Chapter 256
2012 -- H 7909 SUBSTITUTE A
Enacted 06/18/12
A N A C T
RELATING TO
INSURANCE -- HEALTH INSURANCE - CONSUMER PROTECTION
Introduced
By: Representatives Kennedy, San Bento,
Date Introduced: March 07, 2012
It is enacted by the
General Assembly as follows:
SECTION
1. Purpose and intent.
It is the purpose of
this act to amend
health insurance consumer protections enacted in
federal law. This act is intended to establish
health insurance rules, standards, and policies
pursuant to, and in furtherance of, the health
insurance standards established in the federal Patient
Protection and Affordable Care Act of 2010,
as amended by the federal Health Care and Education
Reconciliation Act of 2010.
SECTION
2. Chapter 27-18 of the General laws entitled "Accident and Sickness
Insurance Policies" is
hereby amended by adding thereto the following sections:
27-18-1.1.
Definitions. – As used in this chapter:
(1) “Adverse benefit
determination” means any of the following: a denial, reduction, or
termination of, or a failure to provide or make
payment (in whole or in part) for, a benefit,
including any such denial, reduction, termination, or
failure to provide or make payment that is
based on a determination of an individual’s
eligibility to participate in a plan or to receive
coverage under a plan, and including, with respect to
group health plans, a denial, reduction, or
termination of, or a failure to provide or make
payment (in whole or in part) for, a benefit
resulting from the application of any utilization
review, as well as a failure to cover an item or
service for which benefits are otherwise provided
because it is determined to be experimental or
investigational or not medically necessary or
appropriate. The term also includes a rescission of
coverage determination.
(2) “Affordable Care
Act” means the federal Patient Protection and Affordable Care Act
of 2010, as amended by the federal Health Care and
Education Reconciliation Act of 2010, and
federal regulations adopted thereunder.
(3) “Commissioner” or
“health insurance commissioner” means that individual appointed
pursuant to section 42-14.5-1 of the general laws.
(4) “Essential health
benefits” shall have the meaning set forth in section 1302(b) of the
federal Affordable Care Act,
(5) “Grandfathered
health plan” means any group health plan or health insurance
coverage subject to 42 USC section 18011.
(6) “Group health
insurance coverage” means, in connection with a group health plan,
health insurance coverage offered in connection with
such plan.
(7) “Group health
plan” means an employee welfare benefit plan, as defined in 29 USC
section 1002(1), to the extent that the plan provides
health benefits to employees or their
dependents directly or through insurance,
reimbursement, or otherwise.
(8) “Health benefits”
or “covered benefits” means coverage or benefits for the diagnosis,
cure, mitigation, treatment, or prevention of disease,
or amounts paid for the purpose of affecting
any structure or function of the body including
coverage or benefits for transportation primarily
for and essential thereto, and including medical
services as defined in R.I. Gen. Laws § 27-19-17;
(9) “Health care
facility” means an institution providing health care services or a health
care setting, including, but not limited to, hospitals
and other licensed inpatient centers,
ambulatory surgical or treatment centers, skilled
nursing centers, residential treatment centers,
diagnostic, laboratory and imaging centers, and
rehabilitation and other therapeutic health
settings.
(10) “Health care
professional” means a physician or other health care practitioner
licensed, accredited or certified to perform specified
health care services consistent with state
law.
(11) “Health care
provider” or "provider" means a health care professional or a health
care facility.
(12) “Health care
services” means services for the diagnosis, prevention, treatment, cure
or relief of a health condition, illness, injury or
disease.
(13) “Health
insurance carrier” means a person, firm, corporation or other entity subject
to the jurisdiction of the commissioner under this
chapter. Such term does not include a group
health plan.
(14) “Health plan” or
“health benefit plan” means health insurance coverage and a group
health plan, including coverage provided through an
association plan if it covers
residents. Except to the extent specifically provided
by the federal Affordable Care Act, the term
“health plan” shall not include a group health plan to
the extent state regulation of the health plan
is pre-empted under section 514 of the federal
Employee Retirement Income Security Act of
1974. The term also shall not include:
(A)(i) Coverage only for accident, or disability income
insurance, or any combination
thereof.
(ii) Coverage issued
as a supplement to liability insurance.
(iii) Liability
insurance, including general liability insurance and automobile liability
insurance.
(iv) Workers’
compensation or similar insurance.
(v) Automobile
medical payment insurance.
(vi) Credit-only
insurance.
(vii) Coverage for
on-site medical clinics.
(viii) Other similar
insurance coverage, specified in federal regulations issued pursuant to
Pub. L. No. 104-191, the federal health insurance
portability and accountability act of 1996
(“HIPAA”), under which benefits for medical care are
secondary or incidental to other insurance
benefits.
(B) The following
benefits if they are provided under a separate policy, certificate or
contract of insurance or are otherwise not an integral
part of the plan:
(i)
Limited scope dental or vision benefits.
(ii) Benefits for
long-term care, nursing home care, home health care, community-based
care, or any combination thereof.
(iii) Other excepted
benefits specified in federal regulations issued pursuant to federal
Pub. L. No. 104-191 (“HIPAA”).
(C) The following
benefits if the benefits are provided under a separate policy, certificate
or contract of insurance, there is no coordination
between the provision of the benefits and any
exclusion of benefits under any group health plan
maintained by the same plan sponsor, and the
benefits are paid with respect to an event without
regard to whether benefits are provided with
respect to such an event under any group health plan
maintained by the same plan sponsor:
(i)
Coverage only for a specified disease or illness.
(ii) Hospital
indemnity or other fixed indemnity insurance.
(D) The following if
offered as a separate policy, certificate or contract of insurance:
(i)
Medicare supplement health insurance as defined under section 1882(g)(1) of the
federal Social Security Act.
(ii) Coverage
supplemental to the coverage provided under chapter 55 of title 10, United
States Code (Civilian Health and Medical Program of
the Uniformed Services (CHAMPUS)).
(iii) Similar
supplemental coverage provided to coverage under a group health plan.
(15) "Office of
the health insurance commissioner" means the agency established under
section 42-14.5-1 of the General laws.
(16)
“Rescission" means a cancellation or discontinuance of coverage that has
retroactive
effect for reasons unrelated to timely payment of
required premiums or contribution to costs of
coverage.
27-18-2.1. Uniform
explanation of benefits and coverage. – (a) A health insurance
carrier shall provide a summary of benefits and
coverage explanation and definitions to
policyholders and others required by, and at the times
and in the format required, by the federal
regulations adopted under section 2715 of the Public
Health Service Act, as amended by the
federal Affordable Care Act. The forms required by
this section shall be made available to the
commissioner on request. Nothing in this section shall
be construed to limit the authority of the
commissioner under existing state law.
(b) 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.
(c) If the
commissioner of the office of the health insurance commissioner determines
that the corresponding provision of the federal
Patient Protection and Affordable Care Act has
been declared invalid by a final judgment of the
federal judicial branch or has been repealed by
an act of Congress, on the date of the commissioner’s
determination this section shall have its
effectiveness suspended indefinitely, and the
commissioner shall take no action to enforce this
section. Nothing in this section shall be construed to
limit the authority of the commissioner
under existing state law.
27-18-71.
Prohibition on preexisting condition exclusions. – (a) A health
insurance
policy, subscriber contract, or health plan offered,
issued, issued for delivery, or issued to cover a
resident of this state by a health insurance company
licensed pursuant to this title and/or chapter:
(1) Shall not limit
or exclude coverage for an individual under the age of nineteen (19) by
imposing a preexisting condition exclusion on that
individual.
(2) For plan or
policy years beginning on or after January 1, 2014, shall not limit or
exclude coverage for any individual by imposing a
preexisting condition exclusion on that
individual.
(b) As used in this
section:
(1) “Preexisting
condition exclusion” means a limitation or exclusion of benefits,
including a denial of coverage, based on the fact that
the condition (whether physical or mental)
was present before the effective date of coverage, or
if the coverage is denied, the date of denial,
under a health benefit plan whether or not any medical
advice, diagnosis, care or treatment was
recommended or received before the effective date of
coverage.
(2) “Preexisting
condition exclusion” means any limitation or exclusion of benefits,
including a denial of coverage, applicable to an
individual as a result of information relating to an
individual’s health status before the individual’s
effective date of coverage, or if the coverage is
denied, the date of denial, under the health benefit
plan, such as a condition (whether physical or
mental) identified as a result of a pre-enrollment
questionnaire or physical examination given to
the individual, or review of medical records relating
to the pre-enrollment period.
(c) This section
shall not apply to grandfathered health plans providing individual health
insurance coverage.
(d) 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.
27-18-72.
Prohibition on rescission of coverage. – (a)(1) Coverage under
a health
benefit plan subject to the jurisdiction of the
commissioner under this chapter with respect to an
individual, including a group to which the individual
belongs or family coverage in which the
individual is included, shall not be rescinded after
the individual is covered under the plan,
unless:
(A) The individual or
a person seeking coverage on behalf of the individual, performs an
act, practice or omission that constitutes fraud; or
(B) The individual
makes an intentional misrepresentation of material fact, as prohibited
by the terms of the plan or coverage.
(2) For purposes of
paragraph (a)(1)(A), a person seeking coverage on behalf of an
individual does not include an insurance producer or
employee or authorized representative of the
health carrier.
(b) At least thirty
(30) days advance written notice shall be provided to each health
benefit plan enrollee or, for individual health
insurance coverage, primary subscriber, who would
be affected by the proposed rescission of coverage before
coverage under the plan may be
rescinded in accordance with subsection (a) regardless
of, in the case of group health insurance
coverage, whether the rescission applies to the entire
group or only to an individual within the
group.
(c) For purposes of
this section, “to rescind” means to cancel or to discontinue coverage
with retroactive effect for reasons unrelated to
timely payment of required premiums or
contribution to costs of coverage.
(d) This section
applies to grandfathered health plans.
27-18-73.
Prohibition on annual and lifetime limits. – (a) Annual limits.
(1) For plan or
policy years beginning prior to January 1, 2014, for any individual, a
health insurance carrier and a health benefit plan
subject to the jurisdiction of the commissioner
under this chapter may establish an annual limit on
the dollar amount of benefits that are essential
health benefits provided the restricted annual limit
is not less than the following:
(A) For a plan or
policy year beginning after September 22, 2011, but before September
23, 2012 – one million two hundred fifty thousand
dollars ($1,250,000); and
(B) For a plan or
policy year beginning after September 22, 2012, but before January 1,
2014 – two million dollars ($2,000,000).
