S2887

	2012 -- S 2887
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	LC02074
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	STATE OF RHODE ISLAND

	IN GENERAL ASSEMBLY

	JANUARY SESSION, A.D. 2012

	____________


	A N A C T
	RELATING TO INSURANCE -- HEALTH INSURANCE - CONSUMER PROTECTION


	Introduced By: Senator Rhoda E. Perry

	Date Introduced: April 12, 2012

	Referred To: Senate Health & Human Services




	It is enacted by the General Assembly as follows:

1-1	SECTION 1. Purpose and intent.
1-2	It is the purpose of this act to amend Rhode Island statutes so as to be consistent with
1-3	health insurance consumer protections enacted in federal law. This act is intended to establish
1-4	health insurance rules, standards, and policies pursuant to, in furtherance of, and in addition to the
1-5	health insurance standards established in the Patient Protection and Affordable Care Act of 2010,
1-6	as amended by the Health care and Education Reconciliation Act of 2010.
1-7	SECTION 2. Chapter 27-18 of the General laws entitled "Accident and Sickness
1-8	Insurance Policies" is hereby amended by adding thereto the following section:
1-9	27-18-1-1. Definitions. – As used in this chapter:
1-10	(1) “Adverse benefit determination” means any of the following: a denial, reduction, or
1-11	termination of, or a failure to provide or make payment (in whole or in part) for, a benefit,
1-12	including any such denial, reduction, termination, or failure to provide or make payment that is
1-13	based on a determination of a participant's or beneficiary's eligibility to participate in a plan or to
1-14	receive coverage under a plan, and including, with respect to group health plans, a denial,
1-15	reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a
1-16	benefit resulting from the application of any utilization review, as well as a failure to cover an
1-17	item or service for which benefits are otherwise provided because it is determined to be
1-18	experimental or investigational or not medically necessary or appropriate. The term also includes
1-19	a rescission of coverage determination.
2-20	(2) ‘Affordable Care Act’ means the Patient Protection and Affordable Care Act of 2010,
2-21	as amended by the Health Care and Education Reconciliation Act of 2010.
2-22	(3) “Commissioner” or “health insurance commissioner” means that individual appointed
2-23	pursuant to section 42-14.5-1 of the general laws.
2-24	(4) “Grandfathered health plan” means any group health plan or health insurance
2-25	coverage subject to 42 USC section 18011.
2-26	(5) “Group health insurance coverage” means, in connection with a group health plan,
2-27	health insurance coverage offered in connection with such plan.
2-28	(6) “Group health plan” means an employee welfare benefit plan, as defined in 29 USC
2-29	section 1002(1), to the extent that the plan provides health benefits to employees or their
2-30	dependents directly or through insurance, reimbursement, or otherwise.
2-31	(7) “Health benefits” or “covered benefits” means medical, surgical, hospital,
2-32	prescription drug, and such other benefits, whether self-funded, or delivered through the purchase
2-33	of insurance or otherwise.
2-34	(8) “Health care facility” means an institution providing health care services or a health
2-35	care setting, including, but not limited to, hospitals and other licensed inpatient centers,
2-36	ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers,
2-37	diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health
2-38	settings.
2-39	(9) “Health care professional” means a physician or other health care practitioner
2-40	licensed, accredited or certified to perform specified health care services consistent with state
2-41	law.
2-42	(10) “Health care provider” or "provider" means a health care professional or a health
2-43	care facility.
2-44	(11) “Health care services” means services for the diagnosis, prevention, treatment, cure
2-45	or relief of a health condition, illness, injury or disease.
2-46	(12) “Health insurance carrier” means a person, firm, corporation or other entity subject
2-47	to the jurisdiction of the commissioner under this chapter. Such term does not include a group
2-48	health plan.
2-49	(13) “Health plan” or “health benefit plan” means health insurance coverage and a group
2-50	health plan, including coverage provided through an association plan if it covers Rhode Island
2-51	residents. Except to the extent specifically provided by the Affordable Care Act, the term “health
2-52	plan” shall not include a group health plan to the extent state regulation of the health plan is pre-
2-53	empted under section 514 of the Employee Retirement Income Security Act of 1974. The term
2-54	also shall not include:
3-1	(A)(i) Coverage only for accident, or disability income insurance, or any combination
3-2	thereof.
3-3	(ii) Coverage issued as a supplement to liability insurance.
3-4	(iii) Liability insurance, including general liability insurance and automobile liability
3-5	insurance.
3-6	(iv) Workers’ compensation or similar insurance.
3-7	(v) Automobile medical payment insurance.
3-8	(vi) Credit-only insurance.
3-9	(vii) Coverage for on-site medical clinics.
3-10	(viii) Other similar insurance coverage, specified in federal regulations issued pursuant to
3-11	Pub. L. No. 104-191, the health insurance portability and accountability act of 1996 (“HIPAA”),
3-12	under which benefits for medical care are secondary or incidental to other insurance benefits.
3-13	(B) The following benefits if they are provided under a separate policy, certificate or
3-14	contract of insurance or are otherwise not an integral part of the plan:
3-15	(i) Limited scope dental or vision benefits.
3-16	(ii) Benefits for long-term care, nursing home care, home health care, community-based
3-17	care, or any combination thereof.
3-18	(iii) Other excepted benefits specified in federal regulations issued pursuant to Pub. L.
3-19	No. 104-191 (“HIPAA”).
3-20	(C) The following benefits if the benefits are provided under a separate policy, certificate
3-21	or contract of insurance, there is no coordination between the provision of the benefits and any
3-22	exclusion of benefits under any group health plan maintained by the same plan sponsor, and the
3-23	benefits are paid with respect to an event without regard to whether benefits are provided with
3-24	respect to such an event under any group health plan maintained by the same plan sponsor:
3-25	(i) Coverage only for a specified disease or illness.
3-26	(ii) Hospital indemnity or other fixed indemnity insurance.
3-27	(D) The following if offered as a separate policy, certificate or contract of insurance:
3-28	(i) Medicare supplement health insurance as defined under section 1882(g)(1) of the
3-29	Social Security Act.
3-30	(ii) Coverage supplemental to the coverage provided under chapter 55 of title 10, United
3-31	States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)).
3-32	(iii) Similar supplemental coverage provided to coverage under a group health plan.
3-33	(14) "Office of the health insurance commissioner" means the agency established under
3-34	section 42-14.5-1 of the General laws.
4-1	(15) “Rescission" means a cancellation or discontinuance of coverage that has retroactive
4-2	effect for reasons unrelated to timely payment of required premiums or contribution to costs of
4-3	coverage.
4-4	27-18-2.1. Uniform explanation of benefits and coverage. – (a) A health insurance
4-5	carrier shall provide a uniform summary of benefits and coverage explanation and standardized
4-6	definitions to policyholders and others required by, and at the times required, by the federal
4-7	regulations adopted under section 2715 of the Affordable Care Act. A summary required by this
4-8	section shall be filed with the commissioner for approval under Rhode Island general laws section
4-9	27-18-8 et seq. The requirements of this section shall be in addition to the requirements of Rhode
4-10	Island general laws section 27-18-8 et seq. The commissioner may waive one or more of the
4-11	requirements of the regulations adopted under section 2715 of the Affordable Care Act for good
4-12	cause shown. The summary must contain at least the following information:
4-13	(1) Uniform definitions of standard insurance and medical terms.
4-14	(2) A description of coverage and cost sharing for each category of essential benefits and
4-15	other benefits.
4-16	(3) Exceptions, reductions and limitations in coverage.
4-17	(4) Renewability and continuation of coverage provisions.
4-18	(5) A “coverage facts label” that illustrates coverage under common benefits scenarios.
4-19	(6) A statement of whether the policy, contract or plan provides the minimum coverage
4-20	required of a qualified health plan.
4-21	(7) A statement that the outline is a summary and that the actual policy language should
4-22	be consulted; and
4-23	(8) A contact number for the consumer to call with additional questions and the web
4-24	address of where the actual language of the policy, contract or plan can be found.
4-25	(b) The provisions of this section shall apply to grandfathered health plans.
4-26	27-18-78. Prohibition on rescission of coverage. – (a)(1) Coverage under a health
4-27	benefit plan subject to the jurisdiction of the commissioner under this chapter with respect to an
4-28	individual, including a group to which the individual belongs or family coverage in which the
4-29	individual is included, shall not be rescinded after the individual is covered under the plan,
4-30	unless:
4-31	(A) The individual or a person seeking coverage on behalf of the individual, performs an
4-32	act, practice or omission that constitutes fraud; or
4-33	(B) The individual makes an intentional misrepresentation of material fact, as prohibited
4-34	by the terms of the plan or coverage.
5-1	(2) For purposes of paragraph (a)(1)(A), a person seeking coverage on behalf of an
5-2	individual does not include an insurance producer or employee or authorized representative of the
5-3	health carrier.
5-4	(b) At least thirty (30) days advance written notice shall be provided to each health
5-5	benefit plan enrollee or, for individual health insurance coverage, primary subscriber, who would
5-6	be affected by the proposed rescission of coverage before coverage under the plan may be
5-7	rescinded in accordance with subsection (a) regardless of, in the case of group health insurance
5-8	coverage, whether the rescission applies to the entire group or only to an individual within the
5-9	group.
5-10	(c) For purposes of this section, “to rescind” means to cancel or to discontinue coverage
5-11	with retroactive effect for reasons unrelated to timely payment of required premiums or
5-12	contribution to costs of coverage.
5-13	(d) This section applies to grandfathered health plans.
5-14	27-18-79. Prohibition on annual and lifetime limits. – (a) Annual limits.
5-15	(1) For plan or policy years beginning prior to January 1, 2014, for any individual, a
5-16	health insurance carrier and a health benefit plan subject to the jurisdiction of the commissioner
5-17	under this chapter may establish an annual limit on the dollar amount of benefits that are essential
5-18	health benefits provided the restricted annual limit is not less than the following:
5-19	(A) For a plan or policy year beginning after September 22, 2010, but before September
5-20	23, 2011 – seven hundred fifty thousand dollars ($750,000);
5-21	(B) For a plan or policy year beginning after September 22, 2011, but before September
5-22	23, 2012 – one million two hundred fifty thousand dollars ($1,250,000); and
5-23	(C) For a plan or policy year beginning after September 22, 2012, but before January 1,
5-24	2014 – two million dollars ($2,000,000).
5-25	(2) For plan or policy years beginning on or after January 1, 2014, a health insurance
5-26	carrier and a health benefit plan shall not establish any annual limit on the dollar amount of
5-27	essential health benefits for any individual, except:
5-28	(A) A health flexible spending arrangement, as defined in Section 106(c)(2)(i) of the
5-29	Internal Revenue Code, a medical savings account, as defined in section 220 of the Internal
5-30	Revenue Code, and a health savings account, as defined in Section 223 of the Internal Revenue
5-31	Code are not subject to the requirements of subdivisions (1) and (2) of this subsection.
5-32	(B) The provisions of this subsection shall not prevent a health insurance carrier and a
5-33	health benefit plan from placing annual dollar limits for any individual on specific covered
5-34	benefits that are not essential health benefits to the extent that such limits are otherwise permitted
6-1	under applicable federal law or the laws and regulations of this state.
6-2	(3) In determining whether an individual has received benefits that meet or exceed the
6-3	allowable limits, as provided in subdivision (1) of this subsection, a health insurance carrier and a
6-4	health benefit plan shall take into account only essential health benefits.
6-5	(b) Lifetime limits.
6-6	(1)A health insurance carrier and health benefit plan offering group or individual health
6-7	insurance coverage shall not establish a lifetime limit on the dollar value of essential health
6-8	benefits, as designated pursuant to a state determination and in accordance with federal laws and
6-9	regulations, for any individual.
6-10	(2) Notwithstanding subdivision (1) above, a health insurance carrier and health benefit
6-11	plan is not prohibited from placing lifetime dollar limits for any individual on specific covered
6-12	benefits that are not essential health benefits, as designated pursuant to a state determination and
6-13	in accordance with federal laws and regulations.
6-14	(c)(1) Reinstatement of Coverage. Except as provided in subdivision (2) of this
6-15	subsection, this subsection applies to any individual:
6-16	(A) Whose coverage or benefits under a health plan ended by reason of reaching a
6-17	lifetime limit on the dollar value of all benefits for the individual; and
6-18	(B) Who, due to the provisions of this section, becomes eligible, or is required to become
6-19	eligible, for benefits not subject to a lifetime limit on the dollar value of all benefits under the
6-20	health benefit plan:
6-21	(i) For group health insurance coverage, on the first day of the first plan year beginning
6-22	on or after September 23, 2010; or
6-23	(ii) For individual health insurance coverage, on the first day of the first policy year
6-24	beginning on or after September 23, 2010.
6-25	(2) For individual health insurance coverage, an individual is not entitled to reinstatement
6-26	under the health benefit plan under this subsection if the individual reached his or her lifetime
6-27	limit and the contract is not renewed or is otherwise no longer in effect. However, this subsection
6-28	applies to a family member who reached his or her lifetime limit in a family plan and other family
6-29	members remain covered under the plan.
6-30	(3)(A) If an individual described in subdivision (1) is eligible for benefits or is required to
6-31	become eligible for benefits, the health insurance carrier and health benefit plan shall provide the
6-32	individual written notice that:
6-33	(i) The lifetime limit on the dollar value of all benefits no longer applies; and
7-34	(ii) The individual, if still covered under the plan, is again eligible to receive benefits
7-35	under the plan.
7-36	(B) If the individual is not enrolled in the plan, or if an enrolled individual is eligible for,
7-37	but not enrolled in any benefit package under the plan, the health insurance carrier and health
7-38	benefit plan shall provide an opportunity for the individual to enroll in the plan for a period of at
7-39	least thirty (30) days.
7-40	(C) The notices and enrollment opportunity under this subdivision shall be provided
7-41	beginning not later than:
7-42	(i) For group health insurance coverage, the first day of the first plan year beginning on
7-43	or after September 23, 2010;
7-44	(ii) For individual health insurance coverage, the first day of the first policy year
7-45	beginning on or after September 23, 2010; or
7-46	(iii) The notices required under this subsection shall be provided:
7-47	(I) For group health insurance coverage, to an employee on behalf of the employee’s
7-48	dependent; or
7-49	(II) For individual health insurance coverage, to the primary subscriber on behalf of the
7-50	primary subscriber’s dependent.
7-51	(D) For group health insurance coverage, the notices may be included with other
7-52	enrollment materials that a health plan distributes to employees, provided the statement is
7-53	prominent. For group health insurance coverage, if a notice satisfying the requirements of this
7-54	subsection is provided to an individual, a health insurance carrier’s requirement to provide the
7-55	notice with respect to that individual is satisfied.
7-56	(E) For any individual who enrolls in a health plan in accordance with subdivision (2) of
7-57	this subsection, coverage under the plan shall take effect not later than:
7-58	(i) For group health insurance coverage, the first day of the first plan year beginning on
7-59	or after September 23, 2010; or
7-60	(ii) For individual health insurance coverage, the first day of the first policy year
7-61	beginning on or after September 23, 2010.
7-62	(d)(1) An individual enrolling in a health plan for group health insurance coverage in
7-63	accordance with subsection (c) above shall be treated as if the individual were a special enrollee
7-64	as provided under regulations interpreting the HIPAA portability provisions issued pursuant to
7-65	Section 2714 of the Affordable Care Act.
7-66	(2) An individual enrolling in accordance with subsection (c) above:
7-67	(A) Shall be offered all of the benefit packages available to similarly situated individuals
7-68	who did not lose coverage under the plan by reason of reaching a lifetime limit on the dollar value
8-1	of all benefits; and
8-2	(B) Shall not be required to pay more for coverage than similarly situated individuals
8-3	who did not lose coverage by reason of reaching a lifetime limit on the dollar value of all
8-4	benefits.
8-5	(3) For purposes of subsection (B)(1), any difference in benefits or cost-sharing
8-6	constitutes a different benefit package.
8-7	(e)(1) The provisions of this section relating to lifetime limits apply to any health
8-8	insurance carrier providing coverage under an individual or group health plan, including
8-9	grandfathered health plans.
8-10	(2) The provisions of this section relating to annual limits apply to any health insurance
8-11	carrier providing coverage under a group health plan, including grandfathered health plans, but
8-12	the prohibition and limits on annual limits do not apply to grandfathered health plans providing
8-13	individual health insurance coverage.
8-14	27-18-80. Coverage for preventive items and services. – (a) Every health insurance
8-15	carrier providing coverage under an individual or group health plan shall provide coverage for all
8-16	of the following items and services, and shall not impose any cost-sharing requirements, such as a
8-17	copayment, coinsurance or deductible, with respect to the following items and services:
8-18	(1) Except as otherwise provided in subsection (b) of this section, and except as may
8-19	otherwise be provided in federal regulations implementing the Affordable Care Act, evidence-
8-20	based items or services that have in effect a rating of A or B in the recommendations of the
8-21	United States Preventive Services Task Force as of September 23, 2010 and as may subsequently
8-22	be amended.
8-23	(2) Immunizations for routine use in children, adolescents and adults that have in effect a
8-24	recommendation from the Advisory Committee on Immunization Practices of the Centers for
8-25	Disease Control and Prevention with respect to the individual involved. For purposes of this
8-26	subdivision, a recommendation from the Advisory Committee on Immunization Practices of the
8-27	Centers for Disease Control and Prevention is considered in effect after it has been adopted by the
8-28	Director of the Centers for Disease Control and Prevention, and a recommendation is considered
8-29	to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease
8-30	Control and Prevention.
8-31	(3) With respect to infants, children and adolescents, evidence-informed preventive care,
8-32	and screenings provided for in comprehensive guidelines supported by the Health Resources and
8-33	Services Administration.
9-34	(4) With respect to women, to the extent not described in subdivision (1) of this
9-35	subsection, evidence-informed preventive care and screenings provided for in comprehensive
9-36	coverage guidelines supported by the Health Resources and Services Administration.
9-37	(b)(1) A health insurance carrier is not required to provide coverage for any items or
9-38	services specified in any recommendation or guideline described in subsection (a) of this section
9-39	after the recommendation or guideline is no longer described in subsection (a) of this section. The
9-40	provisions of this subdivision shall not affect the obligation of the health insurance carrier to
9-41	provide notice to a covered person before any material modification of coverage becomes
9-42	effective, in accordance with other requirements of state and federal law, including section
9-43	2715(d)(4) of the Public Health Services Act.
9-44	(2) A health insurance carrier shall at least annually at the beginning of each new plan
9-45	year or policy year, whichever is applicable, revise the preventive services covered under its
9-46	health benefit plans pursuant to this section consistent with the recommendations of the United
9-47	States Preventive Services Task Force, the Advisory Committee on Immunization Practices of the
9-48	Centers for Disease Control and Prevention and the guidelines with respect to infants, children,
9-49	adolescents and women evidence-based preventive care and screenings by the Health Resources
9-50	and Services Administration in effect at the time.
9-51	(c)(1) A health insurance carrier may impose cost-sharing requirements with respect to an
9-52	office visit if an item or service described in subsection (a) of this section is billed separately or is
9-53	tracked as individual encounter data separately from the office visit.
9-54	(2) A health insurance carrier shall not impose cost-sharing requirements with respect to
9-55	an office visit if an item or service described in subsection (a) of this section is not billed
9-56	separately or is not tracked as individual encounter data separately from the office visit and the
9-57	primary purpose of the office visit is the delivery of the item or service described in subsection
9-58	(a) of this section.
9-59	(3) A health insurance carrier may impose cost-sharing requirements with respect to an
9-60	office visit if an item or service described in subsection (a) of this section is not billed separately
9-61	or is not tracked as individual encounter data separately from the office visit and the primary
9-62	purpose of the office visit is not the delivery of the item or service.
9-63	(d)(1) Nothing in this section requires a health insurance carrier that has a network of
9-64	providers to providing coverage for items and services described in subsection (a) of this section
9-65	that are delivered by an out-of-network provider.
9-66	(2) Nothing in subsection (a) of this section precludes a health insurance carrier that has a
9-67	network of providers from imposing cost-sharing requirements for items or services described in
9-68	subsection (a) of this section that are delivered by an out-of-network provider.
10-1	(e) Nothing prevents a health insurance carrier from using reasonable medical
10-2	management techniques to determine the frequency, method, treatment or setting for an item or
10-3	service described in subsection (a) of this section to the extent not specified in the
10-4	recommendation or guideline.
10-5	(f) Nothing in this section prohibits a health insurance carrier from providing coverage
10-6	for items and services in addition to those recommended by the United States Preventive Services
10-7	Task Force or the Advisory Committee on Immunization Practices of the Centers for Disease
10-8	Control and Prevention, or provided by guidelines supported by the Health Resources and
10-9	Services Administration, or from denying coverage for items and services that are not
10-10	recommended by that task force or that advisory committee, or under those guidelines. A health
10-11	insurance carrier may impose cost-sharing requirements for a treatment not described in
10-12	subsection (a) of this section even if the treatment results from an item or service described in
10-13	subsection (a) of this section.
10-14	(g) This section shall not apply to grandfathered health plans.
10-15	27-18-81. Coverage for individuals participating in approved clinical trials. – (a) As
10-16	used in this section,
10-17	(1) “Approved clinical trial” means a phase I, phase II, phase III or phase IV clinical trial
10-18	that is conducted in relation to the prevention, detection or treatment of cancer or a life-
10-19	threatening disease or condition and is described in any of the following:
10-20	(A) The study or investigation is approved or funded, which may include funding through
10-21	in-kind contributions, by one or more of the following:
10-22	(i) The National Institutes of Health;
10-23	(ii) The Centers for Disease Control and Prevention;
10-24	(iii) The Agency for Health Care Research and Quality;
10-25	(iv) The Centers for Medicare & Medicaid Services;
10-26	(v) A cooperative group or center of any of the entities described in items (i) through (iv)
10-27	or the Department of Defense or the Department of Veteran Affairs;
10-28	(vi) A qualified non-governmental research entity identified in the guidelines issued by
10-29	the National Institutes of Health for center support grants; or
10-30	(vii) A study or investigation conducted by the Department of Veteran Affairs, the
10-31	Department of Defense, or the Department of Energy, if the study or investigation has been
10-32	reviewed and approved through a system of peer review that the Secretary of U.S. Department of
10-33	Health and Human Services determines:
11-34	(I) Is comparable to the system of peer review of studies and investigations used by the
11-35	National Institutes of Health; and
11-36	(II) Assures unbiased review of the highest scientific standards by qualified individuals
11-37	who have no interest in the outcome of the review.
