2022 -- H 7077

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LC003682

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2022

____________

A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

     Introduced By: Representatives Edwards, Fogarty, Bennett, Baginski, and Shanley

     Date Introduced: January 12, 2022

     Referred To: House Health & Human Services

     It is enacted by the General Assembly as follows:

     SECTION 1. Section 27-18-76 of the General Laws in Chapter 27-18 entitled "Accident

and Sickness Insurance Policies" is hereby amended to read as follows:

     27-18-76. Emergency services.

     (a) As used in this section:

     (1) "Emergency medical condition" means a medical condition manifesting itself by acute

symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses

an average knowledge of health and medicine, could reasonably expect the absence of immediate

medical attention to result in a condition: (i) Placing the health of the individual, or with respect to

a pregnant woman her unborn child, in serious jeopardy; (ii) Constituting a serious impairment to

bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or part.

     (2) "Emergency services" means, with respect to an emergency medical condition:

     (A) A medical screening examination (as required under section 1867 of the Social Security

Act, 42 U.S.C. § 1395dd) that is within the capability of the emergency department of a hospital,

including ancillary services routinely available to the emergency department to evaluate such

emergency medical condition, and

     (B) Such further medical examination and treatment, to the extent they are within the

capabilities of the staff and facilities available at the hospital, as are required under section 1867 of

the Social Security Act (42 U.S.C. § 1395dd) to stabilize the patient.

     (3) "Stabilize," with respect to an emergency medical condition has the meaning given in

§ 1867(e)(3) of the Social Security Act (42 U.S.C. § 1395dd(e)(3)).

     (b) If a health insurance carrier offering health insurance coverage provides any benefits

with respect to services in an emergency department of a hospital, the carrier must cover emergency

services in compliance with this section.

     (c) A health insurance carrier shall provide coverage for emergency services in the

following manner:

     (1) Without the need for any prior authorization determination, even if the emergency

services are provided on an out-of-network basis;

     (2) Without regard to whether the healthcare provider furnishing the emergency services is

a participating network provider with respect to the services;

     (3) If the emergency services are provided out of network, without imposing any

administrative requirement or limitation on coverage that is more restrictive than the requirements

or limitations that apply to emergency services received from in-network providers;

     (4) If the emergency services are provided out of network, by complying with the cost-

sharing requirements of subsection (d) of this section; and

     (5) Without regard to any other term or condition of the coverage, other than:

     (A) The exclusion of or coordination of benefits;

     (B) An affiliation or waiting period permitted under part 7 of federal ERISA, part A of title

XXVII of the federal PHS Act, or chapter 100 of the federal Internal Revenue Code; or

     (C) Applicable cost-sharing.

     (d)(1) Any cost-sharing requirement expressed as a copayment amount or coinsurance rate

imposed with respect to a participant or beneficiary for out-of-network emergency services cannot

exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if the

services were provided in-network; provided, however, that a participant or beneficiary may be

required to pay, in addition to the in-network cost-sharing, the excess of the amount the out-of-

network provider charges over the amount the health insurance carrier is required to pay under

subdivision (1) of this subsection shall incur no greater out-of-pocket costs for the emergency

services than the participant or beneficiary would have incurred with an in-network provider other

than the in-network cost sharing. A health insurance carrier complies with the requirements of this

subsection if it provides benefits with respect to an emergency service in an amount equal to the

greatest of the three amounts specified in subdivisions (A), (B), and (C) of this subdivision (1)

(which are adjusted for in-network cost-sharing requirements).

     (A) The amount negotiated with in-network providers for the emergency service furnished,

excluding any in-network copayment or coinsurance imposed with respect to the participant or

LC003682 - Page 2 of 12

beneficiary. If there is more than one amount negotiated with in-network providers for the

emergency service, the amount described under this subdivision (A) is the median of these amounts,

excluding any in-network copayment or coinsurance imposed with respect to the participant or

beneficiary. In determining the median described in the preceding sentence, the amount negotiated

with each in-network provider is treated as a separate amount (even if the same amount is paid to

more than one provider). If there is no per-service amount negotiated with in-network providers

(such as under a capitation or other similar payment arrangement), the amount under this

subdivision (A) is disregarded.

     (B) The amount for the emergency service shall be calculated using the same method the

plan generally uses to determine payments for out-of-network services (such as the usual,

customary, and reasonable amount), excluding any in-network copayment or coinsurance imposed

with respect to the participant or beneficiary. The amount in this subdivision (B) is determined

without reduction for out-of-network cost-sharing that generally applies under the plan or health

insurance coverage with respect to out-of-network services.

