Chapter 190
2009 -- H 5453 SUBSTITUTE B AS AMENDED
Enacted 11/04/09
A N A C T
RELATING TO
INSURANCE -- RENTAL NETWORK CONTRACT ARRANGEMENTS
Introduced By: Representatives Kennedy, Naughton, and Gemma
Date Introduced: February 12, 2009
It is enacted by the
General Assembly as follows:
SECTION 1. Title 27 of the General Laws entitled
"INSURANCE" is hereby amended
by adding thereto the following chapter:
CHAPTER
20.10
RENTAL
NETWORK CONTRACT ARRANGEMENTS
27-20.10-1.
Definitions. – For purposes of this chapter, the
following definitions shall
apply:
(1) "Contracting
entity" means any person or entity that enters into direct contracts with
providers for the delivery of health care services in the
ordinary course of business.
(2)
"Control" and "under common control with" shall mean
possession, directly or
indirectly, of the power to direct or cause the direction of the
management and policies of an
entity through the ownership of fifty percent (50%) or more
of the voting securities of the entity.
(3) "Covered
individual" means an individual who is covered under a health insurance
plan.
(4)
"Department" means the department of business regulation.
(5) "Direct
notification" is a written or electronic communication from a contracting
entity to a provider documenting a third-party access to a
provider network.
(6) "Health care
services" means services for the diagnosis, prevention, treatment or cure
of a health condition, illness, injury or disease.
(7)(i) "Health insurance plan" means any hospital and
medical expense incurred policy,
nonprofit health care service plan contract, health maintenance
organization subscriber contract,
or any other health care plan or arrangement that pays
for or furnishes medical or health care
services, whether by insurance or otherwise.
(ii) "Health
insurance plan" shall not include one or more, or any combination of, the
following: coverage only for accident, or disability income
insurance; coverage issued as a
supplement to liability insurance; liability insurance,
including general liability insurance and
automobile liability insurance; workers' compensation or similar
insurance; automobile medical
payment insurance; credit-only insurance; coverage for
on-site medical clinics; coverage similar
to the foregoing as specified in federal regulation
issued pursuant to P.L. No. 104-191, under
which benefits for medical care are secondary or incidental
to other insurance benefits; dental or
vision benefits; benefits for long-term care, nursing home
care, home health care, or community-
based care; specified disease or illness coverage, hospital
indemnity or other fixed indemnity
insurance, or such other similar, limited benefits as are
specified in regulations; Medicare
supplemental health insurance as defined under section 1882(g)(1)
of the Social Security Act;
coverage supplemental to the coverage provided under chapter
55 of title 10, United States Code;
or other similar limited benefit supplemental coverages.
(8)(i) "Provider" means a physician, a physician
organization, or a physician hospital
organization that is acting exclusively as an administrator on
behalf of a provider to facilitate the
provider's participation in health care contracts.
(ii)
"Provider" does not include a physician organization or physician
hospital
organization that leases or rents the physician organization's or
physician hospital organization's
network to a third-party.
(9) "Provider
network contract" means a contract between a contracting entity and a
provider specifying the rights and responsibilities of the
contracting entity and provider for the
delivery of and payment for health care services to covered
individuals.
(10)
"Third-party" means an organization that enters into a contract with
a contracting
entity or with another third-party to gain access to a
provider network contract.
27-20.10-2.
Scope. – (a) This
chapter shall apply to health insurance corporations subject
to chapter 1 of this title, nonprofit hospital or medical
service corporations subject to chapters 19
or 20 of this title, and health maintenance organization
incorporated or resident in the state of
(b) This chapter
shall not apply to provider network contracts for services provided to
Medicaid, Medicare or state
children's health insurance program (SCHIP) beneficiaries.
(c) This chapter
shall not apply in circumstances where access to the provider network
contract is granted to an entity operating under common
control with or under the same brand
licensee program as the contracting entity ("affiliate
entities"). Contracting entities shall,
however, make the list of such affiliate entities available
on a website or by other means. The
affiliate entities shall have the same rights and
responsibilities under the provider network
contracts as the contracting entities.
(d) This chapter
shall not apply to a contract between a contracting entity and a discount
medical plan organization.
(e) This chapter
shall not apply to any entity, such as employers, church plans or
government plans, receiving administrative services from the
contracting entity or an affiliate
entity. Such exempt entities shall have the same rights and
responsibilities under the provider
network contracts as the contracting entities, except the
exempt entities shall not grant access to a
provider's health care services and contractual discounts to any
other entity.
27-20.10-3.
Registration. – (a) Any
person that commences business as a contracting
entity shall register with the department within thirty (30)
days of commencing business in the
state of
passage of this chapter, each person not licensed by the
department as a contracting entity shall
register with the department within ninety (90) days of the
effective date of this chapter.
(1) Registration
shall consist of the submission of the following information:
(i)
The official name of the contracting entity, including and d/b/a designations
used in
this state;
(ii) The mailing
address and main telephone number for the contracting entity's main
headquarters; and
(iii) The name and telephone
number of the contracting entity's representative who shall
serve as the primary contact with the department.
(2) The information
required by this section shall be submitted in written or electronic
format, as prescribed by the department.
(b) The department
may collect a reasonable fee for the purpose of administering the
registration process.
27-20.10-4.
Contracting entity rights and responsibilities. – (a)
A contracting entity
may not grant access to a provider's health care services
and contractual discounts pursuant to a
provider network contract unless:
(1) The provider
network contract specifically states that the contracting entity may enter
into an agreement with a third-party allowing the
third-party to obtain the contracting entity's
rights and responsibility's under the provider network
contract as if the third-party were the
contracting entity; and
(2) The third-party
accessing the provider network contract is contractually obligated to
comply with all applicable terms, limitations and conditions
of the provider network contract.
