Bill Sponsors
Urso, DiMario, Kallman, Murray, Acosta, Rogers, Gu, and Britto
Committee
Senate Health & Human Services
Summary
Select
This legislation prohibits health insurance companies and pharmacy benefit managers from requiring prior authorization or concurrent review for specific medications used to treat alcohol or opioid use disorders. This applies to drugs like methadone, buprenorphine, and naltrexone, as well as other FDA-approved treatments for these conditions. Additionally, the bill mandates that Medicaid managed care organizations must use specific medical necessity criteria selected by the state's Executive Office of Health and Human Services when conducting utilization reviews for Medicaid benefits.
Sponsor
Analysis
Pros for Progressives
- Removes bureaucratic barriers to essential healthcare, ensuring that vulnerable individuals suffering from addiction can access life-saving medication immediately without administrative delays.
- Standardizes Medicaid criteria, which likely improves the quality and consistency of care provided to low-income populations and ensures they are not denied treatment based on arbitrary insurance decisions.
- Supports harm reduction and public health by facilitating easier access to treatments like methadone and buprenorphine, which are proven to reduce overdose deaths and assist in recovery.
Cons for Progressives
- Focuses heavily on pharmaceutical interventions, potentially neglecting the need for funded holistic support systems like counseling, housing, and job training for those in recovery.
- Does not address the cost of the medications themselves, meaning that high deductibles or copays could still act as a barrier to access for the poor even without prior authorization.
- Allowing private insurers to remain the primary gatekeepers of health coverage, even with reduced restrictions, maintains a profit-driven healthcare system rather than moving toward a single-payer model.
Pros for Conservatives
- Promotes public safety and order by facilitating treatment that helps individuals overcome addiction, potentially reducing drug-related crime and vagrancy in communities.
- Streamlines government operations by establishing a single standard for medical necessity within Medicaid, potentially reducing administrative waste and confusion.
- Reduces the administrative burden on doctors and medical practices, allowing them to focus on treating patients rather than spending time on paperwork and phone calls with insurance companies.
Cons for Conservatives
- Interferes with the free market by dictating how private insurance companies must manage their benefit plans and restricting their ability to use utilization reviews to control costs.
- May lead to increased insurance premiums for all policyholders if the removal of utilization reviews results in higher utilization of expensive prescription drugs.
- Expands the power of the state government (Executive Office of Health and Human Services) to dictate medical necessity criteria, removing flexibility from managed care organizations.
Constitutional Concerns
None Likely
Impact Overview
Groups Affected
- Individuals with substance use disorders
- Health insurance companies
- Pharmacy benefit managers
- Medicaid managed care organizations
- Medical providers
Towns Affected
All
Cost to Taxpayers
Amount unknown
Revenue Generated
None
BillBuddy Impact Ratings
Importance
Measures population affected and overall level of impact.
Freedom Impact
Level of individual freedom impacted by the bill.
Public Services
How much the bill is likely to impact one or more public services.
Regulatory
Estimated regulatory burden imposed on the subject(s) of the bill.
Clarity of Bill Language
How clear the language of the bill is. Higher ambiguity equals a lower score.
Enforcement Provisions
Measures enforcement provisions and penalties for non-compliance (if applicable).
Environmental Impact
Impact the bill will have on the environment, positive or negative.
Privacy Impact
Impact the bill is likely to have on the privacy of individuals.
Bill Status
Current Status
Held
Comm Passed
Floor Passed
Law
History
• 01/16/2026 Introduced, referred to Senate Health and Human Services
Bill Text
SECTION 1. Chapter 27-18.9 of the General Laws entitled "Benefit Determination and Utilization Review Act" is hereby amended by adding thereto the following section:
27-18.9-17. Utilization review decisions for the treatment of alcohol or substance use disorder.
(a) For health benefit plans issued or renewed on or after the effective date of this section, an insurer or pharmacy benefit manager shall not require or conduct a prospective or concurrent review for a prescription medicine:
(1) That is used in the treatment of alcohol or opioid use disorder and contains methadone, buprenorphine or naltrexone; or
(2) That is used in the treatment of alcohol or opioid use disorder and has been approved by the United States Food and Drug Administration for the management of alcohol or opioid use disorder, or the mitigation of opioid withdrawal symptoms.
SECTION 2. Chapter 40-8 of the General Laws entitled "Medical Assistance" is hereby amended by adding thereto the following section:
40-8-33. Utilization reviews for Medicaid benefits.
In conducting utilization reviews for Medicaid benefits, each Medicaid managed care organization shall use the medical necessity criteria selected by the executive office of health and human services for making determinations of medical necessity and clinical appropriateness pursuant to the utilization review plan.
SECTION 3. This act shall take effect upon passage.
27-18.9-17. Utilization review decisions for the treatment of alcohol or substance use disorder.
(a) For health benefit plans issued or renewed on or after the effective date of this section, an insurer or pharmacy benefit manager shall not require or conduct a prospective or concurrent review for a prescription medicine:
(1) That is used in the treatment of alcohol or opioid use disorder and contains methadone, buprenorphine or naltrexone; or
(2) That is used in the treatment of alcohol or opioid use disorder and has been approved by the United States Food and Drug Administration for the management of alcohol or opioid use disorder, or the mitigation of opioid withdrawal symptoms.
SECTION 2. Chapter 40-8 of the General Laws entitled "Medical Assistance" is hereby amended by adding thereto the following section:
40-8-33. Utilization reviews for Medicaid benefits.
In conducting utilization reviews for Medicaid benefits, each Medicaid managed care organization shall use the medical necessity criteria selected by the executive office of health and human services for making determinations of medical necessity and clinical appropriateness pursuant to the utilization review plan.
SECTION 3. This act shall take effect upon passage.