     (C) The amount that would be paid under Medicare (part A or part B of title XVIII of the

Social Security Act, 42 U.S.C. § 1395 et seq.) for the emergency service, excluding any in-network

copayment or coinsurance imposed with respect to the participant or beneficiary.

     (2) Any cost-sharing requirement other than a copayment or coinsurance requirement (such

as a deductible or out-of-pocket maximum) may be imposed with respect to emergency services

provided out of network if the cost-sharing requirement generally applies to out-of-network

benefits. A deductible may be imposed with respect to out-of-network emergency services only as

part of a deductible that generally applies to out-of-network benefits. If an out-of-pocket maximum

generally applies to out-of-network benefits, that out-of-pocket maximum must apply to out-of-

network emergency services.

     (e) The provisions of this section apply for plan years beginning on or after September 23,

2010.

     (f) This section shall not apply to grandfathered health plans. This section shall not apply

to insurance coverage providing benefits for: (1) hospital confinement indemnity; (2) disability

income; (3) accident only; (4) long term care; (5) Medicare supplement; (6) limited benefit health;

(7) specified disease indemnity; (8) sickness or bodily injury or death by accident or both; and (9)

other limited benefit policies.

     SECTION 2. Section 27-19-66 of the General Laws in Chapter 27-19 entitled "Nonprofit

Hospital Service Corporations" is hereby amended to read as follows:

     27-19-66. Emergency services.

LC003682 - Page 3 of 12

     (a) As used in this section:

     (1) "Emergency medical condition" means a medical condition manifesting itself by acute

symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses

an average knowledge of health and medicine, could reasonably expect the absence of immediate

medical attention to result in a condition: (i) Placing the health of the individual, or with respect to

a pregnant woman her unborn child, in serious jeopardy; (ii) Constituting a serious impairment to

bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or part.

     (2) "Emergency services" means, with respect to an emergency medical condition:

     (A) A medical screening examination (as required under section 1867 of the Social Security

Act, 42 U.S.C. § 1395dd) that is within the capability of the emergency department of a hospital,

including ancillary services routinely available to the emergency department to evaluate such

emergency medical condition, and

     (B) Such further medical examination and treatment, to the extent they are within the

capabilities of the staff and facilities available at the hospital, as are required under section 1867 of

the Social Security Act (42 U.S.C. § 1395dd) to stabilize the patient.

     (3) "Stabilize," with respect to an emergency medical condition has the meaning given in

section 1867(e)(3) of the Social Security Act (42 U.S.C. § 1395dd(e)(3)).

     (b) If a nonprofit hospital service corporation provides any benefits to subscribers with

respect to services in an emergency department of a hospital, the plan must cover emergency

services consistent with the rules of this section.

     (c) A nonprofit hospital service corporation shall provide coverage for emergency services

in the following manner:

     (1) Without the need for any prior authorization determination, even if the emergency

services are provided on an out-of-network basis;

     (2) Without regard to whether the healthcare provider furnishing the emergency services is

a participating network provider with respect to the services;

     (3) If the emergency services are provided out of network, without imposing any

administrative requirement or limitation on coverage that is more restrictive than the requirements

or limitations that apply to emergency services received from in-network providers;

     (4) If the emergency services are provided out of network, by complying with the cost-

sharing requirements of subsection (d) of this section; and

     (5) Without regard to any other term or condition of the coverage, other than:

     (A) The exclusion of or coordination of benefits;

     (B) An affiliation or waiting period permitted under part 7 of federal ERISA, part A of title

LC003682 - Page 4 of 12

XXVII of the federal PHS Act, or chapter 100 of the federal Internal Revenue Code; or

     (C) Applicable cost sharing.

     (d)(1) Any cost-sharing requirement expressed as a copayment amount or coinsurance rate

imposed with respect to a participant or beneficiary for out-of-network emergency services cannot

exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if the

services were provided in-network. However, a participant or beneficiary may be required to pay,

in addition to the in-network cost sharing, the excess of the amount the out-of-network provider

charges over the amount the plan or health insurance carrier is required to pay under subdivision

(1) of this subsection shall incur no greater out-of-pocket costs for the emergency services than the

participant or beneficiary would have incurred with an in-network provider other than the in-

network cost sharing. A group health plan or health insurance carrier complies with the

requirements of this subsection if it provides benefits with respect to an emergency service in an

amount equal to the greatest of the three amounts specified in subdivisions (A), (B), and (C) of this

subdivision (1) (which are adjusted for in-network cost-sharing requirements).

