2015 -- H 5425

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LC001160

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2015

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A N   A C T

RELATING TO INSURANCE - MEANINGFUL ACCESS TO ACCURATE PROVIDER

DIRECTORIES

     

     Introduced By: Representatives Regunberg, Ackerman, Bennett, Morin, and Tanzi

     Date Introduced: February 12, 2015

     Referred To: House Corporations

     It is enacted by the General Assembly as follows:

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     SECTION 1. Title 27 of the General Laws entitled "INSURANCE" is hereby amended

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by adding thereto the following chapter:

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CHAPTER 81

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MEANINGFUL ACCESS TO ACCURATE PROVIDER DIRECTORIES

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     27-81-1. Title. – This act shall be known and may be cited as the "Meaningful Access to

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Accurate Provider Directories Act."

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     27-81-2. Purpose. – The general assembly hereby finds and declares that:

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     (1) A critical attribute of health care coverage is the network of contracted physicians and

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other health care providers, commonly referred to as the "provider network". The provider

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network is comprised of physicians and other individual or institutional health care providers who

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have contracted to "participate" by agreeing to abide by the network's rules and accept a specified

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discount off their retail charges. Physicians and other health care providers generally offer

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substantial discounts to participate in provider networks because they may receive significant

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benefits in return such as: (i) A promise of prompt payments; (ii) Increased patient volume by

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virtue of inclusion in provider directories and benefit plans that give patients a substantial

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financial incentive to go to in-network providers; and (iii) Maintenance of patient loyalty by

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meeting their patients’ request that they be "in-network".

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     (2) Because, for financial reasons, patients are most likely to obtain medical care from

 

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physicians and other health care providers who have contracted with a provider network to which

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the patient has a right of access, a provider network that does not have an adequate number of

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contracted physicians and other health care providers in each specialty and geographic region

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deprives consumers of the benefit of the money they have paid for health care coverage;

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     (3) Inadequate provider networks also undermine the public health and welfare by forcing

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consumers to reduce utilization of appropriate preventive services and fail to obtain necessary

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medical care, which in turn leads to reduced productivity and increased work absenteeism,

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unnecessary illness and increased emergency department utilization;

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     (4) To assess the appropriateness of a provider network before selecting a particular

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health insurance plan, consumers must have all the information relevant to the medical needs of

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themselves and their families, including whether their physicians and preferred hospitals are in-

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or out-of-network, whether these physicians and hospitals are still accepting new patients, and

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what the likely wait-time is for an appointment;

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     (5) Consumers also continue to need access to a robust, up-to-date provider directory to

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enable them to determine which physicians, other health care professionals and health facilities

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remain in the network as their medical needs change; and

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     (c) Physicians and other health care providers need a robust, up-to-date provider directory

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so that their network participation status is accurately reflected.

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     27-81-3. Definitions. – (a) "Contracting entity" means any person or entity that enters

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into direct contracts with providers for the delivery of health care services in the ordinary course

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of business.

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     (b) "Health care facility" means all persons or institutions, including mobile facilities

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which offer diagnosis, treatment, inpatient or ambulatory care to two (2) or more unrelated

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persons, and the buildings in which those services are offered. This includes hospitals, chronic

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disease facilities, birthing centers, psychiatric facilities, nursing homes, home health agencies,

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outpatient or independent surgical, diagnostic or therapeutic center or facility, including, but not

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limited to, kidney disease treatment centers, mental health agencies or centers, diagnostic imaging

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facilities, independent diagnostic laboratories (including independent imaging facilities), cardiac

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catheterization laboratories and radiation therapy facilities.

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     (c) "Health Care services" means services for the diagnosis, prevention, treatment or cure

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of a health condition, illness injury or disease.

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     (d) "Health insurer" means an entity or person that offers or administers a health

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insurance plan, coverage or policy in this state; or contracts with physicians and other health care

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providers to furnish specified health care services to enrollees covered under a health insurance

 

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plan or policy. "Health insurer" includes, but is not limited to, a nonprofit service corporation, a

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health maintenance organization, or an entity offering a policy of accident and sickness insurance.

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     (e) "Health insurance plan" means any hospital and medical expense incurred policy,

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nonprofit health care service plan contract, health maintenance organization subscriber contract or

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any other health care plan, policy, coverage or arrangement that pays for or furnishes medical or

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healthcare services, whether by insurance or otherwise, offered in this state.