(2) For plan or
policy years beginning on or after January 1, 2014, a health insurance
carrier and a health benefit plan shall not establish
any annual limit on the dollar amount of
essential health benefits for any individual, except:
(A) A health flexible
spending arrangement, as defined in Section 106(c)(2)(i)
of the
Federal Internal Revenue Code, a medical savings
account, as defined in section 220 of the
federal Internal Revenue Code, and a health savings account,
as defined in Section 223 of the
federal Internal Revenue Code are not subject to the
requirements of subdivisions (1) and (2) of
this subsection.
(B) The provisions of
this subsection shall not prevent a health insurance carrier and a
health benefit plan from placing annual dollar limits
for any individual on specific covered
benefits that are not essential health benefits to the
extent that such limits are otherwise permitted
under applicable federal law or the laws and regulations
of this state.
(3) In determining
whether an individual has received benefits that meet or exceed the
allowable limits, as provided in subdivision (1) of
this subsection, a health insurance carrier and a
health benefit plan shall take into account only
essential health benefits.
(b) Lifetime limits.
(1) A health
insurance carrier and health benefit plan offering group or individual health
insurance coverage shall not establish a lifetime
limit on the dollar value of essential health
benefits for any individual.
(2) Notwithstanding
subdivision (1) above, a health insurance carrier and health benefit
plan is not prohibited from placing lifetime dollar
limits for any individual on specific covered
benefits that are not essential health benefits, in
accordance with federal laws and regulations.
(c)(1) The provisions
of this section relating to lifetime limits apply to any health
insurance carrier providing coverage under an
individual or group health plan, including
grandfathered health plans.
(2) The provisions of
this section relating to annual limits apply to any health insurance
carrier providing coverage under a group health plan,
including grandfathered health plans, but
the prohibition and limits on annual limits do not
apply to grandfathered health plans providing
individual health insurance coverage.
(d) This section
shall not apply to a plan or to policy years prior to January 1, 2014 for
which the Secretary of the
pursuant to 45 C.F.R. § 147.126(d)(3). This section
also 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.
(e) If the
commissioner of the office of the health insurance commissioner determines
that the corresponding provision of the federal
Patient Protection and Affordable Care Act has
been declared invalid by a final judgment of the
federal judicial branch or has been repealed by
an act of Congress, on the date of the commissioner’s
determination this section shall have its
effectiveness suspended indefinitely, and the
commissioner shall take no action to enforce this
section. Nothing in this subsection shall be construed
to limit the authority of the Commissioner
to regulate health insurance under existing state law.
27-18-74. Coverage
for individuals participating in approved clinical trials. – (a)
As
used in this section,
(1) “Approved
clinical trial” means a phase I, phase II, phase III or phase IV clinical trial
that is conducted in relation to the prevention,
detection or treatment of cancer or a life-
threatening disease or condition and is described in
any of the following:
(A) The study or
investigation is approved or funded, which may include funding through
in-kind contributions, by one or more of the
following:
(i)
The federal National Institutes of Health;
(ii) The federal
Centers for Disease Control and Prevention;
(iii) The federal Agency
for Health Care Research and Quality;
(iv) The federal
Centers for Medicare & Medicaid Services;
(v) A cooperative
group or center of any of the entities described in items (i)
through (iv)
or the
(vi) A qualified
non-governmental research entity identified in the guidelines issued by
the federal National Institutes of Health for center
support grants; or
(vii) A study or
investigation conducted by the
U.S. Department of Defense, or the U.S. Department of
Energy, if the study or investigation has
been reviewed and approved through a system of peer
review that the Secretary of
Department of Health and Human Services determines:
(I) Is comparable to
the system of peer review of studies and investigations used by the
federal National Institutes of Health; and
(II) Assures unbiased
review of the highest scientific standards by qualified individuals
who have no interest in the outcome of the review.
(B) The study or
investigation is conducted under an investigational new drug application
reviewed by the
(C) The study or investigation
is a drug trial that is exempt from having such an
investigational new drug application.
(2) “Participant” has
the meaning stated in section 3(7) of federal ERISA.
(3) “Participating
provider” means a health care provider that, under a contract with the
health carrier or with its contractor or
subcontractor, has agreed to provide health care services to
covered persons with an expectation of receiving
payment, other than coinsurance, copayments or
deductibles, directly or indirectly from the health
carrier.
(4) “Qualified
individual” means a participant or beneficiary who meets the following
conditions:
(A) The individual is
eligible to participate in an approved clinical trial according to the
trial protocol with respect to the treatment of cancer
or other life-threatening disease or condition;
and
(B)(i) The referring health care professional is a
participating provider and has concluded
that the individual’s participation in such trial
would be appropriate based on the individual
meeting the conditions described in subdivision (A) of
this subdivision (3); or
(ii) The participant
or beneficiary provides medical and scientific information
establishing the individual’s participation in such
trial would be appropriate based on the
individual meeting the conditions described in
subdivision (A) of this subdivision (3).
(5) “Life-threatening
condition” means any disease or condition from which the
likelihood of death is probable unless the course of
the disease or condition is interrupted.
(b)(1) If a health
insurance carrier offering group or individual health insurance coverage
provides coverage to a qualified individual, the
health insurance carrier:
(A) Shall not deny
the individual participation in an approved clinical trial.
(B) Subject to
subdivision (3) of this subsection, shall not deny or limit or impose
additional conditions on the coverage of routine
patient costs for items and services furnished in
connection with participation in the approved clinical
trial; and
(C) Shall not
discriminate against the individual on the basis of the individual’s
participation in the approved clinical trial.
(2)(A) Subject to subdivision
(B) of this subdivision (2), routine patient costs include all
items and services consistent with the coverage
typically covered for a qualified individual who is
not enrolled in an approved clinical trial.
(B) For purposes of subdivision
(B) of this subdivision (2), routine patient costs do not
include:
(i)
The investigational item, device or service itself;
(ii) Items and
services that are provided solely to satisfy data collection and analysis
needs and that are not used in the direct clinical
management of the patient; or
(iii) A service that
is clearly inconsistent with widely accepted and established standards
of care for a particular diagnosis.
(3) If one or more
participating providers are participating in a clinical trial, nothing in
subdivision (1) of this subsection shall be construed
as preventing a health carrier from requiring
that a qualified individual participate in the trial
through such a participating provider if the
provider will accept the individual as a participant
in the trial.
(4) Notwithstanding
subdivision (3) of this subsection, subdivision (1) of this subsection
shall apply to a qualified individual participating in
an approved clinical trial that is conducted
outside this state.
(5) This section
shall not be construed to require a health insurance carrier offering group
or individual health insurance coverage to provide
benefits for routine patient care services
provided outside of the coverage’s health care provider
network unless out-of-network benefits
are otherwise provided under the coverage.
(6) Nothing in this
section shall be construed to limit a health insurance carrier’s
coverage with respect to clinical trials.
(c) The requirements
of this section shall be in addition to the requirements of Rhode
Island general laws sections 27-18-36 through
27-18-36.3.
(d) 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.
(e) This section
shall be effective for plan years beginning on or after January 1, 2014.
27-18-75. Medical
loss ratio reporting and rebates. – (a) A health insurance
carrier
offering group or individual health insurance coverage
of a health benefit plan, including a
grandfathered health plan, shall comply with the
provisions of Section 2718 of the Public Health
Services Act as amended by the federal Affordable Care
Act, in accordance with regulations
adopted thereunder.
(b) Health insurance
carriers required to report medical loss ratio and rebate calculations
and other medical loss ratio and rebate information to
the
Services shall concurrently file such information with
the commissioner.
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
section 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 health care 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. 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 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.
27-18-77. Internal
and external appeal of adverse benefit determinations. – (a)
The
commissioner shall adopt regulations to implement
standards and procedures with respect to
internal claims and appeals of adverse benefit
determinations, and with respect to external appeals
of adverse benefit determinations.
(b) The regulations
adopted by the commissioner shall apply only to those adverse
benefit determinations which are not subject to the
jurisdiction of the department of health
pursuant to R.I. Gen. Laws § 23-17.12 et seq.
(Utilization Review Act).
(c) 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. This section also shall
not apply to grandfathered health plans.
SECTION
3. Sections 27-18-8, 27-18-44 and 27-18-59 of the General laws in Chapter
27-18 entitled
"Accident and Sickness Insurance Policies" are hereby amended to read
as follows:
27-18-8. Filing of
accident and sickness insurance policy forms. – (a) Any insurance
company authorized to do an accident and sickness
business within this state in accordance with
the provisions of this title shall file all accident
and sickness insurance policy forms and rates
used by it in the state with the insurance
commissioner, including the forms of any rider,
endorsement, application blank, and other matter
generally used or incorporated by reference in
its policies or contracts of insurance. No
such form shall be used if disapproved by the
commissioner under this section, or if the
commissioner’s approval has been withdrawn under
section 27-18-8.3, or until the expiration of the
waiting period established under section 27-18-
8.3. Such a company shall comply with its filed and
approved forms. If the
commissioner finds
from a examination of any form that it is contrary to
the public interest, or the requirements of
this code or duly promulgated regulations, he or she
shall forbid its use, and shall notify the
company in writing as provided in section 27-18-8.2. Each
form shall include a certification by a
qualified actuary that to the best of the actuary's
knowledge and judgment, the entire rate is in
compliance with applicable laws and that the benefits
are reasonable in relation to the premium to
be charged.
(b) Each rate filing
shall include a certification by a qualified actuary that to the best of
the actuary's knowledge and judgment, the entire rate
filing is in compliance with applicable laws
and that the benefits offered or proposed to be
offered are reasonable in relation to the premium
to be charged. A health insurance carrier shall comply
with its filed and approved rates and forms.
27-18-44. Primary
and preventive obstetric and gynecological care. – (a) Any
insurer
or health plan, nonprofit
health medical service plan, or nonprofit hospital service
plan that
provides coverage for obstetric and gynecological care
for issuance or delivery in the state to any
group or individual on an expense-incurred basis,
including a health plan offered or issued by a
health insurance carrier or a health maintenance organization, shall
permit a woman to receive an
annual visit to an in-network
obstetrician/gynecologist for routine gynecological care without
requiring the woman to first obtain a referral from a
primary care provider.
(b)(1)(A) Any health
plan, nonprofit medical service plan or nonprofit hospital service
plan, including a health insurance carrier or a health
maintenance organization which requires or
provides for the designation by a covered person of a
participating primary health care
professional shall permit each covered person to:
(i)
Designate any participating primary care health care professional who is
available to
accept the covered person; and
(ii) For a child,
designate any participating physician who specializes in pediatrics as the
child’s primary care health care professional and is
available to accept the child.
(2) The provisions of
subdivision (1) of this subsection shall not be construed to waive
any exclusions of coverage under the terms and
conditions of the health benefit plan with respect
to coverage of pediatric care.