(b) A contracting
entity that grants access to a provider's health care services and
contractual discounts pursuant to a provider network contract
shall:
(1) Identify and
provide to the provider, upon request at the time a provider network
contract is entered into with a provider, a written or
electronic list of all third-parties known at the
time of contracting, to which the contracting entity has
or will grant access to the provider's
health care services and contractual discounts pursuant to a
provider network contract;
(2) Maintain an
Internet website or other readily available mechanism, such as a toll-free
telephone number, through which a provider may obtain a
listing, updated at least every ninety
(90) days, of the
third-parties to which the contracting entity or another third-party has
executed
contracts to grant access to such provider's health care
services and contractual discounts pursuant
to a provider network contract;
(3) Provide each
third-party who contracts with the contracting entity to gain access to
the provider network contract with a summary of the
contracting entity's current standard
provider contract terms;
(4) Require that the
third-party who contracts with the contracting entity to gain access to
the provider network contract identify the source of the
contractual discount taken by the third-
party on each remittance advice (RA) or explanation of
payment (EOP) form furnished to a health
care provider when such discount is pursuant to the
contracting entity's provider network
contract;
(5)(i) Notify the third-party who contracts with the
contracting entity to gain access to the
provider network contract of the termination of the provider
network contract no later than ten
(10) days after receipt of
notice of the termination of the provider network contract;
(ii) Require those
that are by contract eligible to claim the right to access a provider’s
discounted rate to cease claiming entitlement to those rates or
other contracted rights or
obligations for services rendered after termination of the
provider network contract; and
(iii) The notice
required under paragraph (i) above can be provided
through any
reasonable means, including, but not limited to: written notice,
electronic communication, or an
update to electronic database or other provider listing.
(c) Subject to any
applicable continuity of care requirements, agreements, or contractual
provisions:
(1) A third-party’s
right to access a provider’s health care services and contractual
discounts pursuant to a provider network contract shall
terminate on the date the provider network
contract is terminated;
(2)_Claims for
health care services performed after the termination date of the provider
network contract are not eligible for processing and payment
in accordance with the provider
network contract; and
(3) Claims for health
care services performed before the termination date of the provider
network contract, but processed after the termination date,
are eligible for processing and
payment in accordance with the provider network contract.
(d)(1) All information
made available to provider in accordance with the requirements of
this chapter shall be confidential and shall not be
disclosed to any person or entity not involved in
the provider’s practice or the administration thereof
without the prior written consent of the
contracting entity.
(2) Nothing contained
in this chapter shall be construed to prohibit a contracting entity
from requiring the provider to execute a reasonable
confidentiality agreement to ensure that
confidential or proprietary information disclosed by the
contracting entity is not used for any
purpose other than the provider’s director practice
management or billing activities.
27-20.10-5.
Third-party rights and responsibilities. -- (a)
A third-party, having itself
been granted access to a provider’s health care services
and contractual discounts pursuant to a
provider network contract, that subsequently grants access to
another third-party is obligated to
comply with the rights and responsibilities imposed on contracting
entities under section 27-
20.10-4 and 27-20.10-6.
(b) A third-party
that enters into a contract with another third-party to access a provider’s
health care services and contractual discounts pursuant to a
provider network contract is obligated
to comply with the rights and responsibilities imposed
on third-parties under this section 27-
20.10-5.
(c)(1) A third-party
will provide to the contracting entity the location of a website, or
identify another readily available mechanism such as a
toll-free telephone number, which the
contracting entity will make available to the providers under the
provider network contract
accessed through the contracting entity. The website or other
readily available mechanism will
identify the name of the person or entity to which the
third-party subsequently grants access to the
provider’s health care services and contractual discounts
pursuant to the provider network
contract.
(2) The website will
allow the providers under the contracting entity’s provider network
contract access to the information referenced in (c)(1) above,
and will be updated on a routine
basis as additional persons or entities are granted access.
The website must be updated to reflect
all current persons and entities with access every ninety
(90) days. Upon request, a contracting
entity shall make updated access information available to a
provider via telephone or through
direct notification.
27-20.10-6. Unauthorized access to provider network contracts. --
(a) It is an unfair
insurance practice for the purposes of chapter 27-29 of the
knowingly access or utilize a provider’s contractual discount
pursuant to a provider network
contract without a contractual relationship with the provider,
contracting entity, or third-party, as
specified in this chapter;
(b) Contracting entities and third-parties are obligated to comply with subdivisions 27-
20.10-4(b)(2) or 27-20.10-5(c)(1) and (2) concerning the services referenced on a remittance
advice (RA) or explanation of payment (EOP). A provider may refuse the discount taken on the
(RA) or (EOP) if the discount is taken without a contractual basis or in violation of these sections.
However, an error in the (RA) or (EOP) may be corrected within thirty (30) days following notice
by the provider.
(c) A contracting
entity may not lease, rent, or otherwise grant to a third-party, access to
a provider network contract unless the third-party
accessing the health care contract is:
(1) A payer or
third-party administrator or another entity that administers or processes
claims on behalf of the payer;
(2) A preferred
provider organization or preferred provider network, including a
physician organization or physician-hospital organization; or
(3) An entity engaged
in the electronic claims transport between the contracting entity
and the payer that does not provide access to the
provider’s services and discount to any other
third-party.
27-20.10-7.
Enforcement. – Enforcement of this model will
follow that of chapter 27-29
of the
SECTION 2. This act shall take effect as of January 1, 2010
and shall apply to provider
network contracts entered into or materially amended on or
after said date.
=======
LC01039/SUB B
=======