     (A) The amount negotiated with in-network providers for the emergency service furnished,

excluding any in-network copayment or coinsurance imposed with respect to the participant or

beneficiary. If there is more than one amount negotiated with in-network providers for the

emergency service, the amount described under this subdivision (A) is the median of these amounts,

excluding any in-network copayment or coinsurance imposed with respect to the participant or

beneficiary. In determining the median described in the preceding sentence, the amount negotiated

with each in-network provider is treated as a separate amount (even if the same amount is paid to

more than one provider). If there is no per-service amount negotiated with in-network providers

(such as under a capitation or other similar payment arrangement), the amount under this

subdivision (A) is disregarded.

     (B) The amount for the emergency service shall be calculated using the same method the

plan generally uses to determine payments for out-of-network services (such as the usual,

customary, and reasonable amount), excluding any in-network copayment or coinsurance imposed

with respect to the participant or beneficiary. The amount in this subdivision (B) is determined

without reduction for out-of-network cost sharing that generally applies under the plan or health

insurance coverage with respect to out-of-network services. Thus, for example, if a plan generally

pays seventy percent (70%) of the usual, customary, and reasonable amount for out-of-network

services, the amount in this subdivision (B) for an emergency service is the total, that is, one

hundred percent (100%), of the usual, customary, and reasonable amount for the service, not

reduced by the thirty percent (30%) coinsurance that would generally apply to out-of-network

LC003682 - Page 5 of 12

services (but reduced by the in-network copayment or coinsurance that the individual would be

responsible for if the emergency service had been provided in-network).

     (C) The amount that would be paid under Medicare (part A or part B of title XVIII of the

Social Security Act, 42 U.S.C. § 1395 et seq.) for the emergency service, excluding any in-network

copayment or coinsurance imposed with respect to the participant or beneficiary.

     (2) Any cost-sharing requirement other than a copayment or coinsurance requirement (such

as a deductible or out-of-pocket maximum) may be imposed with respect to emergency services

provided out of network if the cost-sharing requirement generally applies to out-of-network

benefits. A deductible may be imposed with respect to out-of-network emergency services only as

part of a deductible that generally applies to out-of-network benefits. If an out-of-pocket maximum

generally applies to out-of-network benefits, that out-of-pocket maximum must apply to out-of-

network emergency services.

     (e) The provisions of this section apply for plan years beginning on or after September 23,

2010.

     (f) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare

supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily

injury or death by accident or both; and (9) Other limited benefit policies.

     SECTION 3. Section 27-20-62 of the General Laws in Chapter 27-20 entitled "Nonprofit

Medical Service Corporations" is hereby amended to read as follows:

     27-20-62. Emergency services.

     (a) As used in this section:

     (1) "Emergency medical condition" means a medical condition manifesting itself by acute

symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses

an average knowledge of health and medicine, could reasonably expect the absence of immediate

medical attention to result in a condition: (i) Placing the health of the individual, or with respect to

a pregnant woman her unborn child, in serious jeopardy; (ii) Constituting a serious impairment to

bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or part.

     (2) "Emergency services" means, with respect to an emergency medical condition:

     (A) A medical screening examination (as required under section 1867 of the Social Security

Act, 42 U.S.C. § 1395dd) that is within the capability of the emergency department of a hospital,

including ancillary services routinely available to the emergency department to evaluate such

emergency medical condition, and

     (B) Such further medical examination and treatment, to the extent they are within the

LC003682 - Page 6 of 12

capabilities of the staff and facilities available at the hospital, as are required under section 1867 of

the Social Security Act (42 U.S.C. § 1395dd) to stabilize the patient.

     (3) "Stabilize," with respect to an emergency medical condition has the meaning given in

section 1867(e)(3) of the Social Security Act (42 U.S.C. § 1395dd(e)(3)).

     (b) If a nonprofit medical service corporation offering health insurance coverage provides

any benefits with respect to services in an emergency department of a hospital, it must cover

emergency services consistent with the rules of this section.