(c)(1) If a health
plan, nonprofit medical service plan or nonprofit hospital service plan,
including a health insurance carrier or a health
maintenance organization, provides coverage for
obstetrical or gynecological care and requires the
designation by a covered person of a
participating primary care health care professional,
then it:
(A) Shall not require
any person’s, including a primary care health care professional’s,
prior authorization or referral in the case of a
female covered person who seeks coverage for
obstetrical or gynecological care provided by a
participating health care professional who
specializes in obstetrics or gynecology; and
(B) Shall treat the
provision of obstetrical and gynecological care, and the ordering of
related obstetrical and gynecological items and
services, pursuant to subdivision (A) of this
subdivision (c)(1), by a participating health care
professional who specializes in obstetrics or
gynecology as the authorization of the primary care
health care professional.
(2)(A) A health plan,
nonprofit medical service plan or nonprofit hospital service plan,
including a health insurance carrier or a health
maintenance organization may require the health
care professional to agree to otherwise adhere to its
policies and procedures, including procedures
relating to referrals, obtaining prior authorization,
and providing services in accordance with a
treatment plan, if any, approved by the plan, carrier
or health maintenance organization.
(B)For purposes of
subdivision (A) of this subdivision (c)(1), a health care professional,
who specializes in obstetrics or gynecology, means any
individual, including an individual other
than a physician, who is authorized under state law to
provide obstetrical or gynecological care.
(3) The provisions of
subdivision (A) of this subdivision (c)(1) shall not be construed to:
(A) Waive any
exclusions of coverage under the terms and conditions of the health
benefit plan with respect to coverage of obstetrical
or gynecological care; or
(B) Preclude the
health plan, nonprofit medical service plan or nonprofit hospital service
plan, including a health insurance carrier or a health
maintenance organization involved from
requiring that the participating health care
professional providing obstetrical or gynecological
care notify the primary care health care professional or
the plan, carrier or health maintenance
organization of treatment decisions.
(d) Notice
Requirements:
(1) A health plan,
nonprofit medical service plan or nonprofit hospital service plan,
including a health insurance carrier or a health maintenance
organization subject to this section
shall provide notice to covered persons of the terms
and conditions of the plan related to the
designation of a participating health care
professional and of a covered person’s rights with
respect to those provisions.
(2)(A) In the case of
group health insurance coverage, the notice described in subdivision
(1) of this subsection shall be included whenever the
a participant is provided with a summary
plan description or other similar description of benefits
under the health benefit plan.
(B) In the case of
individual health insurance coverage, the notice described in
subdivision (1) of this subsection shall be included
whenever the primary subscriber is provided
with a policy, certificate or contract of health
insurance.
(C) A health plan,
nonprofit medical service plan or nonprofit hospital service plan,
including a health insurance carrier or a health
maintenance organization, may use the model
language in federal regulation 45 CFR section
147.138(a)(4)(iii) to satisfy the requirements of
this subsection.
(e) The requirements
of subsections (b), (c), and (d) 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.
27-18-59. Termination
of children's benefits Eligibility for children’s benefits. --
(a)(1) Every individual health insurance
contract, plan, or policy health benefit plan delivered,
issued for delivery, or renewed in this state and
every group health insurance contract, plan, or
policy delivered, issued for delivery or renewed in
this state which provides medical health
benefits
coverage for dependent children that includes coverage for physician
services in a
physician's office, and every policy which provides
major medical or similar comprehensive type
coverage dependents,
except for supplemental policies which only provide coverage for specified
diseases and other supplemental policies, shall provide
make coverage available of an unmarried
child under the age of nineteen (19) years, an
unmarried child who is a student under the age of
twenty-five (25) years and who is financially
dependent upon the parent and an unmarried child
of any age who is financially dependent upon the
parent and medically determined to have a
physical or mental impairment which can be expected to
result in death or which has lasted or can
be expected to last for a continuous period of not
less than twelve (12) months for
children until
attainment of twenty-six (26) years of age, and an
unmarried child of any age who is financially
dependent upon the parent and medically determined to
have a physical or mental impairment
which can be expected to result in death or which has
lasted or can be expected to last for a
continuous period of not less than twelve (12) months. Such contract, plan or policy shall also
include a provision that policyholders shall receive
no less than thirty (30) days notice from the
accident and sickness insurer that a child covered as
a dependent by the policy holder is about to
lose his or her coverage as a result of reaching the
maximum age for a dependent child, and that
the child will only continue to be covered upon
documentation being provided of current full or
part-time enrollment in a post-secondary educational
institution or that the child may purchase a
conversion policy if he or she is not an eligible
student. Nothing in this section prohibits an
accident and sickness insurer from requiring a
policyholder to annually provide proof of a child's
current full or part-time enrollment in a
post-secondary educational institution in order to
maintain the child's coverage. Provided, nothing in
this section requires coverage inconsistent
with the membership criteria in effect under the
policyholder's health benefits coverage.
(2) With respect to a
child who has not attained twenty-six (26) years of age, a health
insurance carrier shall not define “dependent” for
purposes of eligibility for dependent coverage
of children other than the terms of a relationship
between a child and the plan participant, or
subscriber.
(3) A health
insurance carrier shall not deny or restrict coverage for a child who has not
attained twenty-six (26) years of age based on the
presence or absence of the child’s financial
dependency upon the participant, primary subscriber or
any other person, residency with the
participant and in the individual market the primary subscriber,
or with any other person, marital
status, student status, employment or any combination
of those factors. A health carrier shall not
deny or restrict coverage of a child based on
eligibility for other coverage, except as provided in
subparagraph (b)(1) of this section.
(4) Nothing in this
section shall be construed to require a health insurance carrier to make
coverage available for the child of a child receiving
dependent coverage, unless the grandparent
becomes the legal guardian or adoptive parent of that
grandchild.
(5) The terms of
coverage in a health benefit plan offered by a health insurance carrier
providing dependent coverage of children cannot vary
based on age except for children who are
twenty-six (26) years of age or older.
(b)(1) For plan years
beginning before January 1, 2014, a health insurance carrier
providing group health insurance coverage that is a
grandfathered health plan and makes
available dependent coverage of children may exclude
an adult child who has not attained twenty-
six (26) years of age from coverage only if the adult
child is eligible to enroll in an eligible
employer-sponsored health benefit plan, as defined in
section 5000A(f)(2) of the federal Internal
Revenue Code, other than the group health plan of a
parent.
(2) For plan years,
beginning on or after January 1, 2014, a health insurance carrier
providing group health insurance coverage that is a
grandfathered health plan shall comply with
the requirements of subsections (a) through (e) of
this section.
(b)(c)This
section does 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 diseased indemnity; or (8) sickness
or bodily injury or death by accident or both; or (9) other limited benefit policies.
SECTION
4. Chapter 27-18.5 of the General Laws entitled “Individual Health Insurance
Coverage” is hereby amended
by adding thereto the following section:
27-18.5-10.
Prohibition on preexisting condition exclusions. -- (a) A
health insurance
policy, subscriber contract, or health plan offered, issued,
issued for delivery, or issued to cover a
resident of this state by a health insurance company
licensed pursuant to this title and/or chapter:
(1) Shall not limit
or exclude coverage for an individual under the age of nineteen (19) by
imposing a preexisting condition exclusion on that
individual.
(2) For plan or
policy years beginning on or after January 1, 2014, shall not limit or
exclude coverage for any individual by imposing a
preexisting condition exclusion on that
individual.
(b) As used in this
section:
(1) “Preexisting
condition exclusion” means a limitation or exclusion of benefits,
including a denial of coverage, based on the fact that
the condition (whether physical or mental)
was present before the effective date of coverage, or
if the coverage is denied, the date of denial,
under a health benefit plan whether or not any medical
advice, diagnosis, care or treatment was
recommended or received before the effective date of
coverage.
(2) “Preexisting
condition exclusion” means any limitation or exclusion of benefits,
including a denial of coverage, applicable to an
individual as a result of information relating to an
individual’s health status before the individual’s
effective date of coverage, or if the coverage is
denied, the date of denial, under the health benefit
plan, such as a condition (whether physical or
mental) identified as a result of a pre-enrollment
questionnaire or physical examination given to
the individual, or review of medical records relating
to the pre-enrollment period.
(c) This section
shall not apply to grandfathered health plans providing individual health
insurance coverage.
(d) 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. Sections 27-19-1 and 27-19-50 of the General laws in Chapter 27-19
entitled "Nonprofit
Hospital Service Corporations" are hereby amended to read as follows:
27-19-1.
Definitions. -- As used in this chapter:
(1) "Contracting
hospital" means an eligible hospital which has contracted with a
nonprofit hospital service corporation to render
hospital care to subscribers to the nonprofit
hospital service plan operated by the corporation;
(2) "Adverse
benefit determination" means any of the following: a denial, reduction, or
termination of, or a failure to provide or make
payment (in whole or in part) for, a benefit,
including any such denial, reduction, termination, or
failure to provide or make payment that is
based on a determination of an individual's
eligibility to participate in a plan or to receive
coverage under a plan, and including, with respect to
group health plans, a denial, reduction, or
termination of, or a failure to provide or make
payment (in whole or in part) for, a benefit
resulting from the application of any utilization
review, as well as a failure to cover an item or
service for which benefits are otherwise provided
because it is determined to be experimental or
investigational or not medically necessary or
appropriate. The term also includes a rescission of
coverage determination.
(3) "Affordable
Care Act" means the federal Patient Protection and Affordable Care Act
of 2010, as amended by the federal Health Care and Education
Reconciliation Act of 2010, and
federal regulations adopted thereunder;
(4) “Commissioner” or
“health insurance commissioner” means that individual appointed
pursuant to section 42-14.5-1 of the General laws;
(5) "Eligible
hospital" is one which is maintained either by the state or by any of its
political subdivisions or by a corporation organized
for hospital purposes under the laws of this
state or of any other state or of the
majority of the directors of the nonprofit hospital
service corporation;
(6) "Essential
health benefits" shall have the meaning set forth in section 1302(b) of
the
federal Affordable Care Act.