11-38	(B) The study or investigation is conducted under an investigational new drug application
11-39	reviewed by the Food and Drug Administration; or
11-40	(C) The study or investigation is a drug trial that is exempt from having such an
11-41	investigational new drug application.
11-42	(2) “Participant” has the meaning stated in section 3(7) of ERISA.
11-43	(3) “Participating provider” means a health care provider that, under a contract with the
11-44	health carrier or with its contractor or subcontractor, has agreed to provide health care services to
11-45	covered persons with an expectation of receiving payment, other than coinsurance, copayments or
11-46	deductibles, directly or indirectly from the health carrier.
11-47	(4) “Qualified individual” means a participant or beneficiary who meets the following
11-48	conditions:
11-49	(A) The individual is eligible to participate in an approved clinical trial according to the
11-50	trial protocol with respect to the treatment of cancer or other life-threatening disease or condition;
11-51	and
11-52	(B)(i) The referring health care professional is a participating provider and has concluded
11-53	that the individual’s participation in such trial would be appropriate based on the individual
11-54	meeting the conditions described in subdivision (A) of this subdivision (3); or
11-55	(ii) The participant or beneficiary provides medical and scientific information
11-56	establishing the individual’s participation in such trial would be appropriate based on the
11-57	individual meeting the conditions described in subdivision (A) of this subdivision (3).
11-58	(5) “Life-threatening condition” means any disease or condition from which the
11-59	likelihood of death is probable unless the course of the disease or condition is interrupted.
11-60	(b)(1) If a health insurance carrier offering group or individual health insurance coverage
11-61	provides coverage to a qualified individual, the health insurance carrier:
11-62	(A) Shall not deny the individual participation in an approved clinical trial.
11-63	(B) Subject to subdivision (3) of this subsection, shall not deny or limit or impose
11-64	additional conditions on the coverage of routine patient costs for items and services furnished in
11-65	connection with participation in the approved clinical trial; and
11-66	(C) Shall not discriminate against the individual on the basis of the individual’s
11-67	participation in the approved clinical trial.
12-68	(2)(A) Subject to subdivision (B) of this subdivision (2), routine patient costs include all
12-69	items and services consistent with the coverage typically covered for a qualified individual who is
12-70	not enrolled in an approved clinical trial.
12-71	(B) For purposes of subdivision (B) of this subdivision (2), routine patient costs do not
12-72	include:
12-73	(i) The investigational item, device or service itself;
12-74	(ii) Items and services that are provided solely to satisfy data collection and analysis
12-75	needs and that are not used in the direct clinical management of the patient; or
12-76	(iii) A service that is clearly inconsistent with widely accepted and established standards
12-77	of care for a particular diagnosis.
12-78	(3) If one or more participating providers are participating in a clinical trial, nothing in
12-79	subdivision (1) of this subsection shall be construed as preventing a health carrier from requiring
12-80	that a qualified individual participate in the trial through such a participating provider if the
12-81	provider will accept the individual as a participant in the trial.
12-82	(4) Notwithstanding subdivision (3) of this subsection, subdivision (1) of this subsection
12-83	shall apply to a qualified individual participating in an approved clinical trial that is conducted
12-84	outside this state.
12-85	(5) This section shall not be construed to require a health insurance carrier offering group
12-86	or individual health insurance coverage to provide benefits for routine patient care services
12-87	provided outside of the coverage’s health care provider network unless out-of-network benefits
12-88	are otherwise provided under the coverage.
12-89	(6) Nothing in this section shall be construed to limit a health insurance carrier’s
12-90	coverage with respect to clinical trials.
12-91	(c) The requirements of this section shall be in addition to the requirements of Rhode
12-92	Island general laws sections 27-18-36 through 27-18-36.3.
12-93	(d) This section shall not apply to grandfathered health plans.
12-94	(e) This section shall be effective for plan years beginning on or after January 1, 2014.
12-95	27-18-82. Medical loss ratio rebates. – (a) A health insurance carrier offering group or
12-96	individual health insurance coverage, including a grandfathered health plan, shall pay medical
12-97	loss ratio rebates as provided for in Section 2718(b)(1)(A) of the Affordable Care Act, in the
12-98	manner and as required by federal laws and regulations.
12-99	(b) Health insurance carriers required to report medical loss ratio and rebate calculations
12-100	and other medical loss ratio and rebate information to the U.S. Department of Health and Human
12-101	Services shall concurrently file such information with the commissioner.
13-102	27-18-83. Emergency services. – (a) As used in this section:
13-103	(1) “Emergency medical condition” means a medical condition manifesting itself by
13-104	acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who
13-105	possesses an average knowledge of health and medicine, could reasonably expect the absence of
13-106	immediate medical attention to result in a condition: (i) Placing the health of the individual, or
13-107	with respect to a pregnant woman her unborn child, in serious jeopardy; (ii) Constituting a serious
13-108	impairment to bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or
13-109	part
13-110	(2) “Emergency services” means, with respect to an emergency medical condition:
13-111	(A) A medical screening examination (as required under section 1867 of the Social
13-112	Security Act, 42 U.S.C. 1395dd) that is within the capability of the emergency department of a
13-113	hospital, including ancillary services routinely available to the emergency department to evaluate
13-114	such emergency medical condition, and
13-115	(B) Such further medical examination and treatment, to the extent they are within the
13-116	capabilities of the staff and facilities available at the hospital, as are required under section 1867
13-117	of the Social Security Act (42 U.S.C. 1395dd) to stabilize the patient.
13-118	(3) “Stabilize”, with respect to an emergency medical condition has the meaning given in
13-119	section 1867(e)(3) of the Social Security Act (42 U.S.C. 1395dd(e)(3)).
13-120	(b) If a health insurance carrier offering health insurance coverage provides any benefits
13-121	with respect to services in an emergency department of a hospital, the carrier must cover
13-122	emergency services in compliance with this section.
13-123	(c) A health insurance carrier shall provide coverage for emergency services in the
13-124	following manner:
13-125	(1) Without the need for any prior authorization determination, even if the emergency
13-126	services are provided on an out-of-network basis;
13-127	(2) Without regard to whether the health care provider furnishing the emergency services
13-128	is a participating network provider with respect to the services;
13-129	(3) If the emergency services are provided out of network, without imposing any
13-130	administrative requirement or limitation on coverage that is more restrictive than the requirements
13-131	or limitations that apply to emergency services received from in-network providers;
13-132	(4) If the emergency services are provided out of network, by complying with the cost-
13-133	sharing requirements of subsection (d) of this section; and
13-134	(5) Without regard to any other term or condition of the coverage, other than:
13-135	(A) The exclusion of or coordination of benefits;
14-136	(B) An affiliation or waiting period permitted under part 7 of ERISA, part A of title
14-137	XXVII of the PHS Act, or chapter 100 of the Internal Revenue Code; or
14-138	(C) Applicable cost-sharing.
14-139	(d)(1) Any cost-sharing requirement expressed as a copayment amount or coinsurance
14-140	rate imposed with respect to a participant or beneficiary for out-of-network emergency services
14-141	cannot exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if
14-142	the services were provided in-network; provided, however, that a participant or beneficiary may
14-143	be required to pay, in addition to the in-network cost-sharing, the excess of the amount the out-of-
14-144	network provider charges over the amount the health insurance carrier is required to pay under
14-145	subdivision (1) of this subsection. A health insurance carrier complies with the requirements of
14-146	this subsection if it provides benefits with respect to an emergency service in an amount equal to
14-147	the greatest of the three amounts specified in subdivisions (A), (B), and (C) of this subdivision
14-148	(1)(which are adjusted for in-network cost-sharing requirements).
14-149	(A) The amount negotiated with in-network providers for the emergency service
14-150	furnished, excluding any in-network copayment or coinsurance imposed with respect to the
14-151	participant or beneficiary. If there is more than one amount negotiated with in-network providers
14-152	for the emergency service, the amount described under this subdivision (A) is the median of these
14-153	amounts, excluding any in-network copayment or coinsurance imposed with respect to the
14-154	participant or beneficiary. In determining the median described in the preceding sentence, the
14-155	amount negotiated with each in-network provider is treated as a separate amount (even if the
14-156	same amount is paid to more than one provider). If there is no per-service amount negotiated with
14-157	in-network providers (such as under a capitation or other similar payment arrangement), the
14-158	amount under this subdivision (A) is disregarded.
14-159	(B) The amount for the emergency service shall be calculated using the same method the
14-160	plan generally uses to determine payments for out-of-network services (such as the usual,
14-161	customary, and reasonable amount), excluding any in-network copayment or coinsurance
14-162	imposed with respect to the participant or beneficiary. The amount in this subdivision (B) is
14-163	determined without reduction for out-of-network cost-sharing that generally applies under the
14-164	plan or health insurance coverage with respect to out-of-network services.
14-165	(C) The amount that would be paid under Medicare (part A or part B of title XVIII of the
14-166	Social Security Act, 42 U.S.C. 1395 et seq.) for the emergency service, excluding any in-network
14-167	copayment or coinsurance imposed with respect to the participant or beneficiary.
14-168	(2) Any cost-sharing requirement other than a copayment or coinsurance requirement
14-169	(such as a deductible or out-of-pocket maximum) may be imposed with respect to emergency
14-170	services provided out of network if the cost-sharing requirement generally applies to out-of-
15-1	network benefits. A deductible may be imposed with respect to out-of-network emergency
15-2	services only as part of a deductible that generally applies to out-of-network benefits. If an out-of-
15-3	pocket maximum generally applies to out-of-network benefits, that out-of-pocket maximum must
15-4	apply to out-of-network emergency services.
15-5	(e) The provisions of this section apply for plan years beginning on or after September
15-6	23, 2010.
15-7	(f) This section shall not apply to grandfathered health plans.
15-8	27-18-84. Internal and external appeal of adverse benefit determinations. – (a) The
15-9	commissioner shall adopt regulations to implement standards and procedures with respect to
15-10	internal claims and appeals of adverse benefit determinations, and with respect to external appeals
15-11	of adverse benefit determinations.
15-12	(b) The regulations adopted by the commissioner shall apply to those adverse benefit
15-13	determinations within the jurisdiction of the commissioner.
15-14	SECTION 3. Sections 27-18-8, 27-18-44 and 27-18-59 of the General laws in Chapter
15-15	27-18 entitled "Accident and Sickness Insurance Policies" are hereby amended to read as follows:
15-16	27-18-8. Filing of accident and sickness insurance policy forms. -- Any insurance
15-17	company authorized to do an accident and sickness business within this state in accordance with
15-18	the provisions of this title shall file all accident and sickness insurance policy forms and rates
15-19	used by it in the state with the insurance commissioner, including the forms of any rider,
15-20	endorsement, application blank, and other matter generally used or incorporated by reference in
15-21	its policies or contracts of insurance. No such rate shall be used unless first approved by the
15-22	commissioner. No such form shall be used if disapproved by the commissioner under this section,
15-23	or if the commissioner’s approval has been withdrawn under section 27-18-8.3, or until the
15-24	expiration of the waiting period established under section 27-18-8.3. Such a company shall
15-25	comply with its filed and approved rates and forms. If the commissioner finds from an
15-26	examination of any form that it is contrary to the public interest, or the requirements of this code
15-27	or duly promulgated regulations, he or she shall forbid its use, and shall notify the company in
15-28	writing as provided in section 27-18-8.2. Each form shall include a certification by a qualified
15-29	actuary that to the best of the actuary's knowledge and judgment, the entire rate is in compliance
15-30	with applicable laws and that the benefits are reasonable in relation to the premium to be charged.
15-31	27-18-44. Primary and preventive obstetric and gynecological care. – (a) Any insurer
15-32	or health plan, nonprofit health medical service plan, or nonprofit hospital service plan that
15-33	provides coverage for obstetric and gynecological care for issuance or delivery in the state to any
15-34	group or individual on an expense-incurred basis, including a health plan offered or issued by a
16-1	health insurance carrier or a health maintenance organization, shall permit a woman to receive an
16-2	annual visit to an in-network obstetrician/gynecologist for routine gynecological care without
16-3	requiring the woman to first obtain a referral from a primary care provider.
16-4	(b)(1)(A) Any health plan, nonprofit medical service plan or nonprofit hospital service
16-5	plan, including a health insurance carrier or a health maintenance organization which requires or
16-6	provides for the designation by a covered person of a participating primary health care
16-7	professional shall permit each covered person to:
16-8	(i) Designate any participating primary care health care professional who is available to
16-9	accept the covered person; and
16-10	(ii) For a child, designate any participating physician who specializes in pediatrics as the
16-11	child’s primary care health care professional and is available to accept the child.
16-12	(2) The provisions of subdivision (1) of this subsection shall not be construed to waive
16-13	any exclusions of coverage under the terms and conditions of the health benefit plan with respect
16-14	to coverage of pediatric care.
16-15	(c)(1) If a health plan, nonprofit medical service plan or nonprofit hospital service plan,
16-16	including a health insurance carrier or a health maintenance organization, provides coverage for
16-17	obstetrical or gynecological care and requires the designation by a covered person of a
16-18	participating primary care health care professional, then it:
16-19	(A) Shall not require any person’s, including a primary care health care professional’s,
16-20	prior authorization or referral in the case of a female covered person who seeks coverage for
16-21	obstetrical or gynecological care provided by a participating health care professional who
16-22	specializes in obstetrics or gynecology; and
16-23	(B) Shall treat the provision of obstetrical and gynecological care, and the ordering of
16-24	related obstetrical and gynecological items and services, pursuant to subdivision (A) of this
16-25	subdivision (c)(1), by a participating health care professional who specializes in obstetrics or
16-26	gynecology as the authorization of the primary care health care professional.
16-27	(2)(A) A health plan, nonprofit medical service plan or nonprofit hospital service plan,
16-28	including a health insurance carrier or a health maintenance organization may require the health
16-29	care professional to agree to otherwise adhere to its policies and procedures, including procedures
16-30	relating to referrals, obtaining prior authorization, and providing services in accordance with a
16-31	treatment plan, if any, approved by the plan, carrier or health maintenance organization.
16-32	(B)For purposes of subdivision (A) of this subdivision (c)(1), a health care professional,
16-33	who specializes in obstetrics or gynecology, means any individual, including an individual other
16-34	than a physician, who is authorized under state law to provide obstetrical or gynecological care.
17-1	(3) The provisions of subdivision (A) of this subdivision (c)(1) shall not be construed to:
17-2	(A) Waive any exclusions of coverage under the terms and conditions of the health
17-3	benefit plan with respect to coverage of obstetrical or gynecological care; or
17-4	(B) Preclude the health plan, nonprofit medical service plan or nonprofit hospital service
17-5	plan, including a health insurance carrier or a health maintenance organization involved from
17-6	requiring that the participating health care professional providing obstetrical or gynecological
17-7	care notify the primary care health care professional or the plan, carrier or health maintenance
17-8	organization of treatment decisions.
17-9	(d) Notice Requirements:
17-10	(1) A health plan, nonprofit medical service plan or nonprofit hospital service plan,
17-11	including a health insurance carrier or a health maintenance organization subject to this section
17-12	shall provide notice to covered persons of the terms and conditions of the plan related to the
17-13	designation of a participating health care professional and of a covered person’s rights with
17-14	respect to those provisions.
17-15	(2)(A) In the case of group health insurance coverage, the notice described in subdivision
17-16	(1) of this subsection shall be included whenever the a participant is provided with a summary
17-17	plan description or other similar description of benefits under the health benefit plan.
17-18	(B) In the case of individual health insurance coverage, the notice described in
17-19	subdivision (1) of this subsection shall be included whenever the primary subscriber is provided
17-20	with a policy, certificate or contract of health insurance.
17-21	(C) A health plan, nonprofit medical service plan or nonprofit hospital service plan,
17-22	including a health insurance carrier or a health maintenance organization, may use the model
17-23	language in 45 CFR section 147.138(a)(4)(iii) to satisfy the requirements of this subsection.
17-24	(e) The requirements of subsections (b), (c), and (d) shall not apply to grandfathered
17-25	health plans.
17-26	27-18-59. ~~Termination of children's benefits~~ Eligibility for children's benefits. --
17-27	(a)(1) Every individual health insurance contract, plan, or policy delivered, issued for delivery, or
17-28	renewed in this state and every group health insurance contract, plan, or policy delivered, issued
17-29	for delivery or renewed in this state which provides ~~medical~~ health benefits coverage for
17-30	~~dependent children that includes coverage for physician services in a physician's office, and every~~
17-31	~~policy which provides major medical or similar comprehensive type coverage~~ dependents, except
17-32	for supplemental policies which only provide coverage for specified diseases and other
17-33	supplemental policies, shall ~~provide~~ make coverage available ~~of an unmarried child under the age~~
17-34	~~of nineteen (19) years, an unmarried child who is a student under the age of twenty-five (25)~~
18-1	~~years and who is financially dependent upon the parent and an unmarried child of any age who is~~
18-2	~~financially dependent upon the parent and medically determined to have a physical or mental~~
18-3	~~impairment which can be expected to result in death or which has lasted or can be expected to last~~
18-4	~~for a continuous period of not less than twelve (12) months~~ for children until attainment of
18-5	twenty-six (26) years of age. ~~Such contract, plan or policy shall also include a provision that~~
18-6	~~policyholders shall receive no less than thirty (30) days notice from the accident and sickness~~
18-7	~~insurer that a child covered as a dependent by the policy holder is about to lose his or her~~
18-8	~~coverage as a result of reaching the maximum age for a dependent child, and that the child will~~
18-9	~~only continue to be covered upon documentation being provided of current full or part-time~~
18-10	~~enrollment in a post-secondary educational institution or that the child may purchase a conversion~~
18-11	~~policy if he or she is not an eligible student. Nothing in this section prohibits an accident and~~
18-12	~~sickness insurer from requiring a policyholder to annually provide proof of a child's current full~~
18-13	~~or part-time enrollment in a post-secondary educational institution in order to maintain the child's~~
18-14	~~coverage. Provided, nothing in this section requires coverage inconsistent with the membership~~
18-15	~~criteria in effect under the policyholder's health benefits coverage.~~
18-16	(2) With respect to a child who has not attained twenty-six (26) years of age, a health
18-17	insurance carrier shall not define “dependent” for purposes of eligibility for dependent coverage
18-18	of children other than the terms of a relationship between a child and the plan participant, and, in
18-19	the individual market, primary subscriber.
18-20	(3) A health insurance carrier shall not deny or restrict coverage for a child who has not
18-21	attained twenty-six (26) years of age based on the presence or absence of the child’s financial
18-22	dependency upon the participant, primary subscriber or any other person, residency with the
18-23	participant and in the individual market the primary subscriber, or with any other person, marital
18-24	status, student status, employment or any combination of those factors. A health carrier shall not
18-25	deny or restrict coverage of a child based on eligibility for other coverage, except as provided in
18-26	subparagraph (d)(1) of this section.
18-27	(4) Nothing in this section shall be construed to require a health insurance carrier to make
18-28	coverage available for the child of a child receiving dependent coverage, unless the grandparent
18-29	becomes the legal guardian or adoptive parent of that grandchild.
18-30	(5) The terms of coverage in a health benefit plan offered by a health insurance carrier
18-31	providing dependent coverage of children cannot vary based on age except for children who are
18-32	twenty-six (26) years of age or older.
18-33	(b)(1) This subsection applies to any child:
19-34	(A) Whose coverage ended, or who was denied coverage, or was not eligible for group
19-35	health insurance coverage or individual health insurance coverage under a health benefit plan
19-36	because, under the terms of coverage, the availability of dependent coverage of a child ended
19-37	before the attainment of twenty-six (26) years of age; and
19-38	(B) Who becomes eligible, or is required to become eligible, for coverage on the first day
19-39	of the first plan year and, in the individual market, the first day of the first policy year, beginning
19-40	on or after September 23, 2010 by reason of the provisions of this section.
19-41	(2)(A) If group health insurance coverage or individual health insurance coverage, in
19-42	which a child is eligible to enroll, or is required to become eligible to enroll, in the coverage in
19-43	which the child’s coverage ended or did not begin for the reasons described in subdivision (1) of
19-44	this subsection, and if the health insurance carrier is subject to the requirements of this section the
19-45	health insurance carrier shall give the child an opportunity to enroll that continues for at least
19-46	sixty (60) days, including the written notice of the opportunity to enroll as described subdivision
19-47	(3) of this subsection.
19-48	(B) The health insurance carrier shall provide the opportunity to enroll, including the
19-49	written notice beginning not later than the first day of the first plan year and in the individual
19-50	market the first day of the first policy year, beginning on or after September 23, 2010.
19-51	(3)(A) The written notice of opportunity to enroll shall include a statement that children
19-52	whose coverage ended, or who were denied coverage, or were not eligible for coverage, because
19-53	the availability of dependent coverage of children ended before the attainment of twenty-six (26)
19-54	years of age are eligible to enroll in the coverage.
19-55	(B)(i) The notice may be provided to an employee on behalf of the employee’s child and,
19-56	in the individual market, to the primary subscriber on behalf of the primary subscriber’s child.
19-57	(ii) For group health insurance coverage:
19-58	(I)The notice may be included with other enrollment materials that the health carrier
19-59	distributes to employees, provided the statement is prominent; and
19-60	(II) If a notice satisfying the requirements of this subdivision is provided to an employee
19-61	whose child is entitled to an enrollment opportunity under subsection (c) of this section, the
19-62	obligation to provide the notice of enrollment opportunity under subdivision (B) of this
19-63	subdivision (3) with respect to that child is satisfied for both the plan and health insurance carrier.
19-64	(C) The written notice shall be provided beginning not later than the first day of the first
19-65	plan year and in the individual market the first day of the first policy year, beginning on or after
19-66	September 23, 2010.
19-67	(4) For an individual who enrolls under this subsection, the coverage shall take effect not
19-68	later than the first day of the first plan year and, in the individual market, the first day of the first
20-1	policy year, beginning on or after September 23, 2010.