     (c) A nonprofit medical service corporation shall provide coverage for emergency services

in the following manner:

     (1) Without the need for any prior authorization determination, even if the emergency

services are provided on an out-of-network basis;

     (2) Without regard to whether the healthcare provider furnishing the emergency services is

a participating network provider with respect to the services;

     (3) If the emergency services are provided out of network, without imposing any

administrative requirement or limitation on coverage that is more restrictive than the requirements

or limitations that apply to emergency services received from in-network providers;

     (4) If the emergency services are provided out of network, by complying with the cost-

sharing requirements of subsection (d) of this section; and

     (5) Without regard to any other term or condition of the coverage, other than:

     (A) The exclusion of or coordination of benefits;

     (B) An affiliation or waiting period permitted under part 7 of federal ERISA, part A of title

XXVII of the federal PHS Act, or chapter 100 of the federal Internal Revenue Code; or

     (C) Applicable cost-sharing.

     (d)(1) Any cost-sharing requirement expressed as a copayment amount or coinsurance rate

imposed with respect to a participant or beneficiary for out-of-network emergency services cannot

exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if the

services were provided in-network. However, a participant or beneficiary may be required to pay,

in addition to the in-network cost sharing, the excess of the amount the out-of-network provider

charges over the amount the plan or health insurance carrier is required to pay under subdivision

(1) of this subsection shall incur no greater out-of-pocket costs for the emergency services than the

participant or beneficiary would have incurred with an in-network provider other than the in-

network cost sharing. A group health plan or health insurance carrier complies with the

requirements of this subsection if it provides benefits with respect to an emergency service in an

amount equal to the greatest of the three amounts specified in subdivisions (A), (B), and (C) of this

LC003682 - Page 7 of 12

subdivision (1) (which are adjusted for in-network cost-sharing requirements).

     (A) The amount negotiated with in-network providers for the emergency service furnished,

excluding any in-network copayment or coinsurance imposed with respect to the participant or

beneficiary. If there is more than one amount negotiated with in-network providers for the

emergency service, the amount described under this subdivision (A) is the median of these amounts,

excluding any in-network copayment or coinsurance imposed with respect to the participant or

beneficiary. In determining the median described in the preceding sentence, the amount negotiated

with each in-network provider is treated as a separate amount (even if the same amount is paid to

more than one provider). If there is no per-service amount negotiated with in-network providers

(such as under a capitation or other similar payment arrangement), the amount under this

subdivision (A) is disregarded.

     (B) The amount for the emergency service shall be calculated using the same method the

plan generally uses to determine payments for out-of-network services (such as the usual,

customary, and reasonable amount), excluding any in-network copayment or coinsurance imposed

with respect to the participant or beneficiary. The amount in this subdivision (B) is determined

without reduction for out-of-network cost-sharing that generally applies under the plan or health

insurance coverage with respect to out-of-network services.

     (C) The amount that would be paid under Medicare (part A or part B of title XVIII of the

Social Security Act, 42 U.S.C. § 1395 et seq.) for the emergency service, excluding any in-network

copayment or coinsurance imposed with respect to the participant or beneficiary.

     (2) Any cost-sharing requirement other than a copayment or coinsurance requirement (such

as a deductible or out-of-pocket maximum) may be imposed with respect to emergency services

provided out of network if the cost-sharing requirement generally applies to out-of-network

benefits. A deductible may be imposed with respect to out-of-network emergency services only as

part of a deductible that generally applies to out-of-network benefits. If an out-of-pocket maximum

generally applies to out-of-network benefits, that out-of-pocket maximum must apply to out-of-

network emergency services.

     (f) The provisions of this section shall apply to grandfathered health plans. This section

shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity;

(2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6) Limited

benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by accident

or both; and (9) Other limited benefit policies.

     SECTION 4. Section 27-41-79 of the General Laws in Chapter 27-41 entitled "Health

Maintenance Organizations" is hereby amended to read as follows:

LC003682 - Page 8 of 12

     27-41-79. Emergency services.

     (a) As used in this section:

     (1) "Emergency medical condition" means a medical condition manifesting itself by acute

symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses

an average knowledge of health and medicine, could reasonably expect the absence of immediate

medical attention to result in a condition: (i) Placing the health of the individual, or with respect to

a pregnant woman her unborn child in serious jeopardy; (ii) Constituting a serious impairment to

bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or part.

     (2) "Emergency services" means, with respect to an emergency medical condition:

     (A) A medical screening examination (as required under section 1867 of the Social Security

Act, 42 U.S.C. § 1395dd) that is within the capability of the emergency department of a hospital,

including ancillary services routinely available to the emergency department to evaluate such

emergency medical condition, and

     (B) Such further medical examination and treatment, to the extent they are within the

capabilities of the staff and facilities available at the hospital, as are required under section 1867 of

the Social Security Act (42 U.S.C. § 1395dd) to stabilize the patient.