(7) “Grandfathered
health plan” means any group health plan or health insurance
coverage subject to 42 USC section 18011;
(8) “Group health
insurance coverage” means, in connection with a group health plan,
health insurance coverage offered in connection with
such plan;
(9) “Group health
plan” means an employee welfare benefit plan as defined 29 USC
section 1002(1), to the extent that the plan provides
health benefits to employees or their
dependents directly or through insurance,
reimbursement, or otherwise;
(10) “Health
benefits” or “covered benefits” means coverage or benefits for the
diagnosis, cure, mitigation, treatment, or prevention
of disease, or amounts paid for the purpose
of affecting any structure or function of the body
including coverage or benefits for transportation
primarily for and essential thereto, and including
medical services as defined in R.I. Gen. Laws §
27-19-17;
(11) “Health care
facility” means an institution providing health care services or a health
care setting, including but not limited to hospitals
and other licensed inpatient centers, ambulatory
surgical or treatment centers, skilled nursing
centers, residential treatment centers, diagnostic,
laboratory and imaging centers, and rehabilitation and
other therapeutic health settings;
(12) "Health
care professional" means a physician or other health care practitioner
licensed, accredited or certified to perform specified
health care services consistent with state
law;
(13) "Health
care provider" or "provider" means a health care professional or
a health
care facility;
(14) "Health
care services" means services for the diagnosis, prevention, treatment,
cure
or relief of a health condition, illness, injury or
disease;
(15) “Health
insurance carrier” means a person, firm, corporation or other entity subject
to the jurisdiction of the commissioner under this
chapter, and includes nonprofit hospital service
corporations. Such term does not include a group
health plan. The use of this term shall not be
construed to subject a nonprofit hospital service
corporation to the insurance laws of this state
other than as set forth in R.I. Gen. Laws § 27-19-2;
(16) "Health
plan" or "health benefit plan" means health insurance coverage
and a group
health plan, including coverage provided through an
association plan if it covers
residents. Except to the extent specifically provided
by the federal Affordable Care Act, the term
“health plan” shall not include a group health plan to
the extent state regulation of the health plan
is pre- empted under section 514 of the federal
Employee Retirement Income Security Act of
1974. The term also shall not include:
(A)(i) Coverage only for accident, or disability income
insurance, or any combination
thereof.
(ii) Coverage issued
as a supplement to liability insurance.
(iii) Liability
insurance, including general liability insurance and automobile liability
insurance.
(iv) Workers’
compensation or similar insurance.
(v) Automobile
medical payment insurance.
(vi) Credit-only
insurance.
(vii) Coverage for
on-site medical clinics.
(viii) Other similar
insurance coverage, specified in federal regulations issued pursuant to
federal Pub. L. No. 104-191, the federal health
insurance portability and accountability act of
1996 (“HIPAA”), under which benefits for medical care
are secondary or incidental to other
insurance benefits.
(B) The following
benefits if they are provided under a separate policy, certificate or
contract of insurance or are otherwise not an integral
part of the plan:
(i)
Limited scope dental or vision benefits.
(ii) Benefits for
long-term care, nursing home care, home health care, community-based
care, or any combination thereof.
(iii) Other excepted
benefits specified in federal regulations issued pursuant to federal
Pub. L. No. 104-191 (“HIPAA”).
(C) The following
benefits if the benefits are provided under a separate policy, certificate
or contract of insurance, there is no coordination
between the provision of the benefits and any
exclusion of benefits under any group health plan
maintained by the same plan sponsor, and the
benefits are paid with respect to an event without regard
to whether benefits are provided with
respect to such an event under any group health plan
maintained by the same plan sponsor:
(i)
Coverage only for a specified disease or illness.
(ii) Hospital indemnity
or other fixed indemnity insurance.
(D) The following if
offered as a separate policy, certificate or contract of insurance:
(i)
Medicare supplement health insurance as defined under section 1882(g)(1) of the
federal Social Security Act.
(ii) Coverage
supplemental to the coverage provided under chapter 55 of title 10, United
States Code (Civilian Health and Medical Program of
the Uniformed Services (CHAMPUS)).
(iii) Similar
supplemental coverage provided to coverage under a group health plan.
(17) "Nonprofit
hospital service corporation" means any corporation organized pursuant
to this chapter for the purpose of establishing,
maintaining, and operating a nonprofit hospital
service plan;
(18) "Nonprofit
hospital service plan" means a plan by which specified hospital care is to
be provided to subscribers to the plan by a
contracting hospital;
(19) "Office of
the health insurance commissioner" means the agency established under
section 42-14.5-1 of the General Law;
(20)
“Rescission" means a cancellation or discontinuance of coverage that has
retroactive
effect for reasons unrelated to timely payment of
required premiums or contribution to costs of
coverage; and
(21)
"Subscribers" mean those persons, whether or not residents of this
state, who have
contracted with a nonprofit hospital service
corporation for hospital care pursuant to a nonprofit
hospital service plan operated by the corporation.
27-19-50. Termination
of children’s benefits Eligibility for children's benefits. --
(a)(1) Every individual health
insurance contract, plan, or policy health benefit plan delivered,
issued for delivery, or renewed in this state which
provides medical health benefits coverage for
dependent children that includes coverage for
physician services in a physician’s office, and
every policy which provides major medical or similar
comprehensive type coverage dependents,
except for supplemental policies which only provide
coverage for specified diseases and other
supplemental policies, shall provide make coverage available
of an unmarried child under the age
of nineteen (19) years, an unmarried child who is a
student under the age of twenty-five (25)
years and who is financially dependent upon the parent
and an unmarried child of any age who is
financially dependent upon the parent and medically
determined to have a physical or mental
impairment which can be expected to result in death or
which has lasted or can be expected to last
for a continuous period of not less than twelve (12)
months for children until
attainment of
twenty-six (26) years of age, and an unmarried child
of any age who is financially dependent
upon the parent and medically determined to have a
physical or mental impairment which can be
expected to result in death or which has lasted or can
be expected to last for a continuous period
of not less than twelve (12) months. Such contract, plan or policy shall also
include a provision
that policyholders shall receive no less than thirty
(30) days notice from the accident and sickness
insurer that a child covered as a dependent by the
policy holder is about to lose his or her
coverage as a result of reaching the maximum age for a
dependent child, and that the child will
only continue to be covered upon documentation being
provided of current full or part-time
enrollment in a post-secondary educational institution
or that the child may purchase a conversion
policy if he or she is not an eligible student.
(b) Nothing in this
section prohibits a nonprofit hospital service corporation from
requiring a policyholder to annually provide proof of
a child's current full or part-time enrollment
in a post-secondary educational institution in order
to maintain the child's coverage. Provided,
nothing in this section requires coverage inconsistent
with the membership criteria in effect under
the policyholder's health benefits coverage.
(2) With respect to a
child who has not attained twenty-six (26) years of age, a health
insurance carrier shall not define “dependent” for
purposes of eligibility for dependent coverage
of children other than the terms of a relationship
between a child and the plan participant or
subscriber.
(3) A health
insurance carrier shall not deny or restrict coverage for a child who has not
attained twenty-six (26) years of age based on the
presence or absence of the child’s financial
dependency upon the participant, primary subscriber or
any other person, residency with the
participant and in the individual market the primary
subscriber, or with any other person, marital
status, student status, employment or any combination
of those factors. A health carrier shall not
deny or restrict coverage of a child based on
eligibility for other coverage, except as provided in
(b)(1) of this section.
(4) Nothing in this
section shall be construed to require a health insurance carrier to make
coverage available for the child of a child receiving dependent
coverage, unless the grandparent
becomes the legal guardian or adoptive parent of that
grandchild.
(5) The terms of
coverage in a health benefit plan offered by a health insurance carrier
providing dependent coverage of children cannot vary
based on age except for children who are
twenty-six (26) years of age or older.
(b)(1) For plan years
beginning before January 1, 2014, a group health plan providing
group health insurance coverage that is a grandfathered
health plan and makes available
dependent coverage of children may exclude an adult
child who has not attained twenty-six (26)
years of age from coverage only if the adult child is
eligible to enroll in an eligible employer-
sponsored health benefit plan, as defined in section
5000A(f)(2) of the federal Internal Revenue
Code, other than the group health plan of a parent.
(2) For plan years,
beginning on or after January 1, 2014, a group health plan providing
group health insurance coverage that is a
grandfathered health plan shall comply with the
requirements of this section.
(c) This section does
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 diseased indemnity; or (8) Other
limited benefit policies.
SECTION
6. Chapter 27-19 of the General laws entitled "Nonprofit Hospital Service
Corporations" is hereby
amended by adding thereto the following sections:
27-19-7.1. Uniform
explanation of benefits and coverage. – (a) A nonprofit
hospital
service corporation shall provide a summary of
benefits and coverage explanation and definitions
to policyholders and others required by, and at the
times and in the format required, by the federal
regulations adopted under section 2715 of the Public
Health Service Act, as amended by the
federal Affordable Care Act. The forms required by this
section shall be made available to the
commissioner on request. Nothing in this section shall
be construed to limit the authority of the
commissioner under existing state law.
(b) 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.
(c) If the
commissioner of the office of the health insurance commissioner determines
that the corresponding provision of the federal
Patient Protection and Affordable Care Act has
been declared invalid by a final judgment of the
federal judicial branch or has been repealed by
an act of Congress, on the date of the commissioner’s
determination this section shall have its
effectiveness suspended indefinitely, and the
commissioner shall take no action to enforce this
section. Nothing in this section shall be construed to
limit the authority of the commissioner
under existing state law.
27-19-7.2. Filing
of policy forms. – (a) A nonprofit hospital service corporation
shall file all
policy forms and rates used by it in the state with
the commissioner, including the forms of any
rider, endorsement, application blank, and other
matter generally used or incorporated by
reference in its policies or contracts of insurance.
No such form shall be used if disapproved by
the commissioner under this section, or if the
commissioner’s approval has been withdrawn after
notice and an opportunity to be heard, or until the
expiration of sixty (60) days following the
filing of the form. Such a company shall comply with
its filed and approved forms . If the
commissioner finds from an examination of any form
that it is contrary to the public interest, or
the requirements of this code or duly promulgated
regulations, he or she shall forbid its use, and
shall notify the corporation in writing.
(b) Each rate filing
shall include a certification by a qualified actuary that to the best of
the actuary's knowledge and judgment, the entire rate
filing is in compliance with applicable laws
and that the benefits offered or proposed to be
offered are reasonable in relation to the premium
to be charged. A health insurance carrier shall comply
with its filed and approved rates and
forms.
27-19-62.
Prohibition on rescission of coverage. – (a)(1) Coverage under
a health plan
subject to the jurisdiction of the commissioner under
this chapter with respect to an individual,
including a group to which the individual belongs or
family coverage in which the individual is
included, shall not be rescinded after the individual
is covered under the plan, unless:
(A) The individual or
a person seeking coverage on behalf of the individual, performs an
act, practice or omission that constitutes fraud; or
(B) The individual
makes an intentional misrepresentation of material fact, as prohibited
by the terms of the plan or coverage.
(2) For purposes of
paragraph (1)(A), a person seeking coverage on behalf of an
individual does not include an insurance producer or
employee or authorized representative of the
health carrier.
(b) At least thirty
(30) days advance written notice shall be provided to each health
benefit plan enrollee or, for individual health
insurance coverage, primary subscriber, who would
be affected by the proposed rescission of coverage
before coverage under the plan may be
rescinded in accordance with subsection (a) regardless
of, in the case of group health insurance
coverage, whether the rescission applies to the entire
group or only to an individual within the
group.