20-2	(c)(1) A child enrolling in group health insurance coverage pursuant to subsections (b)
20-3	and (c) of this section shall be treated as if the child were a special enrollee, as provided under
20-4	regulations interpreting the Health Insurance Portability and Accountability Act (“HIPAA”)
20-5	portability provisions issued pursuant to Section 2714 of the Affordable Care Act.
20-6	(2)(A) The child and, if the child would not be a participant once enrolled, the participant
20-7	through whom the child is otherwise eligible for coverage under the plan, shall be offered all the
20-8	benefit packages available to similarly situated individuals who did not lose coverage by reason
20-9	of cessation of dependent status.
20-10	(B) For purposes of this subdivision (2), any difference in benefits or cost-sharing
20-11	requirements constitutes a different benefit package.
20-12	(3) The child shall not be required to pay more for coverage than similarly situated
20-13	individuals who did not lose coverage by reason of cessation of dependent status.
20-14	(d)(1) For plan years beginning before January 1, 2014, a health insurance carrier
20-15	providing group health insurance coverage that is a grandfathered health plan and makes
20-16	available dependent coverage of children may exclude an adult child who has not attained twenty-
20-17	six (26) years of age from coverage only if the adult child is eligible to enroll in an eligible
20-18	employer-sponsored health benefit plan, as defined in section 5000A(f)(2) of the Internal
20-19	Revenue Code, other than the group health plan of a parent.
20-20	(2) For plan years, beginning on or after January 1, 2014, a health insurance carrier
20-21	providing group health insurance coverage that is a grandfathered health plan shall comply with
20-22	the requirements of subsections (a) through (e) of this section.
20-23	(3) The provisions of this section shall apply to policy years in the individual market on
20-24	and after September 23, 2010.
20-25	~~(b)~~(e) This section does not apply to insurance coverage providing benefits for: (1)
20-26	hospital confinement indemnity; (2) disability income; (3) accident only; (4) long term care; (5)
20-27	Medicare supplement; (6) limited benefit health; (7) specified diseased indemnity; or (8) other
20-28	limited benefit policies.
20-29	SECTION 4. Sections 27-19-1 and 27-19-50 of the General laws in Chapter 27-19
20-30	entitled "Nonprofit Hospital Service Corporations" are hereby amended to read as follows:
20-31	27-19-1. Definitions. -- As used in this chapter:
20-32	(1) "Contracting hospital" means an eligible hospital which has contracted with a
20-33	nonprofit hospital service corporation to render hospital care to subscribers to the nonprofit
20-34	hospital service plan operated by the corporation;
21-1	(2) Adverse benefit determination" means any of the following: a denial, reduction, or
21-2	termination of, or a failure to provide or make payment (in whole or in part) for, a benefit,
21-3	including any such denial, reduction, termination, or failure to provide or make payment that is
21-4	based on a determination of a participant's or beneficiary's eligibility to participate in a plan or to
21-5	receive coverage under a plan, and including, with respect to group health plans, a denial,
21-6	reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a
21-7	benefit resulting from the application of any utilization review, as well as a failure to cover an
21-8	item or service for which benefits are otherwise provided because it is determined to be
21-9	experimental or investigational or not medically necessary or appropriate. The term also includes
21-10	a rescission of coverage determination.
21-11	(3) "Affordable Care Act" means the Patient Protection and Affordable Care Act of 2010,
21-12	as amended by the Health Care and Education Reconciliation Act of 2010.
21-13	(4) “Commissioner” or “health insurance commissioner” means that individual appointed
21-14	pursuant to section 42-14.5-1 of the General laws.
21-15	(5) "Eligible hospital" is one which is maintained either by the state or by any of its
21-16	political subdivisions or by a corporation organized for hospital purposes under the laws of this
21-17	state or of any other state or of the United States, which is designated as an eligible hospital by a
21-18	majority of the directors of the nonprofit hospital service corporation;
21-19	(6) “Grandfathered health plan” means any group health plan or health insurance
21-20	coverage subject to 42 USC section 18011;
21-21	(7) “Group health insurance coverage” means, in connection with a group health plan,
21-22	health insurance coverage offered in connection with such plan;
21-23	(8) “Group health plan” means an employee welfare benefit plan as defined 29 USC
21-24	section 1002(1), to the extent that the plan provides health benefits to employees or their
21-25	dependents directly or through insurance, reimbursement, or otherwise;
21-26	(9) “Health benefits” or “covered benefits” means medical, surgical, hospital,
21-27	prescription drug, and such other benefits, whether self-funded, or delivered through the purchase
21-28	of insurance or otherwise;
21-29	(10) “Health care facility” means an institution providing health care services or a health
21-30	care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory
21-31	surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic,
21-32	laboratory and imaging centers, and rehabilitation and other therapeutic health settings;
21-33	(11) "Health care professional" means a physician or other health care practitioner
21-34	licensed, accredited or certified to perform specified health care services consistent with state
22-1	law;
22-2	(12) "Health care provider" or "provider" means a health care professional or a health
22-3	care facility;
22-4	(13) "Health care services" means services for the diagnosis, prevention, treatment, cure
22-5	or relief of a health condition, illness, injury or disease;
22-6	(14) “Health insurance carrier” means a person, firm, corporation or other entity subject
22-7	to the jurisdiction of the commissioner under this chapter, and includes nonprofit hospital service
22-8	corporations. Such term does not include a group health plan;
22-9	(15) "Health plan" or "health benefit plan" means health insurance coverage and a group
22-10	health plan, including coverage provided through an association plan if it covers Rhode Island
22-11	residents. Except to the extent specifically provided by the Affordable Care Act, the term “health
22-12	plan” shall not include a group health plan to the extent state regulation of the health plan is pre-
22-13	empted under section 514 of the Employee Retirement Income Security Act of 1974. The term
22-14	also shall not include:
22-15	(A)(i) Coverage only for accident, or disability income insurance, or any combination
22-16	thereof.
22-17	(ii) Coverage issued as a supplement to liability insurance.
22-18	(iii) Liability insurance, including general liability insurance and automobile liability
22-19	insurance.
22-20	(iv) Workers’ compensation or similar insurance.
22-21	(v) Automobile medical payment insurance.
22-22	(vi) Credit-only insurance.
22-23	(vii) Coverage for on-site medical clinics.
22-24	(viii) Other similar insurance coverage, specified in federal regulations issued pursuant to
22-25	Pub. L. No. 104-191, the health insurance portability and accountability act of 1996 (“HIPAA”),
22-26	under which benefits for medical care are secondary or incidental to other insurance benefits.
22-27	(B) The following benefits if they are provided under a separate policy, certificate or
22-28	contract of insurance or are otherwise not an integral part of the plan:
22-29	(i) Limited scope dental or vision benefits.
22-30	(ii) Benefits for long-term care, nursing home care, home health care, community-based
22-31	care, or any combination thereof.
22-32	(iii)Other excepted benefits specified in federal regulations issued pursuant to Pub. L. No.
22-33	104-191 (“HIPAA”).
23-34	(C) The following benefits if the benefits are provided under a separate policy, certificate
23-35	or contract of insurance, there is no coordination between the provision of the benefits and any
23-36	exclusion of benefits under any group health plan maintained by the same plan sponsor, and the
23-37	benefits are paid with respect to an event without regard to whether benefits are provided with
23-38	respect to such an event under any group health plan maintained by the same plan sponsor:
23-39	(i) Coverage only for a specified disease or illness.
23-40	(ii) Hospital indemnity or other fixed indemnity insurance.
23-41	(D) The following if offered as a separate policy, certificate or contract of insurance:
23-42	(i) Medicare supplement health insurance as defined under section 1882(g)(1) of the
23-43	Social Security Act.
23-44	(ii) Coverage supplemental to the coverage provided under chapter 55 of title 10, United
23-45	States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)).
23-46	(iii) Similar supplemental coverage provided to coverage under a group health plan.
23-47	~~(3)~~(16) "Nonprofit hospital service corporation" means any corporation organized
23-48	pursuant to this chapter for the purpose of establishing, maintaining, and operating a nonprofit
23-49	hospital service plan;
23-50	~~(4)~~(17) "Nonprofit hospital service plan" means a plan by which specified hospital care
23-51	is to be provided to subscribers to the plan by a contracting hospital; ~~and~~
23-52	(18) "Office of the health insurance commissioner" means the agency established under
23-53	section 42-14.5-1 of the General Law;
23-54	(19) “Rescission" means a cancellation or discontinuance of coverage that has retroactive
23-55	effect for reasons unrelated to timely payment of required premiums or contribution to costs of
23-56	coverage; and
23-57	~~(5)~~(20) "Subscribers" mean those persons, whether or not residents of this state, who
23-58	have contracted with a nonprofit hospital service corporation for hospital care pursuant to a
23-59	nonprofit hospital service plan operated by the corporation.
23-60	27-19-50. ~~Termination of children's benefits~~ Eligibility for children's benefits. -- (a)
23-61	(1) Every individual health insurance contract, plan, or policy delivered, issued for delivery, or
23-62	renewed in this state and every group health insurance contract, plan, or policy delivered, issued
23-63	for delivery or renewed in this state which provides ~~medical~~ health benefits coverage ~~for~~
23-64	~~dependent children that includes coverage for physician services in a physician's office, and every~~
23-65	~~policy which provides major medical or similar comprehensive type coverage~~ dependents, except
23-66	for supplemental policies which only provide coverage for specified diseases and other
23-67	supplemental policies, shall ~~provide~~ make coverage available ~~of an unmarried child under the age~~
23-68	~~of nineteen (19) years, an unmarried child who is a student under the age of twenty-five (25)~~
24-1	~~years and who is financially dependent upon the parent and an unmarried child of any age who is~~
24-2	~~financially dependent upon the parent and medically determined to have a physical or mental~~
24-3	~~impairment which can be expected to result in death or which has lasted or can be expected to last~~
24-4	~~for a continuous period of not less than twelve (12) months~~ for children until attainment of
24-5	twenty-six (26) years of age. ~~Such contract, plan or policy shall also include a provision that~~
24-6	~~policyholders shall receive no less than thirty (30) days notice from the nonprofit hospital service~~
24-7	~~corporation that a child covered as a dependent by the policyholder is about to lose his or her~~
24-8	~~coverage as a result of reaching the maximum age for a dependent child and that the child will~~
24-9	~~only continue to be covered upon documentation being provided of current full or part-time~~
24-10	~~enrollment in a post-secondary educational institution, or that the child may purchase a~~
24-11	~~conversion policy if he or she is not an eligible student.~~
24-12	~~(b) Nothing in this section prohibits a nonprofit hospital service corporation from~~
24-13	~~requiring a policyholder to annually provide proof of a child's current full or part-time enrollment~~
24-14	~~in a post-secondary educational institution in order to maintain the child's coverage. Provided,~~
24-15	~~nothing in this section requires coverage inconsistent with the membership criteria in effect under~~
24-16	~~the policyholder's health benefits coverage.~~
24-17	(2) With respect to a child who has not attained twenty-six (26) years of age, a health
24-18	insurance carrier shall not define “dependent” for purposes of eligibility for dependent coverage
24-19	of children other than the terms of a relationship between a child and the plan participant, and, in
24-20	the individual market, primary subscriber.
24-21	(3) A health insurance carrier shall not deny or restrict coverage for a child who has not
24-22	attained twenty-six (26) years of age based on the presence or absence of the child’s financial
24-23	dependency upon the participant, primary subscriber or any other person, residency with the
24-24	participant and in the individual market the primary subscriber, or with any other person, marital
24-25	status, student status, employment or any combination of those factors. A health carrier shall not
24-26	deny or restrict coverage of a child based on eligibility for other coverage, except as provided in
24-27	(d)(1) of this section.
24-28	(4) Nothing in this section shall be construed to require a health insurance carrier to make
24-29	coverage available for the child of a child receiving dependent coverage, unless the grandparent
24-30	becomes the legal guardian or adoptive parent of that grandchild.
24-31	(5) The terms of coverage in a health benefit plan offered by a health insurance carrier
24-32	providing dependent coverage of children cannot vary based on age except for children who are
24-33	twenty-six (26) years of age or older.
25-34	(b)(1) This subsection applies to any child:
25-35	(A) Whose coverage ended, or who was denied coverage, or was not eligible for group
25-36	health insurance coverage or individual health insurance coverage under a health benefit plan
25-37	because, under the terms of coverage, the availability of dependent coverage of a child ended
25-38	before the attainment of twenty-six (26) years of age; and
25-39	(B) Who becomes eligible, or is required to become eligible, for coverage on the first day
25-40	of the first plan year and, in the individual market, the first day of the first policy year, beginning
25-41	on or after September 23, 2010 by reason of the provisions of this section.
25-42	(2)(A) If group health insurance coverage or individual health insurance coverage, in
25-43	which a child is eligible to enroll, or is required to become eligible to enroll, in the coverage in
25-44	which the child’s coverage ended or did not begin for the reasons described in subdivision (1) of
25-45	this subsection, and if the health insurance carrier is subject to the requirements of this section the
25-46	health insurance carrier shall give the child an opportunity to enroll that continues for at least
25-47	sixty (60) days, including the written notice of the opportunity to enroll as described subdivision
25-48	(3) of this subsection.
25-49	(B) The health insurance carrier shall provide the opportunity to enroll, including the
25-50	written notice beginning not later than the first day of the first plan year and in the individual
25-51	market the first day of the first policy year, beginning on or after September 23, 2010.
25-52	(3)(A) The written notice of opportunity to enroll shall include a statement that children
25-53	whose coverage ended, or who were denied coverage, or were not eligible for coverage, because
25-54	the availability of dependent coverage of children ended before the attainment of twenty-six (26)
25-55	years of age are eligible to enroll in the coverage.
25-56	(B)(i) The notice may be provided to an employee on behalf of the employee’s child and,
25-57	in the individual market, to the primary subscriber on behalf of the primary subscriber’s child.
25-58	(ii) For group health insurance coverage:
25-59	(I) The notice may be included with other enrollment materials that the health carrier
25-60	distributes to employees, provided the statement is prominent; and
25-61	(II) If a notice satisfying the requirements of this subdivision is provided to an employee
25-62	whose child is entitled to an enrollment opportunity under subsection (b) of this section, the
25-63	obligation to provide the notice of enrollment opportunity under subdivision (B) of this
25-64	subdivision (3) with respect to that child is satisfied for both the plan and health insurance carrier.
25-65	(C) The written notice shall be provided beginning not later than the first day of the first
25-66	plan year and in the individual market the first day of the first policy year, beginning on or after
25-67	September 23, 2010.
26-68	(4) For an individual who enrolls under this subsection, the coverage shall take effect not
26-69	later than the first day of the first plan year and, in the individual market, the first day of the first
26-70	policy year, beginning on or after September 23, 2010.
26-71	(c)(1) A child enrolling in group health insurance coverage pursuant to subsection (b) of
26-72	this section shall be treated as if the child were a special enrollee, as provided under regulations
26-73	interpreting the HIPAA portability provisions issued pursuant to Section 2714 of the Affordable
26-74	Care Act.
26-75	(2)(A) The child and, if the child would not be a participant once enrolled, the participant
26-76	through whom the child is otherwise eligible for coverage under the plan, shall be offered all the
26-77	benefit packages available to similarly situated individuals who did not lose coverage by reason
26-78	of cessation of dependent status.
26-79	(B) For purposes of this subdivision (2), any difference in benefits or cost-sharing
26-80	requirements constitutes a different benefit package.
26-81	(3) The child shall not be required to pay more for coverage than similarly situated
26-82	individuals who did not lose coverage by reason of cessation of dependent status.
26-83	(d)(1) For plan years beginning before January 1, 2014, a group health plan providing
26-84	group health insurance coverage that is a grandfathered health plan and makes available
26-85	dependent coverage of children may exclude an adult child who has not attained twenty-six (26)
26-86	years of age from coverage only if the adult child is eligible to enroll in an eligible employer-
26-87	sponsored health benefit plan, as defined in section 5000A(f)(2) of the Internal Revenue Code,
26-88	other than the group health plan of a parent.
26-89	(2) For plan years, beginning on or after January 1, 2014, a group health plan providing
26-90	group health insurance coverage that is a grandfathered health plan shall comply with the
26-91	requirements of subsections (a) through (e).
26-92	(3) The provision of this section applies to policy years in the individual market on and
26-93	after September 23, 2010, and shall apply to grandfathered health plans.
26-94	~~(b)~~(e) This section does not apply to insurance coverage providing benefits for: (1)
26-95	hospital confinement indemnity; (2) disability income; (3) accident only; (4) long term care; (5)
26-96	Medicare supplement; (6) limited benefit health; (7) specified diseased indemnity; or (8) other
26-97	limited benefit policies.
26-98	SECTION 5. Chapter 27-19 of the General laws entitled "Nonprofit Hospital Service
26-99	Corporations" is hereby amended by adding thereto the following sections:
26-100	27-19-7.1. Uniform explanation of benefits and coverage. – (a) A nonprofit hospital
26-101	service corporation shall provide a uniform summary of benefits and coverage explanation and
26-102	standardized definitions to policyholders and others required by, and at the times required by, the
27-1	federal regulations adopted under section 2715 of the Affordable Care Act. A summary required
27-2	by this section shall be filed with the commissioner for approval under Rhode Island general laws
27-3	section 27-19-7.2. The requirements of this section shall be in addition to the requirements of
27-4	Rhode Island general laws section 27-19-7.2. The commissioner may waive one or more of the
27-5	requirements of the regulations adopted under section 2715 of the Affordable Care Act for good
27-6	cause shown. The summary must contain at least the following information:
27-7	(1) Uniform definitions of standard insurance and medical terms.
27-8	(2) A description of coverage and cost-sharing for each category of essential benefits and
27-9	other benefits.
27-10	(3) Exceptions, reductions and limitations in coverage.
27-11	(4) Renewability and continuation of coverage provisions.
27-12	(5) A “coverage facts label” that illustrates coverage under common benefits scenarios.
27-13	(6) A statement of whether the policy, contract or plan provides the minimum coverage
27-14	required of a qualified health plan.
27-15	(7) A statement that the outline is a summary and that the actual policy language should
27-16	be consulted; and
27-17	(8) A contact number for the consumer to call with additional questions and the web
27-18	address of where the actual language of the policy, contract or plan can be found.
27-19	(b) The provisions of this section shall apply to grandfathered health plans.
27-20	27-19-7.2. Filing of policy forms. – A nonprofit hospital service corporation shall file all
27-21	policy forms and rates used by it in the state with the commissioner, including the forms of any
27-22	rider, endorsement, application blank, and other matter generally used or incorporated by
27-23	reference in its policies or contracts of insurance. No such rate shall be used unless first approved
27-24	by the commissioner. No such form shall be used if disapproved by the commissioner under this
27-25	section, or if the commissioner's approval has been withdrawn after notice and an opportunity to
27-26	be heard, or until the expiration of sixty (60) days following the filing of the form. A nonprofit
27-27	hospital service corporation shall comply with its filed and approved rates and forms. If the
27-28	commissioner finds from an examination of any form that it is contrary to the public interest, or
27-29	the requirements of this code or duly promulgated regulations, he or she shall forbid its use, and
27-30	shall notify the corporation in writing. Each form shall include a certification by a qualified
27-31	actuary that to the best of the actuary's knowledge and judgment, the entire rate is in compliance
27-32	with applicable laws and that the benefits are reasonable in relation to the premium to be charged.
27-33	27-19-62. Prohibition on rescission of coverage. – (a)(1) Coverage under a health plan
27-34	subject to the jurisdiction of the commissioner under this chapter with respect to an individual,
28-1	including a group to which the individual belongs or family coverage in which the individual is
28-2	included, shall not be rescinded after the individual is covered under the plan, unless:
28-3	(A) The individual or a person seeking coverage on behalf of the individual, performs an
28-4	act, practice or omission that constitutes fraud; or
28-5	(B) The individual makes an intentional misrepresentation of material fact, as prohibited
28-6	by the terms of the plan or coverage.
28-7	(2) For purposes of paragraph (1)(A), a person seeking coverage on behalf of an
28-8	individual does not include an insurance producer or employee or authorized representative of the
28-9	health carrier.
28-10	(b) At least thirty (30) days advance written notice shall be provided to each health
28-11	benefit plan enrollee or, for individual health insurance coverage, primary subscriber, who would
28-12	be affected by the proposed rescission of coverage before coverage under the plan may be
28-13	rescinded in accordance with subsection (a) regardless of, in the case of group health insurance
28-14	coverage, whether the rescission applies to the entire group or only to an individual within the
28-15	group.
28-16	(c) For purposes of this section, “to rescind” means to cancel or to discontinue coverage
28-17	with retroactive effect for reasons unrelated to timely payment of required premiums or
28-18	contribution to costs of coverage.
28-19	(d) This section applies to grandfathered health plans.
28-20	27-19-63. Prohibition on annual and lifetime limits. – (a) Annual limits. (1) For plan or
28-21	policy years beginning prior to January 1, 2014, for any individual, a health insurance carrier and
28-22	health benefit plan subject to the jurisdiction of the commissioner under this chapter may
28-23	establish an annual limit on the dollar amount of benefits that are essential health benefits
28-24	provided the restricted annual limit is not less than the following:
28-25	(A) For a plan or policy year beginning after September 22, 2010, but before September
28-26	23, 2011 – seven hundred fifty thousand dollars ($750,000);
28-27	(B) For a plan or policy year beginning after September 22, 2011, but before September
28-28	23, 2012 – one million two hundred fifty thousand dollars ($1,250,000); and
28-29	(C) For a plan or policy year beginning after September 22, 2012, but before January 1,
28-30	2014 – two million dollars ($2,000,000).
28-31	(2) For plan or policy years beginning on or after January 1, 2014, a health insurance
28-32	carrier and health benefit plan shall not establish any annual limit on the dollar amount of
28-33	essential health benefits for any individual, except:
29-34	(A) A health flexible spending arrangement, as defined in Section 106(c)(2)(i) of the
29-35	Internal Revenue Code, a medical savings account, as defined in Section 220 of the Internal
29-36	Revenue Code, and a health savings account, as defined in Section 223 of the Internal Revenue
29-37	Code, are not subject to the requirements of subdivisions (1) and (2) of this subsection .