     (3) "Stabilize," with respect to an emergency medical condition has the meaning given in

section 1867(e)(3) of the Social Security Act (42 U.S.C. § 1395dd(e)(3)).

     (b) If a health maintenance organization offering group health insurance coverage provides

any benefits with respect to services in an emergency department of a hospital, it must cover

emergency services consistent with the rules of this section.

     (c) A health maintenance organization shall provide coverage for emergency services in

the following manner:

     (1) Without the need for any prior authorization determination, even if the emergency

services are provided on an out-of-network basis;

     (2) Without regard to whether the healthcare provider furnishing the emergency services is

a participating network provider with respect to the services;

     (3) If the emergency services are provided out of network, without imposing any

administrative requirement or limitation on coverage that is more restrictive than the requirements

or limitations that apply to emergency services received from in-network providers;

     (4) If the emergency services are provided out of network, by complying with the cost-

sharing requirements of subsection (d) of this section; and

     (5) Without regard to any other term or condition of the coverage, other than:

     (A) The exclusion of or coordination of benefits;

LC003682 - Page 9 of 12

     (B) An affiliation or waiting period permitted under part 7 of federal ERISA, part A of title

XXVII of the federal PHS Act, or chapter 100 of the federal Internal Revenue Code; or

     (C) Applicable cost sharing.

     (d)(1) Any cost-sharing requirement expressed as a copayment amount or coinsurance rate

imposed with respect to a participant or beneficiary for out-of-network emergency services cannot

exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if the

services were provided in-network; provided, however, that a participant or beneficiary may be

required to pay, in addition to the in-network cost sharing, the excess of the amount the out-of-

network provider charges over the amount the plan or health maintenance organization is required

to pay under subdivision (1) of this subsection shall incur no greater out-of-pocket costs for the

emergency services than the participant or beneficiary would have incurred with an in-network

provider other than the in-network cost sharing. A health maintenance organization complies with

the requirements of this subsection if it provides benefits with respect to an emergency service in

an amount equal to the greatest of the three amounts specified in subdivisions (A), (B), and (C) of

this subdivision (1) (which are adjusted for in-network cost-sharing requirements).

     (A) The amount negotiated with in-network providers for the emergency service furnished,

excluding any in-network copayment or coinsurance imposed with respect to the participant or

beneficiary. If there is more than one amount negotiated with in-network providers for the

emergency service, the amount described under this subdivision (A) is the median of these amounts,

excluding any in-network copayment or coinsurance imposed with respect to the participant or

beneficiary. In determining the median described in the preceding sentence, the amount negotiated

with each in-network provider is treated as a separate amount (even if the same amount is paid to

more than one provider). If there is no per-service amount negotiated with in-network providers

(such as under a capitation or other similar payment arrangement), the amount under this

subdivision (A) is disregarded.

     (B) The amount for the emergency service calculated using the same method the plan

generally uses to determine payments for out-of-network services (such as the usual, customary,

and reasonable amount), excluding any in-network copayment or coinsurance imposed with respect

to the participant or beneficiary. The amount in this subdivision (B) is determined without reduction

for out-of-network cost sharing that generally applies under the plan or health insurance coverage

with respect to out-of-network services.

     (C) The amount that would be paid under Medicare (part A or part B of title XVIII of the

Social Security Act, 42 U.S.C. § 1395 et seq.) for the emergency service, excluding any in-network

copayment or coinsurance imposed with respect to the participant or beneficiary.

LC003682 - Page 10 of 12

     (2) Any cost-sharing requirement other than a copayment or coinsurance requirement (such

as a deductible or out-of-pocket maximum) may be imposed with respect to emergency services

provided out of network if the cost-sharing requirement generally applies to out-of-network

benefits. A deductible may be imposed with respect to out-of-network emergency services only as

part of a deductible that generally applies to out-of-network benefits. If an out-of-pocket maximum

generally applies to out-of-network benefits, that out-of-pocket maximum must apply to out-of-

network emergency services.

     (e) The provisions of this section apply for plan years beginning on or after September 23,

2010.

     (f) The provisions of this section shall apply to grandfathered health plans. This section

shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity;

(2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6) Limited

benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by accident

or both; and (9) Other limited benefit policies.

     SECTION 5. This act shall take effect upon passage.

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LC003682

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

***

     This act would require that a participant or beneficiary of a health insurance plan incur no

greater out-of-pocket costs for emergency services than they would have incurred with an in-

network provider other than in-network cost sharing.

     This act would take effect upon passage.

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LC003682

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LC003682 - Page 12 of 12