(c) For purposes of
this section, “to rescind” means to cancel or to discontinue coverage
with retroactive effect for reasons unrelated to
timely payment of required premiums or
contribution to costs of coverage.
(d) This section
applies to grandfathered health plans.
27-19-63.
Prohibition on annual and lifetime limits. – (a) Annual limits.
(1) For plan or
policy years beginning prior to January 1, 2014, for
any individual, a health insurance carrier and
health benefit plan subject to the jurisdiction of the
commissioner under this chapter may
establish an annual limit on the dollar amount of
benefits that are essential health benefits
provided the restricted annual limit is not less than
the following:
(A) For a plan or
policy year beginning after September 22, 2011, but before September
23, 2012 – one million two hundred fifty thousand
dollars ($1,250,000); and
(B) For a plan or
policy year beginning after September 22, 2012, but before January 1,
2014 – two million dollars ($2,000,000).
(2) For plan or
policy years beginning on or after January 1, 2014, a health insurance
carrier and health benefit plan shall not establish
any annual limit on the dollar amount of
essential health benefits for any individual, except:
(A) A health flexible
spending arrangement, as defined in Section 106(c)(2)(i)
of the
federal Internal Revenue Code, a medical savings
account, as defined in Section 220 of the
federal Internal Revenue Code, and a health savings
account, as defined in Section 223 of the
federal Internal Revenue Code, are not subject to the
requirements of subdivisions (1) and (2) of
this subsection.
(B) The provisions of
this subsection shall not prevent a health insurance carrier and
health benefit plan from placing annual dollar limits
for any individual on specific covered
benefits that are not essential health benefits to the
extent that such limits are otherwise permitted
under applicable federal law or the laws and
regulations of this state.
(3) In determining
whether an individual has received benefits that meet or exceed the
allowable limits, as provided in subdivision (1) of this
subsection, a health insurance carrier and
health benefit plan shall take into account only
essential health benefits.
(b) Lifetime limits.
(1) A health
insurance carrier and health benefit plan offering group or individual health
insurance coverage shall not establish a lifetime
limit on the dollar value of essential health
benefits for any individual.
(2) Notwithstanding
subdivision (1) above, a health insurance carrier and health benefit
plan is not prohibited from placing lifetime dollar
limits for any individual on specific covered
benefits that are not essential health benefits in
accordance with federal laws and regulations.
(c)(1) The provisions
of this section relating to lifetime limits apply to any health
insurance carrier providing coverage under an
individual or group health plan, including
grandfathered health plans.
(2) The provisions of
this section relating to annual limits apply to any health insurance
carrier providing coverage under a group health plan,
including grandfathered health plans, but
the prohibition and limits on annual limits do not
apply to grandfathered health plans providing
individual health insurance coverage.
(d) This section shall
not apply to a plan or to policy years prior to January 1, 2014 for
which the Secretary of the
pursuant to 45 C.F.R. § 147.126(d)(3)This section also
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.
(e) If the
commissioner of the office of the health insurance commissioner determines
that the corresponding provision of the federal
Patient Protection and Affordable Care Act has
been declared invalid by a final judgment of the
federal judicial branch or has been repealed by
an act of Congress, on the date of the commissioner’s
determination this section shall have its
effectiveness suspended indefinitely, and the
commissioner shall take no action to enforce this
section. Nothing in this subsection shall be construed
to limit the authority of the Commissioner
to regulate health insurance under existing state law.
27-19-64. Coverage
for individuals participating in approved clinical trials. – (a)
As
used in this section:
(1) “Approved
clinical trial” means a phase I, phase II, phase III or phase IV clinical trial
that is conducted in relation to the prevention,
detection or treatment of cancer or a life-
threatening disease or condition and is described in
any of the following:
(A) The study or
investigation is approved or funded, which may include funding through
in-kind contributions, by one or more of the
following:
(i)
The federal National Institutes of Health;
(ii) The federal
Centers for Disease Control and Prevention;
(iii) The federal
Agency for Health Care Research and Quality;
(iv) The federal
Centers for Medicare & Medicaid Services;
(v) A cooperative group
or center of any of the entities described in items (i)
through (iv)
or the
(vi) A qualified
non-governmental research entity identified in the guidelines issued by
the federal National Institutes of Health for center
support grants; or
(vii) A study or
investigation conducted by the
U.S. Department of
Defense, or the U.S. Department of Energy, if the study or
investigation has been reviewed and approved through a
system of peer review that the Secretary
of
(I) Is comparable to
the system of peer review of studies and investigations used by the
Federal National Institutes of Health; and
(II) Assures unbiased
review of the highest scientific standards by qualified individuals
who have no interest in the outcome of the review.
(B) The study or
investigation is conducted under an investigational new drug application
reviewed by the
(C) The study or
investigation is a drug trial that is exempt from having such an
investigational new drug application.
(2) “Participant” has
the meaning stated in section 3(7) of federal ERISA.
(3) “Participating
provider” means a health care provider that, under a contract with the
health carrier or with its contractor or
subcontractor, has agreed to provide health care services to
covered persons with an expectation of receiving
payment, other than coinsurance, copayments or
deductibles, directly or indirectly from the health
carrier.
(4) “Qualified
individual” means a participant or beneficiary who meets the following
conditions:
(A) The individual is
eligible to participate in an approved clinical trial according to the
trial protocol with respect to the treatment of cancer
or other life-threatening disease or condition;
and
(B)(i) The referring health care professional is a
participating provider and has concluded
that the individual’s participation in such trial
would be appropriate based on the individual
meeting the conditions described in subdivision (A) of
this subdivision (3); or
(ii) The participant or
beneficiary provides medical and scientific information
establishing the individual’s participation in such
trial would be appropriate based on the
individual meeting the conditions described in
subdivision (A) of this subdivision (3).
(5) “Life-threatening
condition” means any disease or condition from which the
likelihood of death is probable unless the course of
the disease or condition is interrupted.
(b)(1) If a health
insurance carrier offering group or individual health insurance coverage
provides coverage to a qualified individual, the
health carrier:
(A) Shall not deny
the individual participation in an approved clinical trial.
(B) Subject to
subdivision (3) of this subsection, shall not deny or limit or impose
additional conditions on the coverage of routine
patient costs for items and services furnished in
connection with participation in the approved clinical
trial; and
(C) Shall not
discriminate against the individual on the basis of the individual’s
participation in the approved clinical trial.
(2)(A) Subject to
subdivision (B) of this subdivision (2), routine patient costs include all
items and services consistent with the coverage
typically covered for a qualified individual who is
not enrolled in an approved clinical trial.
(B) For purposes of
subdivision (B) of this subdivision (2), routine patient costs do not
include:
(i)
The investigational item, device or service itself;
(ii) Items and
services that are provided solely to satisfy data collection and analysis
needs and that are not used in the direct clinical
management of the patient; or
(iii) A service that
is clearly inconsistent with widely accepted and established standards
of care for a particular diagnosis.
(3) If one or more
participating providers are participating in a clinical trial, nothing in
subdivision (1) of this subsection shall be construed
as preventing a health carrier from requiring
that a qualified individual participate in the trial
through such a participating provider if the
provider will accept the individual as a participant
in the trial.
(4) Notwithstanding
subdivision (3) of this subsection, subdivision (1) of this subsection
shall apply to a qualified individual participating in
an approved clinical trial that is conducted
outside this state.
(5) This section
shall not be construed to require a health carrier offering group or
individual health insurance coverage to provide
benefits for routine patient care services provided
outside of the coverage’s health care provider network
unless out-of-network benefits are
otherwise provided under the coverage.
(6) Nothing in this
section shall be construed to limit a health carrier’s coverage with
respect to clinical trials.
(c) The requirements
of this section shall be in addition to the requirements of Rhode
Island general laws sections 27-18-32 through
27-19-32.2.
(d) 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.
(e) This section
shall be effective for plan years beginning on or after January 1, 2014.
27-19-65. Medical
loss ratio reporting and rebates. – (a) A nonprofit hospital
service
corporation offering group or individual health
insurance coverage of a health benefit plan,
including a grandfathered health plan, shall comply
with the provisions of Section 2718 of the
Public Health Services Act as amended by the federal
Affordable Care Act, in accordance with
regulations adopted thereunder.
(b) Health insurance
carriers required to report medical loss ratio and rebate calculations
and other medical loss ratio and rebate information to
the
Services shall concurrently file such information with
the commissioner.
27-19-66.
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 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 health care 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. 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 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.
27-19-67. Internal
and external appeal of adverse benefit determinations. – (a)
The
commissioner shall adopt regulations to implement
standards and procedures with respect to
internal claims and appeals of adverse benefit
determinations, and with respect to external appeals
of adverse benefit determinations.
(b) The regulations
adopted by the commissioner shall apply only to those adverse
benefit determinations which are not subject to the jurisdiction
of the department of health
pursuant to R.I. Gen. Laws § 23-17.12 et seq.
(Utilization Review Act).
(c) 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. This section also
shall not apply to grandfathered health plans.
27-19-68.
Prohibition on preexisting condition exclusions. -- (a) A
health insurance
policy, subscriber contract, or health plan offered,
issued, issued for delivery, or issued to cover a
resident of this state by a health insurance company
licensed pursuant to this title and/or chapter:
(1) Shall not limit
or exclude coverage for an individual under the age of nineteen (19) by
imposing a preexisting condition exclusion on that
individual.
(2) For plan or
policy years beginning on or after January 1, 2014, shall not limit or
exclude coverage for any individual by imposing a
preexisting condition exclusion on that
individual.
(b) As used in this
section:
(1) “Preexisting
condition exclusion” means a limitation or exclusion of benefits,
including a denial of coverage, based on the fact that
the condition (whether physical or mental)
was present before the effective date of coverage, or
if the coverage is denied, the date of denial,
under a health benefit plan whether or not any medical
advice, diagnosis, care or treatment was
recommended or received before the effective date of
coverage.
(2) “Preexisting
condition exclusion” means any limitation or exclusion of benefits,
including a denial of coverage, applicable to an
individual as a result of information relating to an
individual’s health status before the individual’s
effective date of coverage, or if the coverage is
denied, the date of denial, under the health benefit
plan, such as a condition (whether physical or
mental) identified as a result of a pre-enrollment
questionnaire or physical examination given to
the individual, or review of medical records relating
to the pre-enrollment period.
(c) This section shall
not apply to grandfathered health plans providing individual health
insurance coverage.
(d) 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
7. Sections 27-20-1 and 27-20-45 of the General laws in Chapter 27-20
entitled "Nonprofit
Medical Service Corporations" are hereby amended to read as follows:
27-20-1.