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     (f) "Health maintenance organization" means a health maintenance organization as

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defined in chapter 41 of this title.

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     (g) "Hospital-based physician" means any physician, excluding interns and residents,

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which, as either a hospital employee or an independent contractor, provides services to patients in

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a hospital rather than at a separate physician practice, and typically includes anesthesiologists,

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radiologists, pathologists and emergency physicians, but may also include other physician

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specialists such as hospitalists, intensivists and neonatologists, among others.

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     (h) "Physician tiering" means a system that compares, rates, ranks, measures, tiers or

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classifies a physician’s or physician group's performance, quality or cost of care against objective

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standards, subjective standards or the practice of other physicians, and shall include quality

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improvement programs, pay-for-performance program, public reporting on physician

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performance or ratings and the use of tiered or narrowed networks.

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     (i) "Provider" means a physician, other health care professional, hospital, health care

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facility or other provider who/that is accredited, licensed or certified where required in the state of

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practice and performing within the scope of that accreditation, license or certification.

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     (j) "Provider directory" means a listing of every participating provider within a provider

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network.

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     (k) "Network" or "provider network" means the physicians, healthcare professionals,

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health care facilities, and ancillary health care providers with whom a health insurer is contracted

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to provide health care services to a specified group of enrollees under a health insurance plan

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offered in this state.

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     (l) "Nonprofit service corporation" means a nonprofit hospital service corporation as

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defined in chapter 19 of this title or a nonprofit medical services corporation as defined in chapter

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20 of this title.

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     (m) "Policy of accident and sickness insurance" means a policy of accident and sickness

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insurance as defined in chapter 18 of this title.

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     27-81-4. Approval required. – A health insurer that provides or seeks to market a health

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insurance plan shall first submit its provider directory to the office of the health insurance

 

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commissioner (OHIC) for review and approval. Once OHIC's initial approval has been obtained,

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approval of the updated provider directory must be obtained annually.

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     27-81-5. Provider directory requirements. – The department shall promulgate

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regulations to create a process to review each provider directory submitted pursuant to §27-81-4.

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These regulations shall require that provider directories used by all health insurers offering health

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insurance in the state of Rhode Island comply with all of the following:

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     (1) Physician information. The provider directory must list all the following information

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concerning each participating physician:

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     (i) Physician specific demographic information as follows:

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     (A) Physician name, practice address, office telephone number, and website address or

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other link to more detailed individual physician information, if available;

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     (B) Specialty and/or subspecialty information;

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     (C) Indication of whether the physician may be selected as a primary care physician;

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     (D) The physician’s license number;

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     (E) The hours that the physician is available to treat patients;

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     (F) The names and locations of the hospital(s) where the physician has medical staff

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privileges and whether those hospitals are part of the provider network;

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     (G) Whether the physician is accepting new patients;

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     (H) If applicable to the plan, information about the method used to compensate the

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physician, e.g. by indicating whether the physician is reimbursed on a fee-for-service or capitated

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basis; and

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     (I) If the provider network includes providers who have not contracted directly with the

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health insurer but through a contracting agent, the provider directory must indicate the name,

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website address, mailing address, and telephone number of any contracting agent with whom the

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provider has a direct contract;

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     (ii) A notice regarding the availability of the listed physicians. The notice must be in

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twelve (12) point type or greater and be placed in a prominent place in the directory. The notice

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shall state: "This directory does not guarantee services by a particular provider on this list. If you

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wish to receive care from any of the specific providers listed, you should contact those providers

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to be sure that they are accepting additional patients";

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     (iii) Information about how to select a primary care physician, change a primary care

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physician and how to use the primary care physician for access to other care;

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     (iv) If the network is tiered in a way that impacts enrollee obligations, enrollees shall be

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provided a conspicuous disclaimer in bold, twelve (12) point type, indicating which physicians

 

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are in which tier and how that physician tier impacts the enrollee's financial or other obligations;

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and

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     (v) If the provider directory includes the name of any physician to which the enrollee has

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no right to access on an in-network basis, the directory must contain a conspicuous disclaimer in

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bold, twelve (12) point type, which states: "This physician is not an in-network physician with

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respect to this plan."

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     (2) Other health care professionals. For each participating non-physician health care

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professional who bills independently for healthcare services, the provider directory must list that

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professional's licensure type and all of the information set forth above in subsection (1) of this

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section, to the extent that information is relevant to or available for that professional.