29-38	(B) The provisions of this subsection shall not prevent a health insurance carrier and
29-39	health benefit plan from placing annual dollar limits for any individual on specific covered
29-40	benefits that are not essential health benefits to the extent that such limits are otherwise permitted
29-41	under applicable federal law or the laws and regulations of this state.
29-42	(3) In determining whether an individual has received benefits that meet or exceed the
29-43	allowable limits, as provided in subdivision (1) of this subsection, a health insurance carrier and
29-44	health benefit plan shall take into account only essential health benefits.
29-45	(b) Lifetime limits.
29-46	(1) A health insurance carrier and health benefit plan offering group or individual health
29-47	insurance coverage shall not establish a lifetime limit on-the-dollar-value of essential health
29-48	benefits, as designated pursuant to a state determination and in accordance with federal laws and
29-49	regulations, for any individual.
29-50	(2) Notwithstanding subdivision (1) above, a health insurance carrier and health benefit
29-51	plan is not prohibited from placing lifetime dollar limits for any individual on specific covered
29-52	benefits that are not essential health benefits, as designated pursuant to a state determination and
29-53	in accordance with federal laws and regulations.
29-54	(c)(1) Reinstatement of Coverage. Except as provided in subdivision (2) of this
29-55	subsection, this subsection applies to any individual:
29-56	(A) Whose coverage or benefits under a health plan ended by reason of reaching a
29-57	lifetime limit on the dollar value of all benefits for the individual; and
29-58	(B) Who, due to the provisions of this section, becomes eligible, or is required to become
29-59	eligible, for benefits not subject to a lifetime limit on the dollar value of all benefits under the
29-60	health benefit plan:
29-61	(i) For group health insurance coverage, on the first day of the first plan year beginning
29-62	on or after September 23, 2010; or
29-63	(ii) For individual health insurance coverage, on the first day of the first policy year
29-64	beginning on or after September 23, 2010.
29-65	(2) For individual health insurance coverage, an individual is not entitled to reinstatement
29-66	under the health benefit plan under this subsection if the individual reached his or her lifetime
29-67	limit and the contract is not renewed or is otherwise no longer in effect. However, this subsection
29-68	applies to a family member who reached his or her lifetime limit in a family plan and other family
30-1	members remain covered under the plan.
30-2	(3)(A) If an individual described in subdivision (1) is eligible for benefits or is required to
30-3	become eligible for benefits under the health benefit plan, the health carrier shall provide the
30-4	individual written notice that:
30-5	(i) The lifetime limit on the dollar value of all benefits no longer applies; and
30-6	(ii) The individual, if still covered under the plan, is again eligible to receive benefits
30-7	under the plan.
30-8	(B) If the individual is not enrolled in the plan, or if an enrolled individual is eligible for,
30-9	but not enrolled in any benefit package under the plan, the health benefit plan shall provide an
30-10	opportunity for the individual to enroll in the plan for a period of at least thirty (30) days.
30-11	(C) The notices and enrollment opportunity under this subdivision shall be provided
30-12	beginning not later:
30-13	(i) For group health insurance coverage, the first day of the first plan year beginning on
30-14	or after September 23, 2010; or
30-15	(ii) For individual health insurance coverage, the first day of the first policy year
30-16	beginning on or after September 23, 2010.
30-17	(iii) The notices required under this subsection shall be provided:
30-18	(I)For group health insurance coverage, to an employee on behalf of the employee’s
30-19	dependent; or
30-20	(II) For individual health insurance coverage, to the primary subscriber on behalf of the
30-21	primary subscriber’s dependent.
30-22	(D) For group health insurance coverage, the notices may be included with other
30-23	enrollment materials that a health plan distributes to employees, provided the statement is
30-24	prominent. For group health insurance coverage, if a notice satisfying the requirements of this
30-25	subsection is provided to an individual, a health insurance carrier’s requirement to provide the
30-26	notice with respect to that individual is satisfied.
30-27	(E) For any individual who enrolls in a health plan in accordance with subdivision (2) of
30-28	this subsection, coverage under the plan shall take effect not later than:
30-29	(i) For group health insurance coverage, the first day of the first plan year beginning on
30-30	or after September 23, 2010; or
30-31	(ii) For individual health insurance coverage, the first day of the first policy year
30-32	beginning on or after September 23, 2010.
30-33	(d)(1) An individual enrolling in a health plan for group health insurance coverage in
30-34	accordance with subsection (c) of this subsection shall be treated as if the individual were a
31-1	special enrollee in the plan, as provided under regulations interpreting the HIPAA portability
31-2	provisions issued pursuant to Section 2714 of the Affordable Care Act.
31-3	(2) An individual enrolling in accordance with subsection (c) of this subsection:
31-4	(A) shall be offered all of the benefit packages available to similarly situated individuals
31-5	who did not lose coverage under the plan by reason of reaching a lifetime limit on the dollar value
31-6	of all benefits; and
31-7	(B) Shall not be required to pay more for coverage than similarly situated individuals
31-8	who did not lose coverage by reason of reaching a lifetime limit on the dollar value of all
31-9	benefits.
31-10	(3) For purposes of subsection B(1), any difference in benefits or cost-sharing constitutes
31-11	a different benefit package.
31-12	(e)(1) The provisions of this section relating to lifetime limits apply to any health
31-13	insurance carrier providing coverage under an individual or group health plan, including
31-14	grandfathered health plans.
31-15	(2) The provisions of this section relating to annual limits apply to any health insurance
31-16	carrier providing coverage under a group health plan, including grandfathered health plans, but
31-17	the prohibition and limits on annual limits do not apply to grandfathered health plans providing
31-18	individual health insurance coverage.
31-19	27-19-64. Coverage for preventive items and services. – (a) Every health insurance
31-20	carrier providing coverage under an individual or group health plan shall provide coverage for all
31-21	of the following items and services, and shall not impose any cost-sharing requirements, such as a
31-22	copayment, coinsurance or deductible, with respect to the following items and services:
31-23	(1) Except as otherwise provided in subsection (b) of this section, and except as may
31-24	otherwise be provided in federal regulations implementing the Affordable Care Act, evidence-
31-25	based items or services that have in effect a rating of A or B in the recommendations of the
31-26	United States Preventive Services Task Force as of September 23, 2010, and as may subsequently
31-27	be amended.
31-28	(2) Immunizations for routine use in children, adolescents and adults that have in effect a
31-29	recommendation from the Advisory Committee on Immunization Practices of the Centers for
31-30	Disease Control and Prevention with respect to the individual involved. For purposes of this
31-31	subdivision, a recommendation from the Advisory Committee on Immunization Practices of the
31-32	Centers for Disease Control and Prevention is considered in effect after it has been adopted by the
31-33	Director of the Centers for Disease Control and Prevention, and a recommendation is considered
31-34	to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease
32-1	Control and Prevention.
32-2	(3) With respect to infants, children and adolescents, evidence-informed preventive care,
32-3	and screenings provided for in comprehensive guidelines supported by the Health Resources and
32-4	Services Administration.
32-5	(4) With respect to women, to the extent not described in subdivision (1) of this
32-6	subsection, evidence-informed preventive care and screenings provided for in comprehensive
32-7	coverage guidelines supported by the Health Resources and Services Administration.
32-8	(b)(1) A health insurance carrier is not required to provide coverage for any items or
32-9	services specified in any recommendation or guideline described in subsection (a) of this section
32-10	after the recommendation or guideline is no longer described in subsection (a) of this section. The
32-11	provisions of this subdivision shall not affect the obligation of the health insurance carrier to
32-12	provide notice to a covered person before any material modification of coverage becomes
32-13	effective, in accordance with other requirements of state and federal law, including section
32-14	2715(d)(4) of the Public Health Services Act.
32-15	(2) A health insurance carrier shall at least annually at the beginning of each new plan
32-16	year or policy year, whichever is applicable, revise the preventive services covered under its
32-17	health benefit plans pursuant to this section consistent with the recommendations of the United
32-18	States Preventive Services Task Force, the Advisory Committee on Immunization Practices of the
32-19	Centers for Disease Control and Prevention and the guidelines with respect to infants, children,
32-20	adolescents and women evidence-based preventive care and screenings by the Health Resources
32-21	and Services Administration in effect at the time.
32-22	(c)(1) A health insurance carrier may impose cost-sharing requirements with respect to an
32-23	office visit if an item or service described in subsection (a) of this section is billed separately or is
32-24	tracked as individual encounter data separately from the office visit.
32-25	(2) A health insurance carrier shall not impose cost-sharing requirements with respect to
32-26	an office visit if an item or service described in subsection (a) of this section is not billed
32-27	separately or is not tracked as individual encounter data separately from the office visit and the
32-28	primary purpose of the office visit is the delivery of the item or service described in subsection
32-29	(a) of this section.
32-30	(3) A health insurance carrier may impose cost-sharing requirements with respect to an
32-31	office visit if an item or service described in subsection (a) of this section is not billed separately
32-32	or is not tracked as individual encounter data separately from the office visit and the primary
32-33	purpose of the office visit is not the delivery of the item or service.
33-34	(d)(1) Nothing in this section requires a health insurance carrier that has a network of
33-35	providers to provide coverage for items and services described in subsection (a) of this section
33-36	that are delivered by an out-of-network provider.
33-37	(2) Nothing in subsection (a) of this section precludes a health insurance carrier that has a
33-38	network of providers from imposing cost-sharing requirements for items or services described in
33-39	subsection (a) of this section that are delivered by an out-of-network provider.
33-40	(e) Nothing prevents a health insurance carrier from using reasonable medical
33-41	management techniques to determine the frequency, method, treatment or setting for an item or
33-42	service described in subsection (a) of this section to the extent not specified in the
33-43	recommendation or guideline.
33-44	(f) Nothing in this section prohibits a health insurance carrier from providing coverage
33-45	for items and services in addition to those recommended by the United States Preventive Services
33-46	Task Force or the Advisory Committee on Immunization Practices of the Centers for Disease
33-47	Control and Prevention, or provided by guidelines supported by the Health Resources and
33-48	Services Administration, or from denying coverage for items and services that are not
33-49	recommended by that task force or that advisory committee, or under those guidelines. A health
33-50	insurance carrier may impose cost-sharing requirements for a treatment not described in
33-51	subsection (a) of this section even if the treatment results from an item or service described in
33-52	subsection (a) of this section.
33-53	(g) This section shall not apply to grandfathered health plans.
33-54	27-19-65. Coverage for individuals participating in approved clinical trials. – (a) As
33-55	used in this section:
33-56	(1) “Approved clinical trial” means a phase I, phase II, phase III or phase IV clinical trial
33-57	that is conducted in relation to the prevention, detection or treatment of cancer or a life-
33-58	threatening disease or condition and is described in any of the following:
33-59	(A) The study or investigation is approved or funded, which may include funding through
33-60	in-kind contributions, by one or more of the following:
33-61	(i) The National Institutes of Health;
33-62	(ii) The Centers for Disease Control and Prevention;
33-63	(iii) The Agency for Health Care Research and Quality;
33-64	(iv) The Centers for Medicare & Medicaid Services;
33-65	(v) A cooperative group or center of any of the entities described in items (i) through (iv)
33-66	or the Department of Defense or the Department of Veteran Affairs;
33-67	(vi) A qualified non-governmental research entity identified in the guidelines issued by
33-68	the National Institutes of Health for center support grants; or
34-1	(vii) A study or investigation conducted by the Department of Veteran Affairs, the
34-2	Department of Defense, or the Department of Energy, if the study or investigation has been
34-3	reviewed and approved through a system of peer review that the Secretary of U.S. Department of
34-4	Health and Human Services determines:
34-5	(I) Is comparable to the system of peer review of studies and investigations used by the
34-6	National Institutes of Health; and
34-7	(II) Assures unbiased review of the highest scientific standards by qualified individuals
34-8	who have no interest in the outcome of the review.
34-9	(B) The study or investigation is conducted under an investigational new drug application
34-10	reviewed by the Food and Drug Administration; or
34-11	(C) The study or investigation is a drug trial that is exempt from having such an
34-12	investigational new drug application.
34-13	(2) “Participant” has the meaning stated in section 3(7) of ERISA.
34-14	(3) “Participating provider” means a health care provider that, under a contract with the
34-15	health carrier or with its contractor or subcontractor, has agreed to provide health care services to
34-16	covered persons with an expectation of receiving payment, other than coinsurance, copayments or
34-17	deductibles, directly or indirectly from the health carrier.
34-18	(4) “Qualified individual” means a participant or beneficiary who meets the following
34-19	conditions:
34-20	(A) The individual is eligible to participate in an approved clinical trial according to the
34-21	trial protocol with respect to the treatment of cancer or other life-threatening disease or condition;
34-22	and
34-23	(B)(i) The referring health care professional is a participating provider and has concluded
34-24	that the individual’s participation in such trial would be appropriate based on the individual
34-25	meeting the conditions described in subdivision (A) of this subdivision (3); or
34-26	(ii) The participant or beneficiary provides medical and scientific information
34-27	establishing the individual’s participation in such trial would be appropriate based on the
34-28	individual meeting the conditions described in subdivision (A) of this subdivision (3).
34-29	(5) “Life-threatening condition” means any disease or condition from which the
34-30	likelihood of death is probable unless the course of the disease or condition is interrupted.
34-31	(b)(1) If a health insurance carrier offering group or individual health insurance coverage
34-32	provides coverage to a qualified individual, the health carrier:
34-33	(A) Shall not deny the individual participation in an approved clinical trial.
35-34	(B) Subject to subdivision (3) of this subsection, shall not deny or limit or impose
35-35	additional conditions on the coverage of routine patient costs for items and services furnished in
35-36	connection with participation in the approved clinical trial; and
35-37	(C)Shall not discriminate against the individual on the basis of the individual’s
35-38	participation in the approved clinical trial.
35-39	(2)(A) Subject to subdivision (B) of this subdivision (2), routine patient costs include all
35-40	items and services consistent with the coverage typically covered for a qualified individual who is
35-41	not enrolled in an approved clinical trial.
35-42	(B) For purposes of subdivision (B) of this subdivision (2), routine patient costs do not
35-43	include:
35-44	(i) The investigational item, device or service itself;
35-45	(ii) Items and services that are provided solely to satisfy data collection and analysis
35-46	needs and that are not used in the direct clinical management of the patient; or
35-47	(iii) A service that is clearly inconsistent with widely accepted and established standards
35-48	of care for a particular diagnosis.
35-49	(3) If one or more participating providers are participating in a clinical trial, nothing in
35-50	subdivision (1) of this subsection shall be construed as preventing a health carrier from requiring
35-51	that a qualified individual participate in the trial through such a participating provider if the
35-52	provider will accept the individual as a participant in the trial.
35-53	(4) Notwithstanding subdivision (3) of this subsection, subdivision (1) of this subsection
35-54	shall apply to a qualified individual participating in an approved clinical trial that is conducted
35-55	outside this state.
35-56	(5) This section shall not be construed to require a health carrier offering group or
35-57	individual health insurance coverage to provide benefits for routine patient care services provided
35-58	outside of the coverage’s health care provider network unless out-of-network benefits are
35-59	otherwise provided under the coverage.
35-60	(6) Nothing in this section shall be construed to limit a health carrier’s coverage with
35-61	respect to clinical trials.
35-62	(c) The requirements of this section shall be in addition to the requirements of Rhode
35-63	Island general laws sections 27-18-32 through 27-19-32.2.
35-64	(d) This section shall not apply to grandfathered health plans.
35-65	(e) This section shall be effective for plan years beginning on or after January 1, 2014.
35-66	27-19-66. Medical loss ratio rebates. – (a) A nonprofit hospital service corporation
35-67	offering group or individual health insurance coverage, including a grandfathered health plan,
35-68	shall pay medical loss ratio rebates as provided for in Section 2718(b)(1)(A) of the Affordable
36-1	Care Act, in the manner and as required by federal laws and regulations.
36-2	(b) Health insurance carriers required to report medical loss ratio and rebate calculations
36-3	and other medical loss ratio and rebate information to the U.S. Department of Health and Human
36-4	Services shall concurrently file such information with the commissioner.
36-5	27-19-67. Emergency services. – (a) As used in this section:
36-6	(1) “Emergency medical condition” means a medical condition manifesting itself by
36-7	acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who
36-8	possesses an average knowledge of health and medicine, could reasonably expect the absence of
36-9	immediate medical attention to result in a condition: (i) Placing the health of the individual, or
36-10	with respect to a pregnant woman her unborn child, in serious jeopardy; (ii) Constituting a serious
36-11	impairment to bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or
36-12	part.
36-13	(2) “Emergency services” means, with respect to an emergency medical condition:
36-14	(A) A medical screening examination (as required under section 1867 of the Social
36-15	Security Act, 42 U.S.C. 1395dd) that is within the capability of the emergency department of a
36-16	hospital, including ancillary services routinely available to the emergency department to evaluate
36-17	such emergency medical condition, and
36-18	(B) Such further medical examination and treatment, to the extent they are within the
36-19	capabilities of the staff and facilities available at the hospital, as are required under section 1867
36-20	of the Social Security Act (42 U.S.C. 1395dd) to stabilize the patient.
36-21	(3) “Stabilize”, with respect to an emergency medical condition has the meaning given in
36-22	section 1867(e)(3) of the Social Security Act (42 U.S.C. 1395dd(e)(3)).
36-23	(b) If a nonprofit hospital service corporation provides any benefits to subscribers with
36-24	respect to services in an emergency department of a hospital, the plan must cover emergency
36-25	services consistent with the rules of this section.
36-26	(c) A nonprofit hospital service corporation shall provide coverage for emergency
36-27	services in the following manner:
36-28	(1) Without the need for any prior authorization determination, even if the emergency
36-29	services are provided on an out-of-network basis;
36-30	(2) Without regard to whether the health care provider furnishing the emergency services
36-31	is a participating network provider with respect to the services;
36-32	(3) If the emergency services are provided out of network, without imposing any
36-33	administrative requirement or limitation on coverage that is more restrictive than the requirements
36-34	or limitations that apply to emergency services received from in-network providers;
37-1	(4) If the emergency services are provided out of network, by complying with the cost-
37-2	sharing requirements of subsection (d) of this section; and
37-3	(5) Without regard to any other term or condition of the coverage, other than:
37-4	(A) The exclusion of or coordination of benefits;
37-5	(B) An affiliation or waiting period permitted under part 7 of ERISA, part A of title
37-6	XXVII of the PHS Act, or chapter 100 of the Internal Revenue Code; or
37-7	(C) Applicable cost sharing.
37-8	(d)(1) Any cost-sharing requirement expressed as a copayment amount or coinsurance
37-9	rate imposed with respect to a participant or beneficiary for out-of-network emergency services
37-10	cannot exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if
37-11	the services were provided in-network. However, a participant or beneficiary may be required to
37-12	pay, in addition to the in-network cost sharing, the excess of the amount the out-of-network
37-13	provider charges over the amount the plan or health insurance carrier is required to pay under
37-14	subdivision (1) of this subsection. A group health plan or health insurance carrier complies with
37-15	the requirements of this subsection if it provides benefits with respect to an emergency service in
37-16	an amount equal to the greatest of the three amounts specified in subdivisions (A), (B), and (C) of
37-17	this subdivision (1)(which are adjusted for in-network cost-sharing requirements).
37-18	(A) The amount negotiated with in-network providers for the emergency service
37-19	furnished, excluding any in-network copayment or coinsurance imposed with respect to the
37-20	participant or beneficiary. If there is more than one amount negotiated with in-network providers
37-21	for the emergency service, the amount described under this subdivision (A) is the median of these
37-22	amounts, excluding any in-network copayment or coinsurance imposed with respect to the
37-23	participant or beneficiary. In determining the median described in the preceding sentence, the
37-24	amount negotiated with each in-network provider is treated as a separate amount (even if the
37-25	same amount is paid to more than one provider). If there is no per-service amount negotiated with
37-26	in-network providers (such as under a capitation or other similar payment arrangement), the
37-27	amount under this subdivision (A) is disregarded.
37-28	(B) The amount for the emergency service shall be calculated using the same method the
37-29	plan generally uses to determine payments for out-of-network services (such as the usual,
37-30	customary, and reasonable amount), excluding any in-network copayment or coinsurance
37-31	imposed with respect to the participant or beneficiary. The amount in this subdivision (B) is
37-32	determined without reduction for out-of-network cost sharing that generally applies under the
37-33	plan or health insurance coverage with respect to out-of-network services. Thus, for example, if a
37-34	plan generally pays seventy percent (70%) of the usual, customary, and reasonable amount for
38-1	out-of-network services, the amount in this subdivision (B) for an emergency service is the total,
38-2	that is, one hundred percent (100%), of the usual, customary, and reasonable amount for the
38-3	service, not reduced by the thirty percent (30%) coinsurance that would generally apply to out-of-
38-4	network services (but reduced by the in-network copayment or coinsurance that the individual
38-5	would be responsible for if the emergency service had been provided in-network).
38-6	(C) The amount that would be paid under Medicare (part A or part B of title XVIII of the
38-7	Social Security Act, 42 U.S.C. 1395 et seq.) for the emergency service, excluding any in-network
38-8	copayment or coinsurance imposed with respect to the participant or beneficiary.
38-9	(2) Any cost-sharing requirement other than a copayment or coinsurance requirement
38-10	(such as a deductible or out-of-pocket maximum) may be imposed with respect to emergency
38-11	services provided out of network if the cost-sharing requirement generally applies to out-of-
38-12	network benefits. A deductible may be imposed with respect to out-of-network emergency
38-13	services only as part of a deductible that generally applies to out-of-network benefits. If an out-of-
38-14	pocket maximum generally applies to out-of-network benefits, that out-of-pocket maximum must
38-15	apply to out-of-network emergency services.
38-16	(e) The provisions of this section apply for plan years beginning on or after September
38-17	23, 2010.
38-18	(f) This section shall not apply to grandfathered health plans.
38-19	27-19-68. Internal and external appeal of adverse benefit determinations. – (a) The
38-20	commissioner shall adopt regulations to implement standards and procedures with respect to
38-21	internal claims and appeals of adverse benefit determinations, and with respect to external appeals
38-22	of adverse benefit determinations.
38-23	(b) The regulations adopted by the commissioner shall apply to those adverse benefit
38-24	determinations within the jurisdiction of the commissioner.