Definitions. -- As used in this chapter:
(1) "Adverse
benefit determination" means any of the following: a denial, reduction, or
termination of, or a failure to provide or make
payment (in whole or in part) for, a benefit,
including any such denial, reduction, termination, or
failure to provide or make payment that is
based on a determination of a an individual’s
eligibility to participate in a plan or to receive
coverage under a plan, and including, with respect to
group health plans, a denial, reduction, or
termination of, or a failure to provide or make
payment (in whole or in part) for, a benefit
resulting from the application of any utilization
review, as well as a failure to cover an item or
service for which benefits are otherwise provided
because it is determined to be experimental or
investigational or not medically necessary or
appropriate. The term also includes a rescission of
coverage determination.
(2) "Affordable
Care Act" means the federal Patient Protection and Affordable Care Act
of 2010, as amended by the federal Health Care and
Education Reconciliation Act of 2010, and
federal regulations adopted thereunder;
(1)(3)
"Certified registered nurse practitioners" is an expanded role
utilizing independent
knowledge of physical assessment and management of
health care and illnesses. The practice
includes collaboration with other licensed health care
professionals including, but not limited to,
physicians, pharmacists, podiatrists, dentists, and
nurses;
(4) “Commissioner” or
“health insurance commissioner” means that individual appointed
pursuant to section 42-14.5-1 of the General laws.
(2)(5)
"Counselor in mental health" means a person who has been licensed
pursuant to
section 5-63.2-9.
(6) "Essential
health benefits" shall have the meaning set forth in section 1302(b) of
the
federal Affordable Care Act.
(7) “Grandfathered
health plan” means any group health plan or health insurance
coverage subject to 42 USC section 18011.
(8)
“Group health insurance coverage” means, in connection with a group health
plan,
health insurance coverage offered in connection with
such plan.
(9) “Group health
plan” means an employee welfare benefit plan as defined in 29 USC
section 1002(1) to the extent that the plan provides
health benefits to employees or their
dependents directly or through insurance,
reimbursement, or otherwise.
(10) “Health
benefits” or “covered benefits” means coverage or benefits for the
diagnosis, cure, mitigation, treatment, or prevention
of disease, or amounts paid for the purpose
of affecting any structure or function of the body
including coverage or benefits for transportation
primarily for and essential thereto, and including
medical services as defined in R.I. Gen. Laws §
27-19-17;
(11) “Health care
facility” means an institution providing health care services or a health
care setting, including but not limited to hospitals
and other licensed inpatient centers, ambulatory
surgical or treatment centers, skilled nursing
centers, residential treatment centers, diagnostic,
laboratory and imaging centers, and rehabilitation and
other therapeutic health settings.
(12) "Health
care professional" means a physician or other health care practitioner
licensed, accredited or certified to perform specified
health care services consistent with state
law.
(13) "Health
care provider" or "provider" means a health care professional or
a health
care facility.
(14) "Health
care services" means services for the diagnosis, prevention, treatment,
cure
or relief of a health condition, illness, injury or
disease.
(15) “Health
insurance carrier” means a person, firm, corporation or other entity subject
to the jurisdiction of the commissioner under this
chapter, and includes a nonprofit medical
service corporation. Such term does not include a
group health plan.
(16) "Health
plan" or “health benefit plan” means health insurance coverage and a group
health plan, including coverage provided through an
association plan if it covers
residents. Except to the extent specifically provided
by the federal Affordable Care Act, the term
‘‘health plan’’ shall not include a group health plan
to the extent state regulation of the health
plan is pre- empted under section 514 of the federal
Employee Retirement Income Security Act of
1974. The term also shall not include:
(A)(i) Coverage only for accident, or disability income
insurance, or any combination
thereof.
(ii) Coverage issued
as a supplement to liability insurance.
(iii) Liability
insurance, including general liability insurance and automobile liability
insurance.
(iv) Workers’
compensation or similar insurance.
(v) Automobile
medical payment insurance.
(vi) Credit-only
insurance.
(vii) Coverage for on-site
medical clinics.
(viii)
Other similar insurance coverage, specified in federal regulations issued
pursuant to
Federal Pub. L. No. 104-191, the federal health
insurance portability and accountability act of
1996 (“HIPAA”), under which benefits for medical care
are secondary or incidental to other
insurance benefits.
(B) The following
benefits if they are provided under a separate policy, certificate or
contract of insurance or are otherwise not an integral
part of the plan:
(i)
Limited scope dental or vision benefits.
(ii) Benefits for
long-term care, nursing home care, home health care, community-based
care, or any combination thereof.
(iii) Other excepted
benefits specified in federal regulations issued pursuant to federal
Pub. L. No. 104-191 (“HIPAA”).
(C) The following
benefits if the benefits are provided under a separate policy, certificate
or contract of insurance, there is no coordination
between the provision of the benefits and any
exclusion of benefits under any group health plan
maintained by the same plan sponsor, and the
benefits are paid with respect to an event without
regard to whether benefits are provided with
respect to such an event under any group health plan maintained
by the same plan sponsor:
(i)
Coverage only for a specified disease or illness.
(ii) Hospital
indemnity or other fixed indemnity insurance.
(D) The following if
offered as a separate policy, certificate or contract of insurance:
(i)
Medicare supplement health insurance as defined under section 1882(g)(1) of the
federal Social Security Act.
(ii) Coverage
supplemental to the coverage provided under chapter 55 of title 10, United
States Code (Civilian Health and Medical Program of
the Uniformed Services (CHAMPUS)).
(iii) Similar
supplemental coverage provided to coverage under a group health plan.
(3)(17)"Licensed
midwife" means any midwife licensed under section 23-13-9;
(4)(18)
"Medical services" means those professional services rendered by
persons duly
licensed under the laws of this state to practice
medicine, surgery, chiropractic, podiatry, and
other professional services rendered by a licensed
midwife, certified registered nurse
practitioners, and psychiatric and mental health nurse
clinical specialists, and appliances, drugs,
medicines, supplies, and nursing care necessary in
connection with the services, or the expense
indemnity for the services, appliances, drugs,
medicines, supplies, and care, as may be specified
in any nonprofit medical service plan. Medical service
shall not be construed to include hospital
services;
(5)(19)
"Nonprofit medical service corporation" means any corporation
organized
pursuant hereto for the purpose of establishing,
maintaining, and operating a nonprofit medical
service plan;
(6)(20)
"Nonprofit medical service plan" means a plan by which specified
medical
service is provided to subscribers to the plan by a
nonprofit medical service corporation;
(21) "Office of
the health insurance commissioner" means the agency established under
section 42-14.5-1 of the General laws.
(7)(22)
"Psychiatric and mental health nurse clinical specialist" is an
expanded role
utilizing independent knowledge and management of
mental health and illnesses. The practice
includes collaboration with other licensed health care
professionals, including, but not limited to,
psychiatrists, psychologists, physicians, pharmacists,
and nurses;
(23)
“Rescission" means a cancellation or discontinuance of coverage that has
retroactive
effect for reasons unrelated to timely payment of
required premiums or contribution to costs of
coverage.
(8)(24)
"Subscribers" means those persons or groups of persons who contract
with a
nonprofit medical service corporation for medical
service pursuant to a nonprofit medical service
plan; and
(9)(25)
"Therapist in marriage and family practice" means a person who has
been
licensed pursuant to section 5-63.2-10.
27-20-45. Termination
of children's benefits Eligibility for children's benefits. --
(a)(1) Every individual health insurance
contract, plan, or policy health benefit plan delivered,
issued for delivery, or renewed in this state and
every group health insurance contract, plan, or
policy delivered, issued for delivery or renewed in
this state which provides medical
health
benefits
coverage for dependent children that includes coverage for physician
services in a
physician's office, and every policy which provides
major medical or similar comprehensive type
coverage dependents,
except for supplemental policies which only provide coverage for specified
diseases and other supplemental policies, shall provide
make coverage available of an unmarried
child under the age of nineteen (19) years, an
unmarried child who is a student under the age of
twenty-five (25) years and who is financially
dependent upon the parent and an unmarried child
of any age who is financially dependent upon the
parent and medically determined to have a
physical or mental impairment which can be expected to
result in death or which has lasted or can
be expected to last for a continuous period of not
less than twelve (12) months for
children until
attainment of twenty-six (26) years of age, and an
unmarried child of any age who is financially
dependent upon the parent and medically determined to
have a physical or mental impairment
which can be expected to result in death or which has
lasted or can be expected to last for a
continuous period of not less than twelve (12) months. Such contract, plan or policy shall also
include a provision that policyholders shall receive
no less than thirty (30) days notice from the
accident and sickness insurer that a child covered as
a dependent by the policy holder is about to
lose his or her coverage as a result of reaching the
maximum age for a dependent child, and that
the child will only continue to be covered upon
documentation being provided of current full or
part-time enrollment in a post-secondary educational
institution or that the child may purchase a
conversion policy if he or she is not an eligible
student.
(b) Nothing in this
section prohibits a nonprofit medical service corporation from
requiring a policyholder to annually provide proof of
a child’s current full or part-time enrollment
in a post-secondary educational institution in order
to maintain the child’s coverage.
(2) With respect to a
child who has not attained twenty-six (26) years of age, a nonprofit
medical service corporation shall not define
“dependent” for purposes of eligibility for dependent
coverage of children other than the terms of a
relationship between a child and the plan
participant or subscriber.
(3) A nonprofit
medical service corporation shall not deny or restrict coverage for a child
who has not attained twenty-six (26) years of age
based on the presence or absence of the child’s
financial dependency upon the participant, primary
subscriber or any other person, residency with
the participant and in the individual market the
primary subscriber, or with any other person,
marital status, student status, employment or any
combination of those factors. A nonprofit
medical service corporation shall not deny or restrict
coverage of a child based on eligibility for
other coverage, except as provided in (b)(1) of this
section.
(4) Nothing in this
section shall be construed to require a health insurance carrier to make
coverage available for the child of a child receiving
dependent coverage, unless the grandparent
becomes the legal guardian or adoptive parent of that
grandchild.
(5) The terms of
coverage in a health benefit plan offered by a nonprofit medical service
corporation or providing dependent coverage of
children cannot vary based on age except for
children who are twenty-six (26) years of age or
older.
(b)(1) For plan years
beginning before January 1, 2014, a group health plan providing
group health insurance coverage that is a
grandfathered health plan and makes available
dependent coverage of children may exclude an adult
child who has not attained twenty-six (26)
years of age from coverage only if the adult child is
eligible to enroll in an eligible employer-
sponsored health benefit plan, as defined in section
5000A(f)(2) of the federal Internal Revenue
Code, other than the group health plan of a parent.
(2) For plan years,
beginning on or after January 1, 2014, a health insurance carrier
providing group health insurance coverage that is a
grandfathered health plan shall comply with
the requirements of this section.
(c)This section does 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
diseased indemnity; or (8) other limited
benefit policies.
