programs such as medical assistance, childcare, and food assistance (as part of EOHHS budget considerations).
    • Ensuring PBMs and MCOs in Rhode Island Medicaid are transparent and do not raise unnecessary costs, with specifics:
    • Prohibiting spread pricing by PBMs (charging health plans more than paid to pharmacies).
    • Requiring pass-through pricing (PBMs pass through the exact pharmacy reimbursement with a capped admin fee).
    • Prohibiting discriminatory practices against non-affiliated pharmacies.
    • Eliminating or limiting utilization management (prior authorizations, step therapy, non-medical drug switching) that delay care.
    • Requiring benefits to reflect manufacturer discounts/rebates (e.g., formulary rebates) and providing enforcement documents to EOHHS.
    • Considering options for 2027 recommendations: creating a single Medicaid PBM, carving out pharmacy benefits from MCOs, adopting a uniform Medicaid prescription drug list (PDL), or moving to a Connecticut-style Medicaid program.
    • Establishing rules, staffing, and potential civil fines up to $10,000 per violation for PBMs; enabling enforcement actions by EOHHS; allowing consultation with OHIC, Insurance Commissioner, DBR, and other authorities.
    • Prohibiting administrative burdens that delay medically necessary care, notably prohibiting prior authorization for in-network primary care provider-ordered admissions/services, while allowing prescriptions drug prior authorizations.
    • Establishing an advisory working group (with governor consultation) to analyze potential federal actions impacting Medicaid; the group must produce findings and options by late 2025 for consideration ahead of the Governor’s FY 2026 budget submission.

  • Section 3: Effective date

    • The act takes effect upon passage.

3) Who/What Is Affected

  • Rhode Island residents eligible for Medicaid and other state-administered health and human services programs.
  • State agencies within EOHHS, including departments that administer Medicaid and related services.
  • Managed Care Organizations (MCOs) operating in Rhode Island Medicaid.
  • Pharmacy Benefit Managers (PBMs) contracted to manage Medicaid drug benefits.
  • Health providers and pharmacies, especially those affected by PBM practices and prior authorization rules.
  • The Governor, the General Assembly (via reporting and budget integration), and federal Medicaid partners (through waiver and CMS reporting processes).

4) Procedural and Timeline Aspects

  • Biennial Medicaid eligibility reviews beginning in 2015 (reference point) with ongoing oversight.
  • Annual comprehensive Medicaid expenditures/usage overview due by September 15 each year (starting 2020).
  • Advisory Working Group: must report findings and options to governor and leadership by October 31, 2025, for consideration ahead of the FY 2026 budget process (federal action considerations).
  • By January 1, 2027, the bill requires the administration to analyze and recommend options around:
    • Creating a single Medicaid PBM
    • Carving out pharmacy benefits from MCOs
    • Adopting a Medicaid uniform PDL
    • Moving toward a Connecticut-style Medicaid program
  • Final effective date: immediate upon passage.

5) Potential Impacts

  • Increased transparency and accountability for PBMs and MCOs in Rhode Island’s Medicaid program.
  • Potential cost containment through reform of PBM practices (spread pricing, pass-through pricing, discount/rebate utilization, and reduced prior authorizations).
  • Possible changes to the structure of Medicaid drug benefits (uniform PDL, separate PBM administration, or broader program reconfigurations).
  • Strengthened data collection and reporting to support policy decisions and federal compliance.
  • Expanded state oversight and potential penalties for PBM noncompliance.

This summary provides an overview of HB 7692’s objectives, core provisions, and who would be affected, along with key timing and procedural elements. If you want, I can extract specific subsections into a more detailed, line-by-line annotation.

Compiled from official sources — confirm details with the bill’s official record.

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