38-25	SECTION 6. Sections 27-20-1 and 27-20-45 of the General laws in Chapter 27-20
38-26	entitled "Nonprofit Medical Service Corporations" are hereby amended to read as follows:
38-27	27-20-1. Definitions. -- As used in this chapter:
38-28	(1) Adverse benefit determination" means any of the following: a denial, reduction, or
38-29	termination of, or a failure to provide or make payment (in whole or in part) for, a benefit,
38-30	including any such denial, reduction, termination, or failure to provide or make payment that is
38-31	based on a determination of a participant's or beneficiary's eligibility to participate in a plan or to
38-32	receive coverage under a plan, and including, with respect to group health plans, a denial,
38-33	reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a
38-34	benefit resulting from the application of any utilization review, as well as a failure to cover an
39-1	item or service for which benefits are otherwise provided because it is determined to be
39-2	experimental or investigational or not medically necessary or appropriate. The term also includes
39-3	a rescission of coverage determination.
39-4	(2) "Affordable Care Act" means the Patient Protection and Affordable Care Act of 2010,
39-5	as amended by the Health Care and Education Reconciliation Act of 2010.
39-6	~~(1)~~(3) "Certified registered nurse practitioners" is an expanded role utilizing independent
39-7	knowledge of physical assessment and management of health care and illnesses. The practice
39-8	includes collaboration with other licensed health care professionals including, but not limited to,
39-9	physicians, pharmacists, podiatrists, dentists, and nurses;
39-10	(4) “Commissioner” or “health insurance commissioner” means that individual appointed
39-11	pursuant to section 42-14.5-1 of the General laws.
39-12	~~(2)~~(5) "Counselor in mental health" means a person who has been licensed pursuant to
39-13	section 5-63.2-9.
39-14	(6) “Grandfathered health plan” means any group health plan or health insurance
39-15	coverage subject to 42 USC section 18011.
39-16	(7) “Group health insurance coverage” means, in connection with a group health plan,
39-17	health insurance coverage offered in connection with such plan.
39-18	(8) “Group health plan” means an employee welfare benefit plan as defined in 29 USC
39-19	section 1002(1) to the extent that the plan provides health benefits to employees or their
39-20	dependents directly or through insurance, reimbursement, or otherwise.
39-21	(9) “Health benefits” or “covered benefits” means medical, surgical, hospital,
39-22	prescription drug, and such other benefits, whether self-funded, or delivered through the purchase
39-23	of insurance or otherwise.
39-24	(10) “Health care facility” means an institution providing health care services or a health
39-25	care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory
39-26	surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic,
39-27	laboratory and imaging centers, and rehabilitation and other therapeutic health settings.
39-28	(11) "Health care professional" means a physician or other health care practitioner
39-29	licensed, accredited or certified to perform specified health care services consistent with state
39-30	law.
39-31	(12) "Health care provider" or "provider" means a health care professional or a health
39-32	care facility.
39-33	(13) "Health care services" means services for the diagnosis, prevention, treatment, cure
39-34	or relief of a health condition, illness, injury or disease.
40-1	(14) “Health insurance carrier” means a person, firm, corporation or other entity subject
40-2	to the jurisdiction of the commissioner under this chapter, and includes a nonprofit medical
40-3	service corporation. Such term does not include a group health plan.
40-4	(15) "Health plan" or “health benefit plan” means health insurance coverage and a group
40-5	health plan, including coverage provided through an association plan if it covers Rhode Island
40-6	residents. Except to the extent specifically provided by the Affordable Care Act, the term ‘‘health
40-7	plan’’ shall not include a group health plan to the extent state regulation of the health plan is pre-
40-8	empted under section 514 of the Employee Retirement Income Security Act of 1974. The term
40-9	also shall not include:
40-10	(A)(i) Coverage only for accident, or disability income insurance, or any combination
40-11	thereof.
40-12	(ii) Coverage issued as a supplement to liability insurance.
40-13	(iii) Liability insurance, including general liability insurance and automobile liability
40-14	insurance.
40-15	(iv) Workers’ compensation or similar insurance.
40-16	(v) Automobile medical payment insurance.
40-17	(vi) Credit-only insurance.
40-18	(vii) Coverage for on-site medical clinics.
40-19	(viii) Other similar insurance coverage, specified in federal regulations issued pursuant to
40-20	Pub. L. No. 104-191, the health insurance portability and accountability act of 1996 (“HIPAA”),
40-21	under which benefits for medical care are secondary or incidental to other insurance benefits.
40-22	(B) The following benefits if they are provided under a separate policy, certificate or
40-23	contract of insurance or are otherwise not an integral part of the plan:
40-24	(i) Limited scope dental or vision benefits.
40-25	(ii) Benefits for long-term care, nursing home care, home health care, community-based
40-26	care, or any combination thereof.
40-27	(iii) Other excepted benefits specified in federal regulations issued pursuant to Pub. L.
40-28	No. 104-191 (“HIPAA”).
40-29	(C) The following benefits if the benefits are provided under a separate policy, certificate
40-30	or contract of insurance, there is no coordination between the provision of the benefits and any
40-31	exclusion of benefits under any group health plan maintained by the same plan sponsor, and the
40-32	benefits are paid with respect to an event without regard to whether benefits are provided with
40-33	respect to such an event under any group health plan maintained by the same plan sponsor:
41-34	(i) Coverage only for a specified disease or illness.
41-35	(ii) Hospital indemnity or other fixed indemnity insurance.
41-36	(D) The following if offered as a separate policy, certificate or contract of insurance:
41-37	(i) Medicare supplement health insurance as defined under section 1882(g)(1) of the
41-38	Social Security Act.
41-39	(ii) Coverage supplemental to the coverage provided under chapter 55 of title 10, United
41-40	States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)).
41-41	(iii) Similar supplemental coverage provided to coverage under a group health plan.
41-42	~~(3)~~(16) "Licensed midwife" means any midwife licensed under section 23-13-9;
41-43	~~(4)~~(17) "Medical services" means those professional services rendered by persons duly
41-44	licensed under the laws of this state to practice medicine, surgery, chiropractic, podiatry, and
41-45	other professional services rendered by a licensed midwife, certified registered nurse
41-46	practitioners, and psychiatric and mental health nurse clinical specialists, and appliances, drugs,
41-47	medicines, supplies, and nursing care necessary in connection with the services, or the expense
41-48	indemnity for the services, appliances, drugs, medicines, supplies, and care, as may be specified
41-49	in any nonprofit medical service plan. Medical service shall not be construed to include hospital
41-50	services;
41-51	~~(5)~~(18) "Nonprofit medical service corporation" means any corporation organized
41-52	pursuant hereto for the purpose of establishing, maintaining, and operating a nonprofit medical
41-53	service plan;
41-54	~~(6)~~(19) "Nonprofit medical service plan" means a plan by which specified medical
41-55	service is provided to subscribers to the plan by a nonprofit medical service corporation;
41-56	(20) "Office of the health insurance commissioner" means the agency established under
41-57	section 42-14.5-1 of the General laws.
41-58	~~(7)~~(21) "Psychiatric and mental health nurse clinical specialist" is an expanded role
41-59	utilizing independent knowledge and management of mental health and illnesses. The practice
41-60	includes collaboration with other licensed health care professionals, including, but not limited to,
41-61	psychiatrists, psychologists, physicians, pharmacists, and nurses;
41-62	(22) “Rescission" means a cancellation or discontinuance of coverage that has retroactive
41-63	effect for reasons unrelated to timely payment of required premiums or contribution to costs of
41-64	coverage.
41-65	~~(8)~~(23) "Subscribers" means those persons or groups of persons who contract with a
41-66	nonprofit medical service corporation for medical service pursuant to a nonprofit medical service
41-67	plan; and
42-68	~~(9)~~(24) "Therapist in marriage and family practice" means a person who has been
42-69	licensed pursuant to section 5-63.2-10.
42-70	27-20-45. ~~Termination of children's benefits~~ Eligibility for children's benefits. -- (a)
42-71	Every individual health insurance contract, plan, or policy delivered, issued for delivery, or
42-72	renewed in this state and every group health insurance contract, plan, or policy delivered, issued
42-73	for delivery or renewed in this state which provides ~~medical~~ health benefits coverage for
42-74	~~dependent children that includes coverage for physician services in a physician's office, and every~~
42-75	~~policy which provides major medical or similar comprehensive type coverage~~ dependents, except
42-76	for supplemental policies which only provide coverage for specified diseases and other
42-77	supplemental policies, shall ~~provide~~ make coverage available ~~of an unmarried child under the age~~
42-78	~~of nineteen (19) years, an unmarried child who is a student under the age of twenty-five (25)~~
42-79	~~years and who is financially dependent upon the parent and an unmarried child of any age who is~~
42-80	~~financially dependent upon the parent and medically determined to have a physical or mental~~
42-81	~~impairment which can be expected to result in death or which has lasted or can be expected to last~~
42-82	~~for a continuous period of not less than twelve (12) months~~ for children until attainment of
42-83	twenty-six (26) years of age. ~~Such contract, plan or policy shall also include a provision that~~
42-84	~~policyholders shall receive no less than thirty (30) days notice from the nonprofit medical service~~
42-85	~~corporation that a child covered as a dependent by the policyholder is about to lose his or her~~
42-86	~~coverage as a result of reaching the maximum age for a dependent child and that the child will~~
42-87	~~only continue to be covered upon documentation being provided of current full or part-time~~
42-88	~~enrollment in a post-secondary educational institution, or that the child may purchase a~~
42-89	~~conversion policy if he or she is not an eligible student.~~
42-90	~~(b) Nothing in this section prohibits a nonprofit medical service corporation from~~
42-91	~~requiring a policyholder to annually provide proof of a child's current full or part-time enrollment~~
42-92	~~in a post-secondary educational institution in order to maintain the child's coverage. Provided,~~
42-93	~~nothing in this section requires coverage inconsistent with the membership criteria in effect under~~
42-94	~~the policyholder's health benefits coverage.~~
42-95	(2) With respect to a child who has not attained twenty-six (26) years of age, a nonprofit
42-96	medical service corporation shall not define “dependent” for purposes of eligibility for dependent
42-97	coverage of children other than the terms of a relationship between a child and the plan
42-98	participant, and, in the individual market, primary subscriber.
42-99	(3) A nonprofit medical service corporation shall not deny or restrict coverage for a child
42-100	who has not attained twenty-six (26) years of age based on the presence or absence of the child’s
42-101	financial dependency upon the participant, primary subscriber or any other person, residency with
42-102	the participant and in the individual market the primary subscriber, or with any other person,
43-1	marital status, student status, employment or any combination of those factors. A nonprofit
43-2	medical service corporation shall not deny or restrict coverage of a child based on eligibility for
43-3	other coverage, except as provided in (d)(1) of this section.
43-4	(4) Nothing in this section shall be construed to require a health insurance carrier to make
43-5	coverage available for the child of a child receiving dependent coverage, unless the grandparent
43-6	becomes the legal guardian or adoptive parent of that grandchild.
43-7	(5) The terms of coverage in a health benefit plan offered by a nonprofit medical service
43-8	corporation r providing dependent coverage of children cannot vary based on age except for
43-9	children who are twenty-six (26) years of age or older.
43-10	(b)(1) This subsection applies to any child:
43-11	(A) Whose coverage ended, or who was denied coverage, or was not eligible for group
43-12	health insurance coverage or individual health insurance coverage under a health benefit plan
43-13	because, under the terms of coverage, the availability of dependent coverage of a child ended
43-14	before the attainment of twenty-six (26) years of age; and
43-15	(B) Who becomes eligible, or is required to become eligible, for coverage on the first day
43-16	of the first plan year and, in the individual market, the first day of the first policy year, beginning
43-17	on or after September 23, 2010 by reason of the provisions of this section.
43-18	(2)(A) If group health insurance coverage or individual health insurance coverage, in
43-19	which a child is eligible to enroll, or is required to become eligible to enroll, in the coverage in
43-20	which the child’s coverage ended or did not begin for the reasons described in subdivision (1) of
43-21	this subsection, and if the health insurance carrier is subject to the requirements of this section the
43-22	health insurance carrier shall give the child an opportunity to enroll that continues for at least
43-23	sixty (60) days, including the written notice of the opportunity to enroll as described subdivision
43-24	(3) of this subsection.
43-25	(B) The health insurance carrier shall provide the opportunity to enroll, including the
43-26	written notice beginning not later than the first day of the first plan year and in the individual
43-27	market the first day of the first policy year, beginning on or after September 23, 2010.
43-28	(3)(A) The written notice of opportunity to enroll shall include a statement that children
43-29	whose coverage ended, or who were denied coverage, or were not eligible for coverage, because
43-30	the availability of dependent coverage of children ended before the attainment of twenty-six (26)
43-31	years of age are eligible to enroll in the coverage.
43-32	(B)(i) The notice may be provided to an employee on behalf of the employee’s child and,
43-33	in the individual market, to the primary subscriber on behalf of the primary subscriber’s child.
44-34	(ii) For group health insurance coverage:
44-35	(I)The notice may be included with other enrollment materials that the health carrier
44-36	distributes to employees, provided the statement is prominent; and
44-37	(II) If a notice satisfying the requirements of this subdivision is provided to an employee
44-38	whose child is entitled to an enrollment opportunity under subsection (c) of this section, the
44-39	obligation to provide the notice of enrollment opportunity under subdivision (B) of this
44-40	subdivision (3) with respect to that child is satisfied for both the plan and health insurance carrier.
44-41	(C) The written notice shall be provided beginning not later than the first day of the first
44-42	plan year and in the individual market the first day of the first policy year, beginning on or after
44-43	September 23, 2010.
44-44	(4) For an individual who enrolls under this subsection, the coverage shall take effect not
44-45	later than the first day of the first plan year and, in the individual market, the first day of the first
44-46	policy year, beginning on or after September 23, 2010.
44-47	(c)(1) A child enrolling in group health insurance coverage pursuant to subsection (b) of
44-48	this section shall be treated as if the child were a special enrollee, as provided under regulations
44-49	interpreting the HIPAA portability provisions issued pursuant to Section 2714 of the Affordable
44-50	Care Act.
44-51	(2)(A) The child and, if the child would not be a participant once enrolled, the participant
44-52	through whom the child is otherwise eligible for coverage under the plan, shall be offered all the
44-53	benefit packages available to similarly situated individuals who did not lose coverage by reason
44-54	of cessation of dependent status.
44-55	(B) For purposes of this subdivision (2), any difference in benefits or cost-sharing
44-56	requirements constitutes a different benefit package.
44-57	(3) The child shall not be required to pay more for coverage than similarly situated
44-58	individuals who did not lose coverage by reason of cessation of dependent status.
44-59	(d)(1) For plan years beginning before January 1, 2014, a group health plan providing
44-60	group health insurance coverage that is a grandfathered health plan and makes available
44-61	dependent coverage of children may exclude an adult child who has not attained twenty-six (26)
44-62	years of age from coverage only if the adult child is eligible to enroll in an eligible employer-
44-63	sponsored health benefit plan, as defined in section 5000A(f)(2) of the Internal Revenue Code,
44-64	other than the group health plan of a parent.
44-65	(2) For plan years, beginning on or after January 1, 2014, a group health plan providing
44-66	group health insurance coverage that is a grandfathered health plan shall comply with the
44-67	requirements of subsections (a) through (e).
45-68	(3) The provisions of this section apply to policy years in the individual market on and
45-69	after September 23, 2010.
45-70	~~(b)~~(e) This section does not apply to insurance coverage providing benefits for: (1)
45-71	hospital confinement indemnity; (2) disability income; (3) accident only; (4) long term care; (5)
45-72	Medicare supplement; (6) limited benefit health; (7) specified diseased indemnity; or (8) other
45-73	limited benefit policies.
45-74	SECTION 7. Chapter 27-20 of the General laws entitled "Nonprofit Medical Service
45-75	Corporations" is hereby amended by adding thereto the following sections:
45-76	27-20-6.1. Uniform explanation of benefits and coverage. – (a) A nonprofit medical
45-77	service corporation shall provide a uniform summary of benefits and coverage explanation and
45-78	standardized definitions to policyholders and others required by, and at the times required by the
45-79	federal regulations adopted under section 2715 of the Affordable Care Act. The summary
45-80	required by this section shall be filed with the commissioner for approval under Rhode Island
45-81	general laws section 27-20-6.2. The requirements of this section shall be in addition to the
45-82	requirements of Rhode Island general laws section 27-20-6.2. The commissioner may waive one
45-83	or more of the requirements of the regulations adopted under section 2715 of the Affordable Care
45-84	Act for good cause shown. The summary must contain at least the following information:
45-85	(1) Uniform definitions of standard insurance and medical terms.
45-86	(2) A description of coverage and cost sharing for each category of essential benefits and
45-87	other benefits.
45-88	(3) Exceptions, reductions and limitations in coverage.
45-89	(4) Renewability and continuation of coverage provisions.
45-90	(5) A “coverage facts label” that illustrates coverage under common benefits scenarios.
45-91	(6) A statement of whether the policy, contract or plan provides the minimum coverage
45-92	required of a qualified health plan.
45-93	(7) A statement that the outline is a summary and that the actual policy language should
45-94	be consulted; and
45-95	(8) A contact number for the consumer to call with additional questions and the web
45-96	address of where the actual language of the policy, contract or plan can be found.
45-97	(b) The provisions of this section shall apply to grandfathered health plans.
45-98	27-20-6.2. Filing of policy forms. – A nonprofit medical service corporation shall file all
45-99	policy forms and rates used by it in the state with the commissioner, including the forms of any
45-100	rider, endorsement, application blank, and other matter generally used or incorporated by
45-101	reference in its policies or contracts of insurance. No such rate shall be used unless first approved
45-102	by the commissioner. No such form shall be used if disapproved by the commissioner under this
46-1	section, or if the commissioner's approval has been withdrawn after notice and an opportunity to
46-2	be heard, or until the expiration of sixty (60) days following the filing of the form. A nonprofit
46-3	medical service corporation shall comply with its filed and approved rates and forms. If the
46-4	commissioner finds from an examination of any form that it is contrary to the public interest, or
46-5	the requirements of this code or duly promulgated regulations, he or she shall forbid its use, and
46-6	shall notify the corporation in writing. Each form shall include a certification by a qualified
46-7	actuary that to the best of the actuary's knowledge and judgment, the entire rate is in compliance
46-8	with applicable laws and that the benefits are reasonable in relation to the premium to be charged.
46-9	27-20-62. Prohibition on rescission of coverage. – (a)(1) Coverage under a health
46-10	benefit plan subject to the jurisdiction of the commissioner under this chapter with respect to an
46-11	individual, including a group to which the individual belongs or family coverage in which the
46-12	individual is included, shall not be subject to rescission after the individual is covered under the
46-13	plan, unless:
46-14	(A)The individual or a person seeking coverage on behalf of the individual, performs an
46-15	act, practice or omission that constitutes fraud; or
46-16	(B)The individual makes an intentional misrepresentation of material fact, as prohibited
46-17	by the terms of the plan or coverage.
46-18	(2) For purposes of paragraph (1)(A), a person seeking coverage on behalf of an
46-19	individual does not include an insurance producer or employee or authorized representative of the
46-20	health carrier.
46-21	(b) At least thirty (30) days advance written notice shall be provided to each plan enrollee
46-22	or, for individual health insurance coverage, primary subscriber, who would be affected by the
46-23	proposed rescission of coverage before coverage under the plan may be rescinded in accordance
46-24	with subsection (a) regardless of, in the case of group health insurance coverage, whether the
46-25	rescission applies to the entire group or only to an individual within the group.
46-26	(d) This section applies to grandfathered health plans.
46-27	27-20-63. Annual and lifetime limits. – (a) Annual limits.
46-28	(1) For plan or policy years beginning prior to January 1, 2014, for any individual, a
46-29	health insurance carrier and health benefit plan subject to the jurisdiction of the commissioner
46-30	under this chapter may establish an annual limit on the dollar amount of benefits that are essential
46-31	health benefits provided the restricted annual limit is not less than the following:
46-32	(A) For a plan or policy year beginning after September 22, 2010, but before September
46-33	23, 2011 – seven hundred fifty thousand dollars ($750,000);
47-34	(B) For a plan or policy year beginning after September 22, 2011, but before September
47-35	23, 2012 – one million two hundred fifty thousand dollars ($1,250,000); and
47-36	(C) For a plan or policy year beginning after September 22, 2012, but before January 1,
47-37	2014 – two million dollars ($2,000,000).
47-38	(2) For plan or policy years beginning on or after January 1, 2014, a health insurance
47-39	carrier and health benefit plan shall not establish any annual limit on the dollar amount of
47-40	essential health benefits for any individual, except:
47-41	(A) A health flexible spending arrangement, as defined in section 106(c)(2)(i) of the
47-42	Internal Revenue Code, a medical savings account, as defined in section 220 of the Internal
47-43	Revenue Code, and a health savings account, as defined in section 223 of the Internal Revenue
47-44	Code are not subject to the requirements of subdivisions (1) and (2) of this subsection.
47-45	(B) The provisions of this subsection shall not prevent a health insurance carrier from
47-46	placing annual dollar limits for any individual on specific covered benefits that are not essential
47-47	health benefits to the extent that such limits are otherwise permitted under applicable federal law
47-48	or the laws and regulations of this state.
47-49	(3) In determining whether an individual has received benefits that meet or exceed the
47-50	allowable limits, as provided in subdivision (1) of this subsection, a health insurance carrier shall
47-51	take into account only essential health benefits as administratively established by the
47-52	commissioner.
47-53	(b) Lifetime limits.
47-54	(1) A health insurance carrier and health benefit plan offering group or individual health
47-55	insurance coverage shall not establish a lifetime limit on the dollar value of essential health
47-56	benefits, as designated pursuant to a state determination and in accordance with federal laws and
47-57	regulations, for any individual.
47-58	(2) Notwithstanding subdivision (1) above, a health insurance carrier and health benefit
47-59	plan is not prohibited from placing lifetime dollar limits for any individual on specific covered
47-60	benefits that are not essential health benefits, as designated pursuant to a state determination and
47-61	in accordance with federal laws and regulations.