SECTION
8. Chapter 27-20 of the General laws entitled "Nonprofit Medical Service
Corporations" is
hereby amended by adding thereto the following sections:
27-20-6.1. Uniform
explanation of benefits and coverage. – (a) A nonprofit
medical
service corporation shall provide a summary of
benefits and coverage explanation and definitions
to policyholders and others required by, and at the
times and in the format required, by the federal
regulations adopted under section 2715 of the Public
Health Service Act, as amended by the
federal Affordable Care Act. The forms required by
this section shall be made available to the
commissioner on request. Nothing in this section shall
be construed to limit the authority of the
commissioner under existing state law.
(b) 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.
(c) If the commissioner
of the office of the health insurance commissioner determines
that the corresponding provision of the federal
Patient Protection and Affordable Care Act has
been declared invalid by a final judgment of the
federal judicial branch or has been repealed by
an act of Congress, on the date of the commissioner’s
determination this section shall have its
effectiveness suspended indefinitely, and the
commissioner shall take no action to enforce this
section. Nothing in this section shall be construed to
limit the authority of the commissioner
under existing state law.
27-20-6.2. Filing
of policy forms. – (a) A nonprofit medical service corporation
shall file all
policy forms and rates used by it in the state with
the commissioner, including the forms of any
rider, endorsement, application blank, and other
matter generally used or incorporated by
reference in its policies or contracts of insurance.
No such form shall be used if disapproved by
the commissioner under this section, or if the
commissioner’s approval has been withdrawn after
notice and an opportunity to be heard, or until the
expiration of sixty (60) days following the
filing of the form. Such a company shall comply with
its filed and approved forms. If the
commissioner finds from an examination of any form
that it is contrary to the public interest, or
the requirements of this code or duly promulgated
regulations, he or she shall forbid its use, and
shall notify the corporation in writing.
(b) Each rate filing
shall include a certification by a qualified actuary that to the best of
the actuary's knowledge and judgment, the entire rate
filing is in compliance with applicable laws
and that the benefits offered or proposed to be
offered are reasonable in relation to the premium
to be charged. A health insurance carrier shall comply
with its filed and approved rates and forms.
27-20-57.
Prohibition on preexisting condition exclusions. -- (a) A
health insurance
policy, subscriber contract, or health plan offered,
issued, issued for delivery, or issued to cover a
resident of this state by a health insurance company
licensed pursuant to this title and/or chapter:
(1) Shall not limit
or exclude coverage for an individual under the age of nineteen (19) by
imposing a preexisting condition exclusion on that
individual.
(2) For plan or
policy years beginning on or after January 1, 2014, shall not limit or
exclude coverage for any individual by imposing a
preexisting condition exclusion on that
individual.
(b) As used in this
section:
(1) “Preexisting
condition exclusion” means a limitation or exclusion of benefits,
including a denial of coverage, based on the fact that
the condition (whether physical or mental)
was present before the effective date of coverage, or
if the coverage is denied, the date of denial,
under a health benefit plan whether or not any medical
advice, diagnosis, care or treatment was
recommended or received before the effective date of
coverage.
(2) “Preexisting
condition exclusion” means any limitation or exclusion of benefits,
including a denial of coverage, applicable to an
individual as a result of information relating to an
individual’s health status before the individual’s
effective date of coverage, or if the coverage is
denied, the date of denial, under the health benefit
plan, such as a condition (whether physical or
mental) identified as a result of a pre-enrollment
questionnaire or physical examination given to
the individual, or review of medical records relating
to the pre-enrollment period.
(c) This section
shall not apply to grandfathered health plans providing individual health
insurance coverage.
(d) 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.
27-20-58.
Prohibition on rescission of coverage. – (a)(1) Coverage under
a health
benefit plan subject to the jurisdiction of the
commissioner under this chapter with respect to an
individual, including a group to which the individual
belongs or family coverage in which the
individual is included, shall not be subject to
rescission after the individual is covered under the
plan, unless:
(A)The individual or
a person seeking coverage on behalf of the individual, performs an
act, practice or omission that constitutes fraud; or
(B)The individual
makes an intentional misrepresentation of material fact, as prohibited
by the terms of the plan or coverage.
(2) For purposes of paragraph
(1)(A), a person seeking coverage on behalf of an
individual does not include an insurance producer or
employee or authorized representative of the
health carrier.
(b) At least thirty
(30) days advance written notice shall be provided to each plan enrollee
or, for individual health insurance coverage, primary
subscriber, who would be affected by the
proposed rescission of coverage before coverage under
the plan may be rescinded in accordance
with subsection (a) regardless of, in the case of
group health insurance coverage, whether the
rescission applies to the entire group or only to an
individual within the group.
(c) This section
applies to grandfathered health plans.
27-20-59. Annual
and lifetime limits. – (a) Annual limits.
(1) For plan or
policy years beginning prior to January 1, 2014, for any individual, a
health insurance carrier and health benefit plan
subject to the jurisdiction of the commissioner
under this chapter may establish an annual limit on
the dollar amount of benefits that are essential
health benefits provided the restricted annual limit
is not less than the following:
(A) For a plan or
policy year beginning after September 22, 2011, but before September
23, 2012 – one million two hundred fifty thousand
dollars ($1,250,000); and
(B) For a plan or
policy year beginning after September 22, 2012, but before January 1,
2014 – two million dollars ($2,000,000).
(2) For plan or
policy years beginning on or after January 1, 2014, a health insurance
carrier and health benefit plan shall not establish
any annual limit on the dollar amount of
essential health benefits for any individual, except:
(A) A health flexible
spending arrangement, as defined in section 106(c)(2)(i)
of the
federal Internal Revenue Code, a medical savings
account, as defined in section 220 of the federal
Internal Revenue Code, and a health savings account,
as defined in section 223 of the federal
Internal Revenue Code are not subject to the
requirements of subdivisions (1) and (2) of this
subsection.
(B) The provisions of
this subsection shall not prevent a health insurance carrier from
placing annual dollar limits for any individual on specific
covered benefits that are not essential
health benefits to the extent that such limits are
otherwise permitted under applicable federal law
or the laws and regulations of this state.
(3) In determining
whether an individual has received benefits that meet or exceed the
allowable limits, as provided in subdivision (1) of
this subsection, a health insurance carrier shall
take into account only essential health benefits.
(b) Lifetime limits.
(1) A health
insurance carrier and health benefit plan offering group or individual health
insurance coverage shall not establish a lifetime
limit on the dollar value of essential health
benefits for any individual.
(2) Notwithstanding
subdivision (1) above, a health insurance carrier and health benefit
plan is not prohibited from placing lifetime dollar
limits for any individual on specific covered
benefits that are not essential health benefits, as
designated pursuant to a state determination and
in accordance with federal laws and regulations.
(c)(1) Except as
provided in subdivision (2) of this subsection, this section applies to any
health insurance carrier providing coverage under an
individual or group health plan.
(2)(A) The
prohibition on lifetime limits applies to grandfathered health plans.
(B) The prohibition
and limits on annual limits apply to grandfathered health plans
providing group health insurance coverage, but the
prohibition and limits on annual limits do not
apply to grandfathered health plans providing
individual health insurance coverage.
(d) This section
shall not apply to a plan or to policy years prior to January 1, 2014 for
which the Secretary of the
pursuant to 45 C.F.R. §147.126(d)(3). This section
also 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.
(e) If the
commissioner of the office of the health insurance commissioner determines
that the corresponding provision of the federal
Patient Protection and Affordable Care Act has
been declared invalid by a final judgment of the
federal judicial branch or has been repealed by
an act of Congress, on the date of the commissioner’s
determination this section shall have its
effectiveness suspended indefinitely, and the
commissioner shall take no action to enforce this
section. Nothing in this subsection shall be construed
to limit the authority of the Commissioner
to regulate health insurance under existing state law.
27-20-60. Coverage
for individuals participating in approved clinical trials. – (a)
As
used in this section,
(1) “Approved
clinical trial” means a phase I, phase II, phase III or phase IV clinical trial
that is conducted in relation to the prevention,
detection or treatment of cancer or a life-
threatening disease or condition and is described in
any of the following:
(A) The study or
investigation is approved or funded, which may include funding through
in-kind contributions, by one or more of the
following:
(i)
The federal National Institutes of Health;
(ii) The federal
Centers for Disease Control and Prevention;
(iii) The federal
Agency for Health Care Research and Quality;
(iv) The federal
Centers for Medicare & Medicaid Services;
(v) A cooperative
group or center of any of the entities described in items (i)
through (iv)
or the
(vi) A qualified non-governmental
research entity identified in the guidelines issued by
the federal National Institutes of Health for center
support grants; or
(vii) A study or
investigation conducted by the
U.S. Department of Defense, or the U.S. Department of
Energy, if the study or investigation has
been reviewed and approved through a system of peer
review that the Secretary of
Department of Health and Human Services determines:
(I) Is comparable to
the system of peer review of studies and investigations used by the
federal National Institutes of Health; and
(II) Assures unbiased
review of the highest scientific standards by qualified individuals
who have no interest in the outcome of the review.
(B) The study or
investigation is conducted under an investigational new drug application
reviewed by the
(C) The study or
investigation is a drug trial that is exempt from having such an
investigational new drug application.
(2) “Participant” has
the meaning stated in section 3(7) of federal ERISA.
(3) “Participating
provider” means a health care provider that, under a contract with the
health carrier or with its contractor or
subcontractor, has agreed to provide health care services to
covered persons with an expectation of receiving
payment, other than coinsurance, copayments or
deductibles, directly or indirectly from the health
carrier.
(4) “Qualified
individual” means a participant or beneficiary who meets the following
conditions:
(A) The individual is
eligible to participate in an approved clinical trial according to the
trial protocol with respect to the treatment of cancer
or other life-threatening disease or condition;
and
(B)(i) The referring health care professional is a
participating provider and has concluded
that the individual’s participation in such trial
would be appropriate based on the individual
meeting the conditions described in subdivision (A) of
this subdivision (3); or
(ii) The participant
or beneficiary provides medical and scientific information
establishing the individual’s participation in such
trial would be appropriate based on the
individual meeting the conditions described in
subdivision (A) of this subdivision (3).
(5) “Life-threatening
condition” means any disease or condition from which the
likelihood of death is probable unless the course of
the disease or condition is interrupted.
(b)(1) If a health
insurance carrier offering group or individual health insurance coverage
provides coverage to a qualified individual, the
health carrier:
(A) Shall not deny
the individual participation in an approved clinical trial.
(B) Subject to subdivision
(3) of this subsection, shall not deny or limit or impose
additional conditions on the coverage of routine
patient costs for items and services furnished in
connection with participation in the approved clinical
trial; and
(C) Shall not discriminate
against the individual on the basis of the individual’s
participation in the approved clinical trial.
(2)(A) Subject to
subdivision (B) of this subdivision (2), routine patient costs include all
items and services consistent with the coverage
typically covered for a qualified individual who is
not enrolled in an approved clinical trial.