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     (3) Hospital/health care facility information. A provider directory must list all the

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following information about each participating hospital and other health care facility;

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     (i) Hospital/health care facility contact information as follows:

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     (A) Information concerning all contracted hospital and/or health care facility services,

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including, but not limited to, name and health facility type; address and telephone number, and

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website address, if available;

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     (B) Availability of emergency department services; and

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     (C) If the network is tiered in a way that impacts enrollee obligations, enrollees shall be

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provided clear information indicating which hospital or health facility is in which tier, and how

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that tier impacts the enrollee's financial or other obligations.

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     (ii) If the provider directory includes the name of any hospital to which the enrollee has

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no right to access on an in-network basis, the directory must contain a conspicuous disclaimer in

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bold, twelve (12) point type, which states: "This hospital is not an in-network hospital with

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respect to this plan."

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     (4) Other services information. A provider directory must list the following information,

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including relevant contact information and online links to the entities, if available:

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     (i) Participating pharmacies and pharmacy benefit managers;

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     (ii) Participating durable medical equipment providers;

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     (iii) Participating clinical laboratories; and

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     (iv) Participating ancillary service providers,

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     (5) Online graphic interactive map capability requirement. The health insurer must offer

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an online, graphic interactive map that will provide current and prospective enrollees the means

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to input a reference address and locate physicians, other health care providers, hospitals, and all

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other providers within the provider directory by name, type specialty, subspecialty and distance.

 

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All of the following shall be displayed for each provider identified by each search:

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     (i) Whether the provider is participating in the network, accepting new patients, and if the

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network is tiered, the tier to which the provider is assigned and how that impacts enrollees’

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financial or other obligations;

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     (ii) Distance from input location;

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     (iii) Provider type, specialty and/or subspecialty;

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     (iv) Provider contact information; and

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     (v) With respect to hospital-based physicians, the physician specialty, the name(s) of the

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hospital(s) where each hospital-based physician is contracted and whether each of those hospitals

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is participating in the network.

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     (6) Publication and updating of provider directory. The provider directory shall be:

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     (i) Provided to the enrollee at the time of enrollment in a downloadable or hard copy

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format, depending on the method by which the enrollee enrolled in the plan;

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     (ii) Posted on the health insurer’s public website;

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     (iii) Kept current and accurate as required by the regulations adopted by OHIC, including

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at a minimum:

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     (A) Maintenance of an easy mechanism enabling providers to update their own

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information in the directory;

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     (B) An ongoing provider survey mechanism to confirm the continued accuracy of the

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directory;

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     (C) An easy mechanism enabling enrollees to report directory errors; and

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     (D) Updating the online provider directory at least every thirty (30) days on the health

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insurer's public website.

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     27-81-6. Enforcement provisions. – A violation of this chapter constitutes an unfair and

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deceptive act or practice, in the business of insurance under this chapter. Where OHIC has found

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or it is otherwise determined that the health insurer has failed to meet any of the standards set

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forth by this law, OHIC shall do the following:

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     (1) Institute all appropriate corrective action and use any of its other enforcement powers

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to obtain the health insurer’s compliance with this section, including the imposition of

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administrative fines and other penalties; and

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     (2) Where the violations results in an enrollee's use of an out-of-network provider despite

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the enrollee's reasonable efforts to remain in network, require the health insurer to pay the non-

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contracted provider's usual, customary and reasonable charge as state on the claim form.

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     27-81-7. Private right of action. – Any provider or enrollee may bring an action in a

 

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court of appropriate jurisdiction against any individual or entity for any violation of this chapter.

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The prevailing party in such an action will be entitled to any remedies contained in this chapter

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and any other remedies available at common law, as well as reasonable attorneys' fees and costs.

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     27-81-8. Severability. – If any provision of this chapter or the application thereof to any

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person or circumstance is held invalid, such invalidity shall not affect other provisions or

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applications of the chapter which can be given effect without the invalid provision or application,

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and to this end the provisions of this chapter are declared to be severable.

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     SECTION 2. This act shall take effect upon passage.

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LC001160

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE - MEANINGFUL ACCESS TO ACCURATE PROVIDER

DIRECTORIES

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     This act would require health insurers to maintain accurate and up-to-date directories of

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all in-network providers, and to provide that information to plan enrollees.

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     This act would take effect upon passage.

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LC001160

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