47-62	(c)(1) Reinstatement of Coverage. Except as provided in subdivision (2) of this
47-63	subsection, this subsection applies to any individual:
47-64	(A) Whose coverage or benefits under a health plan ended by reason of reaching a
47-65	lifetime limit on the dollar value of all benefits for the individual; and
47-66	(B) Who, due to the provisions of this section, becomes eligible, or is required to become
47-67	eligible, for benefits not subject to a lifetime limit on the dollar value of all benefits under the
47-68	health benefit plan:
48-1	(i) For group health insurance coverage, on the first day of the first plan year beginning
48-2	on or after September 23, 2010; or
48-3	(ii) For individual health insurance coverage, on the first day of the first policy year
48-4	beginning on or after September 23, 2010.
48-5	(2) For individual health insurance coverage, an individual is not entitled to reinstatement
48-6	under the health benefit plan under this subsection if the individual reached his or her lifetime
48-7	limit and the contract is not renewed or is otherwise no longer in effect. However, this subsection
48-8	applies to a family member who reached his or her lifetime limit in a family plan and other family
48-9	members remain covered under the plan.
48-10	(3)(A) If an individual described in subdivision (1) is eligible for benefits or is required to
48-11	become eligible for benefits under the health benefit plan, the health carrier shall provide the
48-12	individual written notice that:
48-13	(i) The lifetime limit on the dollar value of all benefits no longer applies; and
48-14	(ii) The individual, if still covered under the plan, is again eligible to receive benefits
48-15	under the plan.
48-16	(B) If the individual is not enrolled in the plan, or if an enrolled individual is eligible for,
48-17	but not enrolled in any benefit package under the plan, the health benefit plan shall provide an
48-18	opportunity for the individual to enroll in the plan for a period of at least thirty (30) days.
48-19	(C) The notices and enrollment opportunity under this subdivision shall be provided
48-20	beginning not later than:
48-21	(i) For group health insurance coverage, the first day of the first plan year beginning on
48-22	or after September 23, 2010; or
48-23	(ii) For individual health insurance coverage, the first day of the first policy year
48-24	beginning on or after September 23, 2010.
48-25	(iii) The notices required under this subsection shall be provided:
48-26	(I) For group health insurance coverage, to an employee on behalf of the employee’s
48-27	dependent; or
48-28	(II) For individual health insurance coverage, to the primary subscriber on behalf of the
48-29	primary subscriber’s dependent.
48-30	(D) For group health insurance coverage, the notices may be included with other
48-31	enrollment materials that a health plan distributes to employees, provided the statement is
48-32	prominent. For group health insurance coverage, if a notice satisfying the requirements of this
48-33	subsection is provided to an individual, a health insurance carrier’s requirement to provide the
48-34	notice with respect to that individual is satisfied.
49-1	(E) For any individual who enrolls in a health plan in accordance with subdivision (2) of
49-2	this subsection, coverage under the plan shall take effect not later than:
49-3	(i) For group health insurance coverage, the first day of the first plan year beginning on
49-4	or after September 23, 2010; or
49-5	(ii) For individual health insurance coverage, the first day of the first policy year
49-6	beginning on or after September 23, 2010.
49-7	(d)(1) An individual enrolling in a health plan for group health insurance coverage in
49-8	accordance with subsection (c) above shall be treated as if the individual were a special enrollee,
49-9	as provided under regulations interpreting the Health Insurance Portability and Accountability
49-10	Act (“HIPAA”) portability provisions issued pursuant to Section 2714 of the Affordable Care
49-11	Act.
49-12	(2) An individual enrolling in accordance with subsection (c) above:
49-13	(A) shall be offered all of the benefit packages available to similarly situated individuals
49-14	who did not lose coverage under the plan by reason of reaching a lifetime limit on the dollar value
49-15	of all benefits; and
49-16	(B) shall not be required to pay more for coverage than similarly situated individuals who
49-17	did not lose coverage by reason of reaching a lifetime limit on the dollar value of all benefits.
49-18	(3) For purposes of subsection B(1), any difference in benefits or cost-sharing constitutes
49-19	a different benefit package.
49-20	(e)(1) Except as provided in subdivision (2) of this subsection, this section applies to any
49-21	health insurance carrier providing coverage under an individual or group health plan.
49-22	(2)(A) The prohibition on lifetime limits applies to grandfathered health plans.
49-23	(B) The prohibition and limits on annual limits apply to grandfathered health plans
49-24	providing group health insurance coverage, but the prohibition and limits on annual limits do not
49-25	apply to grandfathered health plans providing individual health insurance coverage.
49-26	27-20-64. Coverage for preventive items and services. – (a) Every health insurance
49-27	carrier providing coverage under an individual or group health plan shall provide coverage for all
49-28	of the following items and services, and shall not impose any cost-sharing requirements, such as a
49-29	copayment, coinsurance or deductible, with respect to the following items and services:
49-30	(1) Except as otherwise provided in subsection (b) of this section, and except as may
49-31	otherwise be provided in federal regulations implementing the Affordable Care Act, evidence-
49-32	based items or services that have in effect a rating of A or B in the recommendations of the
49-33	United States preventive services task force as of September 23, 201 and as may subsequently be
49-34	amended.
50-1	(2) Immunizations for routine use in children, adolescents and adults that have in effect a
50-2	recommendation from the Advisory Committee on Immunization Practices of the Centers for
50-3	Disease Control and Prevention with respect to the individual involved. For purposes of this
50-4	subdivision, a recommendation from the Advisory Committee on Immunization Practices of the
50-5	Centers for Disease Control and Prevention is considered in effect after it has been adopted by the
50-6	Director of the Centers for Disease Control and Prevention, and a recommendation is considered
50-7	to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease
50-8	Control and Prevention.
50-9	(3) With respect to infants, children and adolescents, evidence-informed preventive care,
50-10	and screenings provided for in comprehensive guidelines supported by the Health Resources and
50-11	Services Administration.
50-12	(4) With respect to women, to the extent not described in subdivision (1) of this
50-13	subsection, evidence-informed preventive care and screenings provided for in comprehensive
50-14	coverage guidelines supported by the Health Resources and Services Administration.
50-15	(b)(1) A health insurance carrier is not required to provide coverage for any items or
50-16	services specified in any recommendation or guideline described in subsection (a) of this section
50-17	after the recommendation or guideline is no longer described in subsection (a) of this section. The
50-18	provisions of this subdivision shall not affect the obligation of the health insurance carrier to
50-19	provide notice to a covered person before any material modification of coverage becomes
50-20	effective, in accordance with other requirements of state and federal law, including section
50-21	2715(d)(4) of the Public Health Services Act.
50-22	(2) A health insurance carrier shall at least annually at the beginning of each new plan
50-23	year or policy year, whichever is applicable, revise the preventive services covered under its
50-24	health benefit plans pursuant to this section consistent with the recommendations of the United
50-25	States Preventive Services Task Force, the Advisory Committee on Immunization Practices of the
50-26	Centers for Disease Control and Prevention and the guidelines with respect to infants, children,
50-27	adolescents and women evidence-based preventive care and screenings by the Health Resources
50-28	and Services Administration in effect at the time.
50-29	(c)(1) A health insurance carrier may impose cost-sharing requirements with respect to an
50-30	office visit if an item or service described in subsection (a) of this section is billed separately or is
50-31	tracked as individual encounter data separately from the office visit.
50-32	(2) A health insurance carrier shall not impose cost-sharing requirements with respect to
50-33	an office visit if an item or service described in subsection (a) of this section is not billed
50-34	separately or is not tracked as individual encounter data separately from the office visit and the
51-1	primary purpose of the office visit is the delivery of the item or service described in subsection
51-2	(a) of this section.
51-3	(3) A health insurance carrier may impose cost-sharing requirements with respect to an
51-4	office visit if an item or service described in subsection (a) of this section is not billed separately
51-5	or is not tracked as individual encounter data separately from the office visit and the primary
51-6	purpose of the office visit is not the delivery of the item or service.
51-7	(d)(1) Nothing in this section requires a health insurance carrier that has a network of
51-8	providers to providing coverage for items and services described in subsection (a) of this section
51-9	that are delivered by an out-of-network provider.
51-10	(2) Nothing in subsection (a) of this section precludes a health insurance carrier that has a
51-11	network of providers from imposing cost-sharing requirements for items or services described in
51-12	subsection (a) of this section that are delivered by an out-of-network provider.
51-13	(e) Nothing prevents a health insurance carrier from using reasonable medical
51-14	management techniques to determine the frequency, method, treatment or setting for an item or
51-15	service described in subsection (a) of this section to the extent not specified in the
51-16	recommendation or guideline.
51-17	(f) Nothing in this section prohibits a health insurance carrier from providing coverage
51-18	for items and services in addition to those recommended by the United States Preventive Services
51-19	Task Force or the Advisory Committee on Immunization Practices of the Centers for Disease
51-20	Control and Prevention, or provided by guidelines supported by the Health Resources and
51-21	Services Administration, or from denying coverage for items and services that are not
51-22	recommended by that task force or that advisory committee, or under those guidelines. A health
51-23	insurance carrier may impose cost-sharing requirements for a treatment not described in
51-24	subsection (a) of this section even if the treatment results from an item or service described in
51-25	subsection (a) of this section.
51-26	(g) This section shall not apply to grandfathered health plans.
51-27	27-20-65. Coverage for individuals participating in approved clinical trials. – (a) As
51-28	used in this section,
51-29	(1) “Approved clinical trial” means a phase I, phase II, phase III or phase IV clinical trial
51-30	that is conducted in relation to the prevention, detection or treatment of cancer or a life-
51-31	threatening disease or condition and is described in any of the following:
51-32	(A) The study or investigation is approved or funded, which may include funding through
51-33	in-kind contributions, by one or more of the following:
52-34	(i) The National Institutes of Health;
52-35	(ii) The Centers for Disease Control and Prevention;
52-36	(iii) The Agency for Health Care Research and Quality;
52-37	(iv) The Centers for Medicare & Medicaid Services;
52-38	(v) A cooperative group or center of any of the entities described in items (i) through (iv)
52-39	or the Department of Defense or the Department of Veteran Affairs;
52-40	(vi) A qualified non-governmental research entity identified in the guidelines issued by
52-41	the National Institutes of Health for center support grants; or
52-42	(vii) A study or investigation conducted by the Department of Veteran Affairs, the
52-43	Department of Defense, or the Department of Energy, if the study or investigation has been
52-44	reviewed and approved through a system of peer review that the Secretary of U.S. Department of
52-45	Health and Human Services determines:
52-46	(I) Is comparable to the system of peer review of studies and investigations used by the
52-47	National Institutes of Health; and
52-48	(II) Assures unbiased review of the highest scientific standards by qualified individuals
52-49	who have no interest in the outcome of the review.
52-50	(B) The study or investigation is conducted under an investigational new drug application
52-51	reviewed by the Food and Drug Administration; or
52-52	(C) The study or investigation is a drug trial that is exempt from having such an
52-53	investigational new drug application.
52-54	(2) “Participant” has the meaning stated in section 3(7) of ERISA.
52-55	(3) “Participating provider” means a health care provider that, under a contract with the
52-56	health carrier or with its contractor or subcontractor, has agreed to provide health care services to
52-57	covered persons with an expectation of receiving payment, other than coinsurance, copayments or
52-58	deductibles, directly or indirectly from the health carrier.
52-59	(4) “Qualified individual” means a participant or beneficiary who meets the following
52-60	conditions:
52-61	(A) The individual is eligible to participate in an approved clinical trial according to the
52-62	trial protocol with respect to the treatment of cancer or other life-threatening disease or condition;
52-63	and
52-64	(B)(i) The referring health care professional is a participating provider and has concluded
52-65	that the individual’s participation in such trial would be appropriate based on the individual
52-66	meeting the conditions described in subdivision (A) of this subdivision (3); or
52-67	(ii) The participant or beneficiary provides medical and scientific information
52-68	establishing the individual’s participation in such trial would be appropriate based on the
53-1	individual meeting the conditions described in subdivision (A) of this subdivision (3).
53-2	(5) “Life-threatening condition” means any disease or condition from which the
53-3	likelihood of death is probable unless the course of the disease or condition is interrupted.
53-4	(b)(1) If a health insurance carrier offering group or individual health insurance coverage
53-5	provides coverage to a qualified individual, the health carrier:
53-6	(A) Shall not deny the individual participation in an approved clinical trial.
53-7	(B) Subject to subdivision (3) of this subsection, shall not deny or limit or impose
53-8	additional conditions on the coverage of routine patient costs for items and services furnished in
53-9	connection with participation in the clinical approved trial; and
53-10	(C) Shall not discriminate against the individual on the basis of the individual’s
53-11	participation in the clinical trial.
53-12	(2)(A) Subject to subdivision (B) of this subdivision (2), routine patient costs include all
53-13	items and services consistent with the coverage typically covered for a qualified individual who is
53-14	not enrolled in an approved clinical trial.
53-15	(B) For purposes of subdivision (B) of this subdivision (2), routine patient costs do not
53-16	include:
53-17	(i) The investigational item, device or service itself;
53-18	(ii) Items and services that are provided solely to satisfy data collection and analysis
53-19	needs and that are not used in the direct clinical management of the patient; or
53-20	(iii) A service that is clearly inconsistent with widely accepted and established standards
53-21	of care for a particular diagnosis.
53-22	(3) If one or more participating providers is participating in a clinical trial, nothing in
53-23	subdivision (1) of this subsection shall be construed as preventing a health carrier from requiring
53-24	that a qualified individual participate in the trial through such a participating provider if the
53-25	provider will accept the individual as a participant in the trial.
53-26	(4) Notwithstanding subdivision (3) of this subsection, subdivision (1) of this subsection
53-27	shall apply to a qualified individual participating in an approved clinical trial that is conducted
53-28	outside this state.
53-29	(5) This section shall not be construed to require a nonprofit medical service corporation
53-30	offering group or individual health insurance coverage to provide benefits for routine patient care
53-31	services provided outside of the coverage’s health care provider network unless out-of-network
53-32	benefits are otherwise provided under the coverage.
53-33	(6) Nothing in this section shall be construed to limit a health insurance carrier’s
53-34	coverage with respect to clinical trials.
54-1	(c) The requirements of this section shall be in addition to the requirements of Rhode
54-2	Island general laws sections 27-18-36 through 27-18-36.3.
54-3	(d) This section shall not apply to grandfathered health plans.
54-4	(e) This section shall be effective for plan years beginning on or after January 1, 2014.
54-5	27-20-66. Medical loss ratio rebates. – (a) A nonprofit medical service corporation
54-6	offering group or individual health insurance coverage, including a grandfathered health plan,
54-7	shall pay medical loss ratio rebates as provided for in Section 2718(b)(1)(A) of the Affordable
54-8	Care Act, in the manner and as required by federal laws and regulations.
54-9	(b) Nonprofit medical service corporations required to report medical loss ratio and
54-10	rebate calculations and any other medical loss ratio and rebate information to the U.S.
54-11	Department of Health and Human Services shall concurrently file such information with the
54-12	commissioner.
54-13	27-20-67. Emergency services -- (a) As used in this section:
54-14	(1) “Emergency medical condition” means a medical condition manifesting itself by
54-15	acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who
54-16	possesses an average knowledge of health and medicine, could reasonably expect the absence of
54-17	immediate medical attention to result in a condition: (i) Placing the health of the individual, or
54-18	with respect to a pregnant woman her unborn child, in serious jeopardy; (ii) Constituting a serious
54-19	impairment to bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or
54-20	part
54-21	(2) “Emergency services” means, with respect to an emergency medical condition:
54-22	(A) A medical screening examination (as required under section 1867 of the Social
54-23	Security Act, 42 U.S.C. 1395dd) that is within the capability of the emergency department of a
54-24	hospital, including ancillary services routinely available to the emergency department to evaluate
54-25	such emergency medical condition, and
54-26	(B) Such further medical examination and treatment, to the extent they are within the
54-27	capabilities of the staff and facilities available at the hospital, as are required under section 1867
54-28	of the Social Security Act (42 U.S.C. 1395dd) to stabilize the patient.
54-29	(3) “Stabilize”, with respect to an emergency medical condition has the meaning given in
54-30	section 1867(e)(3) of the Social Security Act (42 U.S.C. 1395dd(e)(3)).
54-31	(b) If a nonprofit medical service corporation offering health insurance coverage provides
54-32	any benefits with respect to services in an emergency department of a hospital, it must cover
54-33	emergency services consistent with the rules of this section.
55-34	(c) A nonprofit medical service corporation shall provide coverage for emergency
55-35	services in the following manner:
55-36	(1) Without the need for any prior authorization determination, even if the emergency
55-37	services are provided on an out-of-network basis;
55-38	(2) Without regard to whether the health care provider furnishing the emergency services
55-39	is a participating network provider with respect to the services;
55-40	(3) If the emergency services are provided out of network, without imposing any
55-41	administrative requirement or limitation on coverage that is more restrictive than the requirements
55-42	or limitations that apply to emergency services received from in-network providers;
55-43	(4) If the emergency services are provided out of network, by complying with the cost-
55-44	sharing requirements of subsection (d) of this section; and
55-45	(5) Without regard to any other term or condition of the coverage, other than:
55-46	(A) The exclusion of or coordination of benefits;
55-47	(B) An affiliation or waiting period permitted under part 7 of ERISA, part A of title
55-48	XXVII of the PHS Act, or chapter 100 of the Internal Revenue Code; or
55-49	(C) Applicable cost-sharing.
55-50	(d)(1) Any cost-sharing requirement expressed as a copayment amount or coinsurance
55-51	rate imposed with respect to a participant or beneficiary for out-of-network emergency services
55-52	cannot exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if
55-53	the services were provided in-network. However, a participant or beneficiary may be required to
55-54	pay, in addition to the in-network cost sharing, the excess of the amount the out-of-network
55-55	provider charges over the amount the plan or health insurance carrier is required to pay under
55-56	subdivision (1) of this subsection. A group health plan or health insurance carrier complies with
55-57	the requirements of this subsection if it provides benefits with respect to an emergency service in
55-58	an amount equal to the greatest of the three amounts specified in subdivisions (A), (B), and (C) of
55-59	this subdivision (1)(which are adjusted for in-network cost-sharing requirements).
55-60	(A) The amount negotiated with in-network providers for the emergency service
55-61	furnished, excluding any in-network copayment or coinsurance imposed with respect to the
55-62	participant or beneficiary. If there is more than one amount negotiated with in-network providers
55-63	for the emergency service, the amount described under this subdivision (A) is the median of these
55-64	amounts, excluding any in-network copayment or coinsurance imposed with respect to the
55-65	participant or beneficiary. In determining the median described in the preceding sentence, the
55-66	amount negotiated with each in-network provider is treated as a separate amount (even if the
55-67	same amount is paid to more than one provider). If there is no per-service amount negotiated with
55-68	in-network providers (such as under a capitation or other similar payment arrangement), the
56-1	amount under this subdivision (A) is disregarded.
56-2	(B) The amount for the emergency service shall be calculated using the same method the
56-3	plan generally uses to determine payments for out-of-network services (such as the usual,
56-4	customary, and reasonable amount), excluding any in-network copayment or coinsurance
56-5	imposed with respect to the participant or beneficiary. The amount in this subdivision (B) is
56-6	determined without reduction for out-of-network cost-sharing that generally applies under the
56-7	plan or health insurance coverage with respect to out-of-network services.
56-8	(C) The amount that would be paid under Medicare (part A or part B of title XVIII of the
56-9	Social Security Act, 42 U.S.C. 1395 et seq.) for the emergency service, excluding any in-network
56-10	copayment or coinsurance imposed with respect to the participant or beneficiary.
56-11	(2) Any cost-sharing requirement other than a copayment or coinsurance requirement
56-12	(such as a deductible or out-of-pocket maximum) may be imposed with respect to emergency
56-13	services provided out of network if the cost-sharing requirement generally applies to out-of-
56-14	network benefits. A deductible may be imposed with respect to out-of-network emergency
56-15	services only as part of a deductible that generally applies to out-of-network benefits. If an out-of-
56-16	pocket maximum generally applies to out-of-network benefits, that out-of-pocket maximum must
56-17	apply to out-of-network emergency services.
56-18	(e) The provisions of this section apply for plan years beginning on or after September
56-19	23, 2010.
56-20	(f) This section shall not apply to grandfathered health plans.
56-21	27-20-68. Internal and external appeal of adverse benefit determinations. -- (a) The
56-22	commissioner shall adopt regulations to implement standards and procedures with respect to
56-23	internal claims and appeals of adverse benefit determinations, and with respect to external appeals
56-24	of adverse benefit determinations.
56-25	(b) The regulations adopted by the commissioner shall apply to those adverse benefit
56-26	determinations within the jurisdiction of the commissioner.
56-27	SECTION 8. Sections 27-41-2 and 27-41-61 of the General laws in Chapter 27-41
56-28	entitled "Health Maintenance Organizations” are hereby amended to read as follows:
56-29	27-41-2. Definitions. – As used in this chapter:
56-30	(a) Adverse benefit determination" means any of the following: a denial, reduction, or
56-31	termination of, or a failure to provide or make payment (in whole or in part) for, a benefit,
56-32	including any such denial, reduction, termination, or failure to provide or make payment that is
56-33	based on a determination of a participant's or beneficiary's eligibility to participate in a plan or to
56-34	receive coverage under a plan, and including, with respect to group health plans, a denial,
57-1	reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a
57-2	benefit resulting from the application of any utilization review, as well as a failure to cover an
57-3	item or service for which benefits are otherwise provided because it is determined to be
57-4	experimental or investigational or not medically necessary or appropriate. The term also includes
57-5	a rescission of coverage determination.
57-6	(b) "Affordable Care Act" means the Patient Protection and Affordable Care act of 2010,
57-7	as amended by the Health Care and Education Reconciliation Act of 2010.
57-8	(c) “Commissioner” or “health insurance commissioner” means that individual appointed
57-9	pursuant to section 42-14.5-1 of the general laws.
57-10	~~(a)~~(d) "Covered health services" means the services that a health maintenance
57-11	organization contracts with enrollees and enrolled groups to provide or make available to an
57-12	enrolled participant.
57-13	~~(b)~~ (e) "Director" means the director of the department of business regulation or his or her
57-14	duly appointed agents.
57-15	~~(c)~~(f) "Employee" means any person who has entered into the employment of or works
57-16	under a contract of service or apprenticeship with any employer. It shall not include a person who
57-17	has been employed for less than thirty (30) days by his or her employer, nor shall it include a
57-18	person who works less than an average of thirty (30) hours per week. For the purposes of this
57-19	chapter, the term "employee" means a person employed by an "employer" as defined in
57-20	subsection (d) of this section. Except as otherwise provided in this chapter the terms "employee"
57-21	and "employer" are to be defined according to the rules and regulations of the department of labor
57-22	and training.
57-23	~~(d)~~(g) "Employer" means any person, partnership, association, trust, estate, or
57-24	corporation, whether foreign or domestic, or the legal representative, trustee in bankruptcy,
57-25	receiver, or trustee of a receiver, or the legal representative of a deceased person, including the
57-26	state of Rhode Island and each city and town in the state, which has in its employ one or more
57-27	individuals during any calendar year. For the purposes of this section, the term "employer" refers
57-28	only to an employer with persons employed within the state of Rhode Island.
57-29	~~(e)~~(h) "Enrollee" means an individual who has been enrolled in a health maintenance
57-30	organization.
57-31	~~(f)~~(i) "Evidence of coverage" means any certificate, agreement, or contract issued to an
57-32	enrollee setting out the coverage to which the enrollee is entitled.
57-33	(j) “Grandfathered health plan” means any group health plan or health insurance coverage
57-34	subject to 42 USC section 18011.
58-1	(k) “Group health insurance coverage” means, in connection with a group health plan,
58-2	health insurance coverage offered in connection with such plan.
58-3	(l) “Group health plan” means an employee welfare benefit plan as defined in 29 USC
58-4	section 1002(1), to the extent that the plan provides health benefits to employees or their
58-5	dependents directly or through insurance, reimbursement, or otherwise.
58-6	(m) “Health benefits” or “covered benefits” means medical, surgical, hospital,
58-7	prescription drug, and such other benefits, whether self-funded, or delivered through the purchase
58-8	of insurance or otherwise.
58-9	(n) “Health care facility” means an institution providing health care services or a health
58-10	care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory
58-11	surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic,
58-12	laboratory and imaging centers, and rehabilitation and other therapeutic health settings.
58-13	(o) "Health care professional" means a physician or other health care practitioner
58-14	licensed, accredited or certified to perform specified health care services consistent with state
58-15	law.
58-16	(p) "Health care provider" or "provider" means a health care professional or a health care
58-17	facility.
58-18	~~(g)~~(q) "Health care services" means any services included in the furnishing to any
58-19	individual of medical, podiatric, or dental care, or hospitalization, or incident to the furnishing of
58-20	that care or hospitalization, and the furnishing to any person of any and all other services for the
58-21	purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability.
58-22	(r) “Health insurance carrier” means a person, firm, corporation or other entity subject to
58-23	the jurisdiction of the commissioner under this chapter, and includes a health maintenance
58-24	organization. Such term does not include a group health plan.
58-25	~~(h)~~(s) "Health maintenance organization" means a single public or private organization
58-26	which:
58-27	(1) Provides or makes available to enrolled participants health care services, including at
58-28	least the following basic health care services: usual physician services, hospitalization, laboratory,
58-29	x-ray, emergency, and preventive services, and out of area coverage, and the services of licensed
58-30	midwives;
58-31	(2) Is compensated, except for copayments, for the provision of the basic health care
58-32	services listed in subdivision (1) of this subsection to enrolled participants on a predetermined
58-33	periodic rate basis; and
59-34	(3) Provides physicians' services primarily:
59-35	(A) Directly through physicians who are either employees or partners of the organization;
59-36	or
59-37	(B) Through arrangements with individual physicians or one or more groups of
59-38	physicians organized on a group practice or individual practice basis;
59-39	(ii) "Health maintenance organization" does not include prepaid plans offered by entities
59-40	regulated under chapter 1, 2, 19, or 20 of this title that do not meet the criteria above and do not
59-41	purport to be health maintenance organizations;
59-42	(4) Provides the services of licensed midwives primarily:
59-43	(i) Directly through licensed midwives who are either employees or partners of the
59-44	organization; or
59-45	(ii) Through arrangements with individual licensed midwives or one or more groups of
59-46	licensed midwives organized on a group practice or individual practice basis.
59-47	~~(i)~~(t) "Licensed midwife" means any midwife licensed pursuant to section 23-13-9.
59-48	~~(j)~~(u) "Material modification" means only systemic changes to the information filed
59-49	under section 27-41-3.
59-50	~~(k)~~(v) "Net worth", for the purposes of this chapter, means the excess of total admitted
59-51	assets over total liabilities.
59-52	(w) "Office of the health insurance commissioner" means the agency established under
59-53	section 42-14.5-1 of the general laws.
59-54	~~(l)~~(x) "Physician" includes podiatrist as defined in chapter 29 of title 5.
59-55	~~(m)~~(y) "Private organization" means a legal corporation with a policy making and
59-56	governing body.
59-57	~~(n)~~(z) "Provider" means any physician, hospital, licensed midwife, or other person who is
59-58	licensed or authorized in this state to furnish health care services.
59-59	~~(o)~~(aa) "Public organization" means an instrumentality of government.
59-60	(bb) “Rescission" means a cancellation or discontinuance of coverage that has retroactive
59-61	effect for reasons unrelated to timely payment of required premiums or contribution to costs of
59-62	coverage.
59-63	~~(p)~~(cc) "Risk based capital ("RBC") instructions" means the risk based capital report
59-64	including risk based capital instructions adopted by the National Association of Insurance
59-65	Commissioners ("NAIC"), as these risk based capital instructions are amended by the NAIC in
59-66	accordance with the procedures adopted by the NAIC.
59-67	~~(q)~~(dd) "Total adjusted capital" means the sum of:
60-68	(1) A health maintenance organization's statutory capital and surplus (i.e. net worth) as
60-69	determined in accordance with the statutory accounting applicable to the annual financial
60-70	statements required to be filed under section 27-41-9; and
60-71	(2) Any other items, if any, that the RBC instructions provide.
60-72	~~(r)~~(ee) "Uncovered expenditures" means the costs of health care services that are covered
60-73	by a health maintenance organization, but that are not guaranteed, insured, or assumed by a
60-74	person or organization other than the health maintenance organization. Expenditures to a provider
60-75	that agrees not to bill enrollees under any circumstances are excluded from this definition.
60-76	27-41-61. ~~Termination of children's benefits. –~~Eligibility for children’s benefits -
60-77	(a)(1) Every individual health insurance contract, plan, or policy delivered, issued for delivery, or
60-78	renewed in this state which provides ~~medical~~ health benefits coverage for ~~dependent children that~~
60-79	~~includes coverage for physician services in a physician's office, and every policy which provides~~
60-80	~~major medical or similar comprehensive type coverage,~~ dependents, except for supplemental
60-81	policies which only provide coverage for specified diseases and other supplemental policies, shall
60-82	~~provide~~ make coverage available ~~of an unmarried child under the age of nineteen (19) years, an~~
60-83	~~unmarried child who is a student under the age of twenty-five (25) years and who is financially~~
60-84	~~dependent upon the parent and an unmarried child of any age who is financially dependent upon~~
60-85	~~the parent and medically determined to have a physical or mental impairment which can be~~
60-86	~~expected to result in death or which has lasted or can be expected to last for a continuous period~~
60-87	~~of not less than twelve (12) months.~~ for children until attainment of twenty-six (26) years of age.
60-88	~~Such contract, plan or policy shall also include a provision that policyholders shall receive no less~~
60-89	~~than thirty (30) days notice from the health maintenance organization that a child is about to lose~~
60-90	~~his or her coverage as a result of reaching the maximum age for a dependent child and that the~~
60-91	~~child will only continue to be covered upon documentation being provided of current full or part-~~
60-92	~~time enrollment in a post-secondary educational institution, or that the child may purchase a~~
60-93	~~conversion policy if he or she is not an eligible student.~~
60-94	~~(b) Nothing in this section prohibits a nonprofit health maintenance organization from~~
60-95	~~requiring a policyholder to annually provide proof of a child's current full or part-time enrollment~~
60-96	~~in a post-secondary educational institution in order to maintain the child's coverage. Provided,~~
60-97	~~nothing in this section requires coverage inconsistent with the membership criteria in effect under~~
60-98	~~the policyholder's health benefits coverage.~~
60-99	(2) With respect to a child who has not attained twenty-six (26) years of age, a health
60-100	maintenance organization shall not define “dependent” for purposes of eligibility for dependent
60-101	coverage of children other than the terms of a relationship between a child and the plan
60-102	participant, and, in the individual market, primary subscriber.
61-1	(3) A health maintenance organization shall not deny or restrict coverage for a child who
61-2	has not attained twenty-six (26) years of age based on the presence or absence of the child’s
61-3	financial dependency upon the participant, primary subscriber or any other person, residency with
61-4	the participant and in the individual market the primary subscriber, or with any other person,
61-5	marital status, student status, employment or any combination of those factors. A health carrier
61-6	shall not deny or restrict coverage of a child based on eligibility for other coverage, except as
61-7	provided in (d)(1) of this section.
61-8	(4) Nothing in this section shall be construed to require a health maintenance
61-9	organization to make coverage available for the child of a child receiving dependent coverage,
61-10	unless the grandparent becomes the legal guardian or adoptive parent of that grandchild.
61-11	(5) The terms of coverage in a health benefit plan offered by a health maintenance
61-12	organization providing dependent coverage of children cannot vary based on age except for
61-13	children who are twenty-six (26) years of age or older.
61-14	(b)(1) This subsection applies to any child:
61-15	(A) Whose coverage ended, or who was denied coverage, or was not eligible for group
61-16	health insurance coverage or individual health insurance coverage under a health benefit plan
61-17	because, under the terms of coverage, the availability of dependent coverage of a child ended
61-18	before the attainment of twenty-six (26) years of age; and
61-19	(B) Who becomes eligible, or is required to become eligible, for coverage on the first day
61-20	of the first plan year and, in the individual market, the first day of the first policy year, beginning
61-21	on or after September 23, 2010 by reason of the provisions of this section.
61-22	(2)(A) If group health insurance coverage or individual health insurance coverage, in
61-23	which a child is eligible to enroll, or is required to become eligible to enroll, in the coverage in
61-24	which the child’s coverage ended or did not begin for the reasons described in subdivision (1) of
61-25	this subsection, and if the health insurance carrier is subject to the requirements of this section the
61-26	health insurance carrier shall give the child an opportunity to enroll that continues for at least 60
61-27	days, including the written notice of the opportunity to enroll as described subdivision (3) of this
61-28	subsection.
61-29	(B) The health insurance carrier shall provide the opportunity to enroll, including the
61-30	written notice beginning not later than the first day of the first plan year and in the individual
61-31	market the first day of the first policy year, beginning on or after September 23, 2010.
61-32	(3)(A) The written notice of opportunity to enroll shall include a statement that children
61-33	whose coverage ended, or who were denied coverage, or were not eligible for coverage, because
61-34	the availability of dependent coverage of children ended before the attainment of twenty-six (26)
62-1	years of age are eligible to enroll in the coverage.
62-2	(B)(i) The notice may be provided to an employee on behalf of the employee’s child and,
62-3	in the individual market, to the primary subscriber on behalf of the primary subscriber’s child.
62-4	(ii) For group health insurance coverage:
62-5	(I) The notice may be included with other enrollment materials that the health carrier
62-6	distributes to employees, provided the statement is prominent; and
62-7	(II) If a notice satisfying the requirements of this subdivision is provided to an employee
62-8	whose child is entitled to an enrollment opportunity under subsection (c) of this section, the
62-9	obligation to provide the notice of enrollment opportunity under subdivision (B) of this
62-10	subdivision (3) with respect to that child is satisfied for both the plan and health insurance carrier.
62-11	(C) The written notice shall be provided beginning not later than the first day of the first
62-12	plan year and in the individual market the first day of the first policy year, beginning on or after
62-13	September 23, 2010.
62-14	(4) For an individual who enrolls under this subsection, the coverage shall take effect not
62-15	later than the first day of the first plan year and, in the individual market, the first day of the first
62-16	policy year, beginning on or after September 23, 2010.
62-17	(c)(1) A child enrolling in group health insurance coverage pursuant to subsection (b) of
62-18	this section shall be treated as if the child were a special enrollee, as provided under regulations
62-19	interpreting the HIPAA portability provisions issued pursuant to section 2714 of the Affordable
62-20	Care.
62-21	(2)(A) The child and, if the child would not be a participant once enrolled, the participant
62-22	through whom the child is otherwise eligible for coverage under the plan, shall be offered all the
62-23	benefit packages available to similarly situated individuals who did not lose coverage by reason
62-24	of cessation of dependent status.
62-25	(B) For purposes of this subdivision (2), any difference in benefits or cost-sharing
62-26	requirements constitutes a different benefit package.
62-27	(3) The child shall not be required to pay more for coverage than similarly situated
62-28	individuals who did not lose coverage by reason of cessation of dependent status.
62-29	(d)(1) For plan years beginning before January 1, 2014, a group health plan providing
62-30	group health insurance coverage that is a grandfathered health plan and makes available
62-31	dependent coverage of children may exclude an adult child who has not attained twenty-six (26)
62-32	years of age from coverage only if the adult child is eligible to enroll in an eligible employer-
62-33	sponsored health benefit plan, as defined in section 5000A(f)(2) of the Internal Revenue Code,
62-34	other than the group health plan of a parent.
63-1	(2) For plan years, beginning on or after January 1, 2014, a group health plan providing
63-2	group health insurance coverage that is a grandfathered health plan shall comply with the
63-3	requirements of subsections (a) through (e).
63-4	(3) The provisions of this section apply to policy years in the individual market on and
63-5	after September 23, 2010.
63-6	~~(b)~~(e) This section does not apply to insurance coverage providing benefits for: (1)
63-7	hospital confinement indemnity; (2) disability income; (3) accident only; (4) long term care; (5)
63-8	Medicare supplement; (6) limited benefit health; (7) specified diseased indemnity; or (8) other
63-9	limited benefit policies.
63-10	SECTION 9. Chapter 27-41 of the General laws entitled "Health Maintenance
63-11	Organizations" is hereby amended by adding thereto the following sections:
63-12	27-41-29.1. Uniform explanation of benefits and coverage. -- (a) A health maintenance
63-13	organization shall provide a uniform summary of benefits and coverage explanation and
63-14	standardized definitions to policyholders and others required by, and at the times required by, the
63-15	federal regulations adopted under section 2715 of the Affordable Care Act. A summary required
63-16	by this section shall be filed with the commissioner for approval under Rhode Island general laws
63-17	section 27-41-29.2. The requirements of this section shall be in addition to any other requirements
63-18	imposed as conditions of approval under Rhode Island general laws sections 27-41-29.2. The
63-19	commissioner may waive one or more of the requirements of the regulations adopted under
63-20	section 2715 of the Affordable Care Act for good cause shown. The summary must contain at
63-21	least the following information:
63-22	(1) Uniform definitions of insurance and medical terms.
63-23	(2) A description of coverage and cost-sharing for each category of essential benefits and
63-24	other benefits.
63-25	(3) Exceptions, reductions and limitations in coverage.
63-26	(4) Renewability and continuation of coverage provisions.
63-27	(5) A “coverage facts label” that illustrates coverage under common benefits scenarios.
63-28	(6) A statement of whether the policy, contract or plan provides the minimum coverage
63-29	required of a qualified health plan.
63-30	(7) A statement that the outline is a summary and that the actual policy language should
63-31	be consulted; and
63-32	(8) A contact number for the consumer to call with additional questions and the web
63-33	address of where the actual language of the policy, contract or plan can be found.
64-34	(b) The provisions of this section shall apply to grandfathered health plans.
64-35	27-41-29.2. Filing of policy forms. -- A health maintenance organization shall file all
64-36	policy forms and rates used by it in the state with the commissioner, including the forms of any
64-37	rider, endorsement, application blank, and other matter generally used or incorporated by
64-38	reference in its policies or contracts of insurance. No such rate shall be used unless first approved
64-39	by the commissioner. No such form shall be used if disapproved by the commissioner under this
64-40	section, or if the commissioner's approval has been withdrawn after notice and an opportunity to
64-41	be heard, or until the expiration of sixty (60) days following the filing of the form. A health
64-42	maintenance organization shall comply with its filed and approved rates and forms. If the
64-43	commissioner finds from an examination of any form that it is contrary to the public interest or
64-44	the requirements of this code or duly promulgated regulations, he or she shall forbid its use, and
64-45	shall notify the corporation in writing. Each form shall include a certification by a qualified
64-46	actuary that to the best of the actuary's knowledge and judgment, the entire rate is in compliance
64-47	with applicable laws and that the benefits are reasonable in relation to the premium to be charged.
64-48	27-41-75. Prohibition on rescission of coverage. -- (a)(1) Coverage under a health plan
64-49	subject to the jurisdiction of the commissioner under this chapter with respect to an individual,
64-50	including a group to which the individual belongs or family coverage in which the individual is
64-51	included, shall not be rescinded after the individual is covered under the plan, unless:
64-52	(A) The individual or a person seeking coverage on behalf of the individual, performs an
64-53	act, practice or omission that constitutes fraud; or
64-54	(B) The individual makes an intentional misrepresentation of material fact, as prohibited
64-55	by the terms of the plan or coverage.
64-56	(2) For purposes of paragraph (1)(A), a person seeking coverage on behalf of an
64-57	individual does not include an insurance producer or employee or authorized representative of the
64-58	health maintenance organization.
64-59	(b) At least thirty (30) days advance written notice shall be provided to each plan enrollee
64-60	or, for individual health insurance coverage, primary subscriber, who would be affected by the
64-61	proposed rescission of coverage before coverage under the plan may be rescinded in accordance
64-62	with subsection (a) regardless of, in the case of group health insurance coverage, whether the
64-63	rescission applies to the entire group or only to an individual within the group.
64-64	(c) For purposes of this section, “to rescind” means to cancel or to discontinue coverage
64-65	with retroactive effect for reasons unrelated to timely payment of required premiums or
64-66	contribution to costs of coverage.
64-67	(d) This section applies to grandfathered health plans.
65-68	27-41-76. Prohibition on annual and lifetime limits. -- (a) Annual limits.
65-69	(1) For plan or policy years beginning prior to January 1, 2014, for any individual, a
65-70	health maintenance organization subject to the jurisdiction of the commissioner under this chapter
65-71	may establish an annual limit on the dollar amount of benefits that are essential health benefits
65-72	provided the restricted annual limit is not less than the following:
65-73	(A) For a plan or policy year beginning after September 22, 2010, but before September
65-74	23, 2011 – seven hundred fifty thousand dollars ($750,000);
65-75	(B) For a plan or policy year beginning after September 22, 2011, but before September
65-76	23, 2012 – one million two hundred fifty thousand dollars ($1,250,000); and
65-77	(C) For a plan or policy year beginning after September 22, 2012, but before January 1,
65-78	2014 – two million dollars ($2,000,000).
65-79	(2 ) For plan or policy years beginning on or after January 1, 2014, a health maintenance
65-80	organization shall not establish any annual limit on the dollar amount of essential health benefits
65-81	for any individual, except:
65-82	(A) A health flexible spending arrangement, as defined in section 106(c)(2)(i) of the
65-83	Internal Revenue Code, a medical savings account, as defined in section 220 of the Internal
65-84	Revenue Code, and a health savings account, as defined in section 223 of the Internal Revenue
65-85	Code are not subject to the requirements of subdivisions (1) and (2) of this subsection .
65-86	(B) The provisions of this subsection shall not prevent a health maintenance organization
65-87	from placing annual dollar limits for any individual on specific covered benefits that are not
65-88	essential health benefits to the extent that such limits are otherwise permitted under applicable
65-89	federal law or the laws and regulations of this state.
65-90	(3) In determining whether an individual has received benefits that meet or exceed the
65-91	allowable limits, as provided in subdivision (1) of this subsection, a health maintenance
65-92	organization shall take into account only essential health benefits as administratively established
65-93	by the commissioner.
65-94	(b) Lifetime limits.
65-95	(1) A health insurance carrier and health benefit plan offering group or individual health
65-96	insurance coverage shall not establish a lifetime limit on the dollar value of essential health
65-97	benefits, as designated pursuant to a state determination and in accordance with federal laws and
65-98	regulations, for any individual.
65-99	(2) Notwithstanding subdivision (1) above, a health insurance carrier and health benefit
65-100	plan is not prohibited from placing lifetime dollar limits for any individual on specific covered
65-101	benefits that are not essential health benefits, as designated pursuant to a state determination and
65-102	in accordance with federal laws and regulations.
66-1	(c)(1) Reinstatement of Coverage. Except as provided in subdivision (2) of this
66-2	subsection, this subsection applies to any individual:
66-3	(A) Whose coverage or benefits under a health plan ended by reason of reaching a
66-4	lifetime limit on the dollar value of all benefits for the individual; and
66-5	(B) Who, due to the provisions of this section, becomes eligible, or is required to become
66-6	eligible, for benefits not subject to a lifetime limit on the dollar value of all benefits under the
66-7	health benefit plan:
66-8	(i) For group health insurance coverage, on the first day of the first plan year beginning
66-9	on or after September 23, 2010; or
66-10	(ii) For individual health insurance coverage, on the first day of the first policy year
66-11	beginning on or after September 23, 2010.
66-12	(2) For individual health insurance coverage, an individual is not entitled to reinstatement
66-13	under the health benefit plan under this subsection if the individual reached his or her lifetime
66-14	limit and the contract is not renewed or is otherwise no longer in effect. However, this subsection
66-15	applies to a family member who reached his or her lifetime limit in a family plan and other family
66-16	members remain covered under the plan.
66-17	(3)(A) If an individual described in subdivision (1) is eligible for benefits or is required
66-18	to become eligible for benefits under the health benefit plan, the health maintenance organization
66-19	shall provide the individual written notice that:
66-20	(i) The lifetime limit on the dollar value of all benefits no longer applies; and
66-21	(ii) The individual, if still covered under the plan, is again eligible to receive benefits
66-22	under the plan.
66-23	(B) If the individual is not enrolled in the plan, or if an enrolled individual is eligible for,
66-24	but not enrolled in any benefit package under the plan, the health maintenance organization shall
66-25	provide an opportunity for the individual to enroll in the plan for a period of at least thirty (30)
66-26	days.
66-27	(C) The notices and enrollment opportunity under this subdivision shall be provided
66-28	beginning not later than:
66-29	(i) For group health insurance coverage, the first day of the first plan year beginning on
66-30	or after September 23, 2010; or
66-31	(ii) For individual health insurance coverage, the first day of the first policy year
66-32	beginning on or after September 23, 2010.
66-33	(iii) The notices required under this subsection shall be provided:
67-34	(I) For group health insurance coverage, to an employee on behalf of the employee’s
67-35	dependent; or
67-36	(II) For individual health insurance coverage, to the primary subscriber on behalf of the
67-37	primary subscriber’s dependent.
67-38	(D) For group health insurance coverage, the notices may be included with other
67-39	enrollment materials that a health maintenance organization distributes to subscribers, provided
67-40	the statement is prominent. For group health insurance coverage, if a notice satisfying the
67-41	requirements of this subsection is provided to an individual, a health maintenance organization’s
67-42	requirement to provide the notice with respect to that individual is satisfied.
67-43	(E) For any individual who enrolls in a health maintenance organization in accordance
67-44	with subdivision (2) of this subsection, coverage under the plan shall take effect not later than:
67-45	(i) For group health insurance coverage, the first day of the first plan year beginning on
67-46	or after September 23, 2010; or
67-47	(ii) For individual health insurance coverage, the first day of the first policy year
67-48	beginning on or after September 23, 2010.
67-49	(d)(1) An individual enrolling in a health maintenance organization for group health
67-50	insurance coverage in accordance with subsection (c) above shall be treated as if the individual
67-51	were a special enrollee in the plan, as provided under regulations interpreting the HIPAA
67-52	portability provisions issued pursuant to Section 2714 of the Affordable Care Act.
67-53	(2) An individual enrolling in accordance with subsection (c) of this subsection:
67-54	(A) shall be offered all of the benefit packages available to similarly situated individuals
67-55	who did not lose coverage under the plan by reason of reaching a lifetime limit on the dollar value
67-56	of all benefits; and
67-57	(B) shall not be required to pay more for coverage than similarly situated individuals who
67-58	did not lose coverage by reason of reaching a lifetime limit on the dollar value of all benefits.
67-59	(3) For purposes of subsection B(1), any difference in benefits or cost-sharing constitutes
67-60	a different benefit package.
67-61	(e)(1) The provisions of this section relating to lifetime limits apply to any health
67-62	maintenance organization or health insurance carrier providing coverage under an individual or
67-63	group health plan, including grandfathered health plans.
67-64	(2) The provisions of this section relating to annual limits apply to any health
67-65	maintenance organization or health insurance carrier providing coverage under a group health
67-66	plan, including grandfathered health plans, but the prohibition and limits on annual limits do not
67-67	apply to grandfathered health plans providing individual health insurance coverage.
68-68	27-41-77. Coverage for Preventive Items and Services. -- (a) Every health maintenance
68-69	organization providing coverage under an individual or group health plan shall provide coverage
68-70	for all of the following items and services, and shall not impose any cost-sharing requirements,
68-71	such as a copayment, coinsurance or deductible, with respect to the following items and services:
68-72	(1) Except as otherwise provided in subsection (b) of this section, and except as may
68-73	otherwise be provided in federal regulations implementing the Affordable Care Act, evidence-
68-74	based items or services that have in effect a rating of A or B in the recommendations of the
68-75	United States Preventive Services Task Force as of September 23, 2010 and as may subsequently
68-76	be amended.
68-77	(2) Immunizations for routine use in children, adolescents and adults that have in effect a
68-78	recommendation from the Advisory Committee on Immunization Practices of the Centers for
68-79	Disease Control and Prevention with respect to the individual involved. For purposes of this
68-80	subdivision, a recommendation from the Advisory Committee on Immunization Practices of the
68-81	Centers for Disease Control and Prevention is considered in effect after it has been adopted by the
68-82	Director of the Centers for Disease Control and Prevention, and a recommendation is considered
68-83	to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease
68-84	Control and Prevention.
68-85	(3) With respect to infants, children and adolescents, evidence-informed preventive care,
68-86	and screenings provided for in comprehensive guidelines supported by the Health Resources and
68-87	Services Administration.
68-88	(4) With respect to women, to the extent not described in subdivision (1) of this
68-89	subsection, evidence-informed preventive care and screenings provided for in comprehensive
68-90	coverage guidelines supported by the Health Resources and Services Administration.
68-91	(b)(1) A health maintenance organization is not required to provide coverage for any
68-92	items or services specified in any recommendation or guideline described in subsection (a) of this
68-93	section after the recommendation or guideline is no longer described in subsection (a) of this
68-94	section. The provisions of this subdivision shall not affect the obligation of the health
68-95	maintenance organization to provide notice to a covered person before any material modification
68-96	of coverage becomes effective, in accordance with including section 2715(d)(4) of the Public
68-97	Health Services Act.
68-98	(2) A health maintenance organization shall at least annually at the beginning of each
68-99	new plan year or policy year, whichever is applicable, revise the preventive services covered
68-100	under its health benefit plans pursuant to this section consistent with the recommendations of the
68-101	United States Preventive Services Task Force, the Advisory Committee on Immunization
68-102	Practices of the Centers for Disease Control and Prevention and the guidelines with respect to
69-1	infants, children, adolescents and women evidence-based preventive care and screenings by the
69-2	Health Resources and Services Administration in effect at the time.
69-3	(c)(1) A health maintenance organization insurance carrier may impose cost-sharing
69-4	requirements with respect to an office visit if an item or service described in subsection (a) of this
69-5	section is billed separately or is tracked as individual encounter data separately from the office
69-6	visit.
69-7	(2) A health maintenance organization shall not impose cost-sharing requirements with
69-8	respect to an office visit if an item or service described in subsection (a) of this section is not
69-9	billed separately or is not tracked as individual encounter data separately from the office visit and
69-10	the primary purpose of the office visit is the delivery of the item or service described in
69-11	subsection (a) of this section.
69-12	(3) A health maintenance organization may impose cost-sharing requirements with
69-13	respect to an office visit if an item or service described in subsection (a) of this section is not
69-14	billed separately or is not tracked as individual encounter data separately from the office visit and
69-15	the primary purpose of the office visit is not the delivery of the item or service.
69-16	(d)(1) Nothing in this section requires a health maintenance organization that has a
69-17	network of providers to providing coverage for items and services described in subsection (a) of
69-18	this section that are delivered by an out-of-network provider.
69-19	(2) Nothing in subsection (a) of this section precludes a health maintenance organization
69-20	insurance carrier that has a network of providers from imposing cost-sharing requirements for
69-21	items or services described in subsection (a) of this section that are delivered by an out-of-
69-22	network provider.
69-23	(e) Nothing prevents a health maintenance organization from using reasonable medical
69-24	management techniques to determine the frequency, method, treatment or setting for an item or
69-25	service described in subsection (a) of this section to the extent not specified in the
69-26	recommendation or guideline.
69-27	(f) Nothing in this section prohibits a health maintenance organization from providing
69-28	coverage for items and services in addition to those recommended by the United States
69-29	Preventive Services Task Force or the Advisory Committee on Immunization Practices of the
69-30	Centers for Disease Control and Prevention, or provided by guidelines supported by the Health
69-31	Resources and Services Administration, or from denying coverage for items and services that are
69-32	not recommended by that task force or that advisory committee, or under those guidelines. A
69-33	health maintenance organization may impose cost-sharing requirements for a treatment not
69-34	described in subsection (a) of this section even if the treatment results from an item or service
70-1	described in subsection (a) of this section.
70-2	(g) This section shall not apply to grandfathered health plans.
70-3	27-41-78. Coverage for individual participating in approved clinical trials. -- (a) As
70-4	used in this section.
70-5	(1) “Approved clinical trial” means a phase I, phase II, phase III or phase IV clinical trial
70-6	that is conducted in relation to the prevention, detection or treatment of cancer or a life-
70-7	threatening disease or condition and is described in any of the following:
70-8	(A) The study or investigation is approved or funded, which may include funding through
70-9	in-kind contributions, by one or more of the following:
70-10	(i) The National Institutes of Health;
70-11	(ii) The Centers for Disease Control and Prevention;
70-12	(iii) The Agency for Health Care Research and Quality;
70-13	(iv) The Centers for Medicare & Medicaid Services;
70-14	(v) A cooperative group or center of any of the entities described in items (i) through (iv)
70-15	or the Department of Defense or the Department of Veteran Affairs;
70-16	(vi) A qualified non-governmental research entity identified in the guidelines issued by
70-17	the National Institutes of Health for center support grants; or
70-18	(vii) A study or investigation conducted by the Department of Veteran Affairs, the
70-19	Department of Defense, or the Department of Energy, if the study or investigation has been
70-20	reviewed and approved through a system of peer review that the Secretary of U.S. Department of
70-21	Health and Human Services determines:
70-22	(I) Is comparable to the system of peer review of studies and investigations used by the
70-23	National Institutes of Health; and
70-24	(II) Assures unbiased review of the highest scientific standards by qualified individuals
70-25	who have no interest in the outcome of the review.
70-26	(B) The study or investigation is conducted under an investigational new drug application
70-27	reviewed by the Food and Drug Administration; or
70-28	(C) The study or investigation is a drug trial that is exempt from having such an
70-29	investigational new drug application.
70-30	(2) “Participant” has the meaning stated in section 3(7) of ERISA.
70-31	(3) “Participating provider” means a health care provider that, under a contract with the
70-32	health carrier or with its contractor or subcontractor, has agreed to provide health care services to
70-33	covered persons with an expectation of receiving payment, other than coinsurance, copayments or
70-34	deductibles, directly or indirectly from the health carrier.
71-1	(4) “Qualified individual” means a participant or beneficiary who meets the following
71-2	conditions:
71-3	(A) The individual is eligible to participate in an approved clinical trial according to the
71-4	trial protocol with respect to the treatment of cancer or other life-threatening disease or condition;
71-5	and
71-6	(B)(i) The referring health care professional is a participating provider and has concluded
71-7	that the individual’s participation in such trial would be appropriate based on the individual
71-8	meeting the conditions described in subdivision (A) of this subdivision (3); or
71-9	(ii) The participant or beneficiary provides medical and scientific information
71-10	establishing the individual’s participation in such trial would be appropriate based on the
71-11	individual meeting the conditions described in subdivision (A) of this subdivision (3).
71-12	(5) “Life-threatening condition” means any disease or condition from which the
71-13	likelihood of death is probable unless the course of the disease or condition is interrupted.
71-14	(b)(1) If a health maintenance organization offering group or individual health insurance
71-15	coverage provides coverage to a qualified individual, it:
71-16	(A) Shall not deny the individual participation in an approved clinical trial.
71-17	(B) Subject to subdivision (3) of this subsection, shall not deny or limit or impose
71-18	additional conditions on the coverage of routine patient costs for items and services furnished in
71-19	connection with participation in the approved clinical trial; and
71-20	(C) Shall not discriminate against the individual on the basis of the individual’s
71-21	participation in the approved clinical trial.
71-22	(2)(A) Subject to subdivision (B) of this subdivision (2), routine patient costs include all
71-23	items and services consistent with the coverage typically covered for a qualified individual who is
71-24	not enrolled in an approved clinical trial.
71-25	(B) For purposes of subdivision (B) of this subdivision (2), routine patient costs do not
71-26	include:
71-27	(i) The investigational item, device or service itself;
71-28	(ii) Items and services that are provided solely to satisfy data collection and analysis
71-29	needs and that are not used in the direct clinical management of the patient; or
71-30	(iii) A service that is clearly inconsistent with widely accepted and established standards
71-31	of care for a particular diagnosis.
71-32	(3) If one or more participating providers is participating in a clinical trial, nothing in
71-33	subdivision (1) of this subsection shall be construed as preventing a health maintenance
71-34	organization from requiring that a qualified individual participate in the trial through such a
72-1	participating provider if the provider will accept the individual as a participant in the trial.
72-2	(4) Notwithstanding subdivision (3) of this subsection, subdivision (1) of this subsection
72-3	shall apply to a qualified individual participating in an approved clinical trial that is conducted
72-4	outside this state.
72-5	(5) This section shall not be construed to require a health maintenance organization
72-6	offering group or individual health insurance coverage to provide benefits for routine patient care
72-7	services provided outside of the coverage’s health care provider network unless out-of-network
72-8	benefits are other provided under the coverage.
72-9	(6) Nothing in this section shall be construed to limit a health maintenance organization’s
72-10	coverage with respect to clinical trials.
72-11	(c) The requirements of this section shall be in addition to the requirements of Rhode
72-12	Island general laws sections 27-41-41 through 27-41-41.3.
72-13	27-41-79. Medical loss ratio rebates. -- (a) A health maintenance organization offering
72-14	group or individual health insurance coverage, including a grandfathered health plan, shall pay
72-15	medical loss ratio rebates as provided for in section 2718(b)(1)(A) of the Affordable Care Act, in
72-16	the manner and as required by federal laws and regulations.
72-17	(b) Health maintenance organizations required to report medical loss ratio and rebate
72-18	calculations and any other medical loss ratio or rebate information to the U.S. Department of
72-19	Health and Human Services shall concurrently file such information with the commissioner.
72-20	27-41-80. Emergency services. -- (a) As used in this section:
72-21	(1)“Emergency medical condition” means a medical condition manifesting itself by acute
72-22	symptoms of sufficient severity (including severe pain) so that a prudent layperson, who
72-23	possesses an average knowledge of health and medicine, could reasonably expect the absence of
72-24	immediate medical attention to result in a condition: (i) Placing the health of the individual, or
72-25	with respect to a pregnant woman her unborn child in serious jeopardy: (ii) Constituting a serious
72-26	impairment to bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or
72-27	part.
72-28	(2) “Emergency services” means, with respect to an emergency medical condition:
72-29	(A) A medical screening examination (as required under section 1867 of the Social
72-30	Security Act, 42 U.S.C. 1395 dd) that is within the capability of the emergency department of a
72-31	hospital, including ancillary services routinely available to the emergency department to evaluate
72-32	such emergency medical condition, and
72-33	(B) Such further medical examination and treatment, to the extent they are within the
72-34	capabilities of the staff and facilities available at the hospital, as are required under section 1867
73-1	of the Social Security Act (42 U.S.C. 1395 dd) to stabilize the patient.
73-2	(3) “Stabilize”, with respect to an emergency medical condition has the meaning given in
73-3	section 1867(e)(3) of the Social Security Act (42 U.S.C.1395 dd(e)(3)).
73-4	(b) If a health maintenance organization offering group health insurance coverage
73-5	provides any benefits with respect to services in an emergency department of a hospital, it must
73-6	cover emergency services consistent with the rules of this section.
73-7	(c) A health maintenance organization shall provide coverage for emergency services in
73-8	the following manner:
73-9	(1) Without the need for any prior authorization determination, even if the emergency
73-10	services are provided on an out-of-network basis;
73-11	(2) Without regard to whether the health care provider furnishing the emergency services
73-12	is a participating network provider with respect to the services;
73-13	(3) If the emergency services are provided out of network, without imposing any
73-14	administrative requirement or limitation on coverage that is more restrictive than the requirements
73-15	or limitations that apply to emergency services received from in-network providers;
73-16	(4) If the emergency services are provided out of network, by complying with the cost-
73-17	sharing requirements of subsection (d) of this section; and
73-18	(5) Without regard to any other term or condition of the coverage, other than:
73-19	(A) The exclusion of or coordination of benefits;
73-20	(B) An affiliation or waiting period permitted under part 7 of ERISA, part A of title
73-21	XXVII of the PHS Act, or chapter 100 of the Internal Revenue Code; or
73-22	(C) Applicable cost sharing.
73-23	(d)(1) Any cost-sharing requirement expressed as a copayment amount or coinsurance
73-24	rate imposed with respect to a participant or beneficiary for out-of-network emergency services
73-25	cannot exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if
73-26	the services were provided in-network; provided, however, that a participant or beneficiary may
73-27	be required to pay, in addition to the in-network cost sharing, the excess of the amount the out-of-
73-28	network provider charges over the amount the plan or health maintenance organization is required
73-29	to pay under subdivision (1) of this subsection. A health maintenance organization complies with
73-30	the requirements of this subsection if it provides benefits with respect to an emergency service in
73-31	an amount equal to the greatest of the three amounts specified in subdivisions (A), (B), and (C) of
73-32	this subdivision (1)(which are adjusted for in-network cost-sharing requirements).
73-33	(A) The amount negotiated with in-network providers for the emergency service
73-34	furnished, excluding any in-network copayment or coinsurance imposed with respect to the
74-1	participant or beneficiary. If there is more than one amount negotiated with in-network providers
74-2	for the emergency service, the amount described under this subdivision (A) is the median of these
74-3	amounts, excluding any in-network copayment or coinsurance imposed with respect to the
74-4	participant or beneficiary. In determining the median described in the preceding sentence, the
74-5	amount negotiated with each in-network provider is treated as a separate amount (even if the
74-6	same amount is paid to more than one provider). If there is no per-service amount negotiated with
74-7	in-network providers (such as under a capitation or other similar payment arrangement), the
74-8	amount under this subdivision (A) is disregarded.
74-9	(B) The amount for the emergency service calculated using the same method the plan
74-10	generally uses to determine payments for out-of-network services (such as the usual, customary,
74-11	and reasonable amount), excluding any in-network copayment or coinsurance imposed with
74-12	respect to the participant or beneficiary. The amount in this subdivision (B) is determined without
74-13	reduction for out-of-network cost sharing that generally applies under the plan or health insurance
74-14	coverage with respect to out-of-network services.
74-15	(C) The amount that would be paid under Medicare (part A or part B of title XVIII of the
74-16	Social Security Act, 42 U.S.C. 1395 et seq.) for the emergency service, excluding any in-network
74-17	copayment or coinsurance imposed with respect to the participant or beneficiary.
74-18	(2) Any cost-sharing requirement other than a copayment or coinsurance requirement
74-19	(such as a deductible or out-of-pocket maximum) may be imposed with respect to emergency
74-20	services provided out of network if the cost-sharing requirement generally applies to out-of-
74-21	network benefits. A deductible may be imposed with respect to out-of-network emergency
74-22	services only as part of a deductible that generally applies to out-of-network benefits. If an out-of-
74-23	pocket maximum generally applies to out-of-network benefits, that out-of-pocket maximum must
74-24	apply to out-of-network emergency services.
74-25	(e) The provisions of this section apply for plan years beginning on or after September
74-26	23, 2010.
74-27	(f) This section shall not apply to grandfathered health plans.
74-28	27-41-81. Internal and external appeal of adverse benefit determinations. -- (a) The
74-29	commissioner shall adopt regulations to implement standards and procedures with respect to
74-30	internal claims and appeals of adverse benefit determinations, and with respect to external appeals
74-31	of adverse benefit determinations.
74-32	(b) The regulations adopted by the commissioner shall apply to those adverse benefit
74-33	determinations within the jurisdiction of the commissioner.
75-34	SECTION 10. Section 42-14-5 of the General laws in Chapter 42-14 entitled
75-35	"Department of Business Regulation" is hereby amended to read as follows:
75-36	42-14-5. Administrator of banking and insurance. -- (a) The director of business
75-37	regulation shall, in addition to his or her regular duties, act as administrator of banking and
75-38	insurance and shall administer the functions of the department relating to the regulation and
75-39	control of banking and insurance, foreign surety companies, sale of securities, building and loan
75-40	associations, and fraternal benefit and beneficiary societies.
75-41	(b) Wherever the words "banking administrator" or "insurance administrator" occur in
75-42	this chapter or any general law, public law, act, or resolution of the general assembly or
75-43	department regulation, they shall be construed to mean banking commissioner and insurance
75-44	commissioner except as delineated in subsection (d) below.
75-45	(c) "Health insurance" shall mean "health insurance coverage," as defined in 27-18.5-2
75-46	and 27-18.6-2, "health benefit plan," as defined in 27-50-3 and a "medical supplement policy," as
75-47	defined in 27-18.2-1or coverage similar to a Medicare supplement policy that is issued to an
75-48	employer to cover retirees, and dental coverage, including, but not limited to, coverage provided
75-49	by a nonprofit dental service plan as defined in subsection 27-20.1-1(3).
75-50	(d) Whenever the words "commissioner," "insurance commissioner", "Health insurance
75-51	commissioner" or "director" appear in Title 27or Title 42, those words shall be construed to mean
75-52	the health insurance commissioner established pursuant to 42-14.5-1with respect to all matters
75-53	relating to health insurance. The health insurance commissioner shall have sole and exclusive
75-54	jurisdiction over enforcement of those statutes with respect to all matters relating to health
75-55	insurance.
75-56	(e) In consultation with the commissioner of health, the health insurance commissioner
75-57	shall have concurrent jurisdiction to monitor, examine, and enforce the requirements of title 23
75-58	and regulations adopted thereunder relating to health insurance.
75-59	SECTION 11. Applicability. This act shall apply to health insurance policies, subscriber
75-60	contracts, and any other health benefit contract on and after July 1, 2012, except as otherwise
75-61	provided by the provisions of this act.
75-62	SECTION 12. This act shall take effect on passage.
75-63
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	LC02074
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	EXPLANATION
	BY THE LEGISLATIVE COUNCIL
	OF
	A N A C T
	RELATING TO INSURANCE -- HEALTH INSURANCE - CONSUMER PROTECTION
	***

76-1	This act would establish health insurance rules and standards in addition to, but not
76-2	inconsistent with, the health insurance standards established in the Patient Protection and
76-3	Affordable Care Act of 2010, as amended by the Health Care and Education Reconciliation Act
76-4	of 2010. These rules and standards would include, but are not limited to, prohibitions on
76-5	rescission of coverage, discrimination in coverage, and prohibitions on annual and lifetime limits
76-6	of coverage unless such limits meet set minimum amounts, as well as adding definitions to the
76-7	chapters covering health insurance.
76-8	This act would take effect upon passage.

	=======
	LC02074
	=======

S2887