(B) For purposes of
subdivision (B) of this subdivision (2), routine patient costs do not
include:
(i)
The investigational item, device or service itself;
(ii) Items and
services that are provided solely to satisfy data collection and analysis
needs and that are not used in the direct clinical
management of the patient; or
(iii) A service that
is clearly inconsistent with widely accepted and established standards
of care for a particular diagnosis.
(3) If one or more
participating providers is participating in a clinical trial, nothing in
subdivision (1) of this subsection shall be construed
as preventing a health carrier from requiring
that a qualified individual participate in the trial
through such a participating provider if the
provider will accept the individual as a participant
in the trial.
(4) Notwithstanding
subdivision (3) of this subsection, subdivision (1) of this subsection
shall apply to a qualified individual participating in
an approved clinical trial that is conducted
outside this state.
(5) This section
shall not be construed to require a nonprofit medical service corporation
offering group or individual health insurance coverage
to provide benefits for routine patient care
services provided outside of the coverage’s health
care provider network unless out-of-network
benefits are otherwise provided under the coverage.
(6) Nothing in this
section shall be construed to limit a health insurance carrier’s
coverage with respect to clinical trials.
(c) The requirements
of this section shall be in addition to the requirements of Rhode
Island general laws sections 27-18-36 through
27-18-36.3.
(d) 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.
(e) This section shall
be effective for plan years beginning on or after January 1, 2014.
27-20-61. Medical
loss ratio reporting and rebates. – (a) A nonprofit medical
service
corporation offering group or individual health
insurance coverage of a health benefit plan,
including a grandfathered health plan, shall comply
with the provisions of Section 2718 of the
Public Health Services Act as amended by the federal
Affordable Care Act, in accordance with
regulations adopted thereunder.
(b) Nonprofit medical
service corporations required to report medical loss ratio and
rebate calculations and any other medical loss ratio
and rebate information to the
Department of Health and Human Services shall
concurrently file such information with the
commissioner.
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
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 health care 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. 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.
(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.
27-20-63. Internal
and external appeal of adverse benefit determinations. -- (a) The
commissioner shall adopt regulations to implement
standards and procedures with respect to
internal claims and appeals of adverse benefit
determinations, and with respect to external appeals
of adverse benefit determinations.
(b) The regulations
adopted by the commissioner shall apply only to those adverse
benefit determinations which are not subject to the
jurisdiction of the department of health
pursuant to R.I. Gen. Laws § 23-17.12 et seq.
(Utilization Review Act).
(c)
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. This section also
shall not apply to
grandfathered health plans.
SECTION
9. Sections 27-41-2 and 27-41-61 of the General laws in Chapter 27-41
entitled "Health
Maintenance Organizations” are hereby amended to read as follows:
27-41-2.
Definitions. – As used in this chapter:
(a) "Adverse
benefit determination" means any of the following: a denial, reduction, or
termination of, or a failure to provide or make
payment (in whole or in part) for, a benefit,
including any such denial, reduction, termination, or
failure to provide or make payment that is
based on a determination of a an individual’s
eligibility to participate in a plan or to receive
coverage under a plan, and including, with respect to
group health plans, a denial, reduction, or
termination of, or a failure to provide or make
payment (in whole or in part) for, a benefit
resulting from the application of any utilization review,
as well as a failure to cover an item or
service for which benefits are otherwise provided
because it is determined to be experimental or
investigational or not medically necessary or
appropriate. The term also includes a rescission of
coverage determination.
(b) "Affordable
Care Act" means the federal Patient Protection and Affordable Care act
of 2010, as amended by the federal Health Care and
Education Reconciliation Act of 2010, and
federal regulations adopted thereunder;
(c) “Commissioner” or
“health insurance commissioner” means that individual appointed
pursuant to section 42-14.5-1 of the general laws.
(d) "Covered
health services" means the services that a health maintenance organization
contracts with enrollees and enrolled groups to
provide or make available to an enrolled
participant.
(e) "Director"
means the director of the department of business regulation or his or her
duly appointed agents.
(f) "Employee"
means any person who has entered into the employment of or works
under a contract of service or apprenticeship with any
employer. It shall not include a person who
has been employed for less than thirty (30) days by
his or her employer, nor shall it include a
person who works less than an average of thirty (30)
hours per week. For the purposes of this
chapter, the term "employee" means a person
employed by an "employer" as defined in
subsection (d) of this section. Except as otherwise
provided in this chapter the terms "employee"
and "employer" are to be defined according
to the rules and regulations of the department of labor
and training.
(g) "Employer"
means any person, partnership, association, trust, estate, or corporation,
whether foreign or domestic, or the legal
representative, trustee in bankruptcy, receiver, or trustee
of a receiver, or the legal representative of a
deceased person, including the state of
and each city and town in the state, which has in its
employ one or more individuals during any
calendar year. For the purposes of this section, the
term "employer" refers only to an employer
with persons employed within the state of
(h) "Enrollee"
means an individual who has been enrolled in a health maintenance
organization.
(i)
"Essential health benefits" shall have the meaning set forth in
section 1302(b) of the
federal Affordable Care Act.
(j)
"Evidence of coverage" means any certificate, agreement, or contract
issued to an
enrollee setting out the coverage to which the enrollee
is entitled.
(k) “Grandfathered
health plan” means any group health plan or health insurance
coverage subject to 42 USC section 18011.
(l) “Group health
insurance coverage” means, in connection with a group health plan,
health insurance coverage offered in connection with
such plan.
(m) “Group health
plan” means an employee welfare benefit plan as defined in 29 USC
section 1002(1), to the extent that the plan provides
health benefits to employees or their
dependents directly or through insurance,
reimbursement, or otherwise.
(n) “Health benefits”
or “covered benefits” means coverage or benefits for the diagnosis,
cure, mitigation, treatment, or prevention of disease,
or amounts paid for the purpose of affecting
any structure or function of the body including
coverage or benefits for transportation primarily
for and essential thereto, and including medical
services as defined in R.I. Gen. Laws § 27-19-17;
(o) “Health care
facility” means an institution providing health care services or a health
care setting, including but not limited to hospitals
and other licensed inpatient centers, ambulatory
surgical or treatment centers, skilled nursing
centers, residential treatment centers, diagnostic,
laboratory and imaging centers, and rehabilitation and
other therapeutic health settings.
(p) "Health care
professional" means a physician or other health care practitioner
licensed, accredited or certified to perform specified
health care services consistent with state
law.
(q) "Health care
provider" or "provider" means a health care professional or a
health care
facility.
(r) "Health
care services" means any services included in the furnishing to any
individual
of medical, podiatric, or dental care, or hospitalization,
or incident to the furnishing of that care or
hospitalization, and the furnishing to any person of
any and all other services for the purpose of
preventing, alleviating, curing, or healing human
illness, injury, or physical disability.
(s) “Health insurance
carrier” means a person, firm, corporation or other entity subject to
the jurisdiction of the commissioner under this
chapter, and includes a health maintenance
organization. Such term does not include a group
health plan.
(t) "Health
maintenance organization" means a single public or private organization
which:
(1) Provides or makes
available to enrolled participants health care services, including at
least the following basic health care services: usual
physician services, hospitalization, laboratory,
x-ray, emergency, and preventive services, and out of
area coverage, and the services of licensed
midwives;
(2) Is compensated,
except for copayments, for the provision of the basic health care
services listed in subdivision (1) of this subsection
to enrolled participants on a predetermined
periodic rate basis; and
(3) Provides physicians'
services primarily:
(A) Directly through
physicians who are either employees or partners of the organization;
or
(B) Through arrangements
with individual physicians or one or more groups of
physicians organized on a group practice or individual
practice basis;
(ii) "Health
maintenance organization" does not include prepaid plans offered by
entities
regulated under chapter 1, 2, 19, or 20 of this title
that do not meet the criteria above and do not
purport to be health maintenance organizations;
(4) Provides the
services of licensed midwives primarily:
(i)
Directly through licensed midwives who are either employees or partners of the
organization; or
(ii) Through
arrangements with individual licensed midwives or one or more groups of
licensed midwives organized on a group practice or
individual practice basis.
(u) "Licensed
midwife" means any midwife licensed pursuant to section 23-13-9.
(v) "Material
modification" means only systemic changes to the information filed under
section 27-41-3.
(w) "Net
worth", for the purposes of this chapter, means the excess of total
admitted
assets over total liabilities.
(x) "Office of
the health insurance commissioner" means the agency established under
section 42-14.5-1 of the general laws.
(y)
"Physician" includes podiatrist as defined in chapter 29 of title 5.
(z) "Private
organization" means a legal corporation with a policy making and governing
body.
(aa)
"Provider" means any physician, hospital, licensed midwife, or other
person who is
licensed or authorized in this state to furnish health
care services.
(bb) "Public
organization" means an instrumentality of government.
(cc)
“Rescission" means a cancellation or discontinuance of coverage that has
retroactive
effect for reasons unrelated to timely payment of
required premiums or contribution to costs of
coverage.
(dd)
"Risk based capital ("RBC") instructions" means the risk
based capital report
including risk based capital instructions adopted by
the National Association of Insurance
Commissioners ("NAIC"), as these risk based
capital instructions are amended by the NAIC in
accordance with the procedures adopted by the NAIC.
(ee)
"Total adjusted capital" means the sum of:
(1) A health
maintenance organization's statutory capital and surplus (i.e. net worth) as
determined in accordance with the statutory accounting
applicable to the annual financial
statements required to be filed under section 27-41-9;
and
(2) Any other items,
if any, that the RBC instructions provide.
(ff) "Uncovered
expenditures" means the costs of health care services that are covered by
a health maintenance organization, but that are not
guaranteed, insured, or assumed by a person or
organization other than the health maintenance
organization. Expenditures to a provider that
agrees not to bill enrollees under any circumstances
are excluded from this definition.
27-41-61. Termination
of children's benefits Eligibility for children’s benefits --
(a)(1) Every
individual health insurance contract, plan, or policy health benefit
plan delivered,
issued for delivery, or renewed in this state which
provides medical health benefits coverage for
dependent children that includes coverage for
physician services in a physician’s office, and
every policy which provides major medical or similar
comprehensive type coverage dependents,
except for supplemental policies which only provide
coverage for specified diseases and other
supplemental policies, shall provide make coverage available
of an unmarried child under the age
of nineteen (19) years, an unmarried child who is a
student under the age of twenty-five (25)
years and who is financially dependent upon the parent
and an unmarried child of any age who is
financially dependent upon the parent and medically
determined to have a physical or mental
impairment which can be expected to result in death or
which has lasted or can be expected to last
for a continuous period of not less than twelve (12)
months for children until
attainment of
twenty-six (26) years of age, and an unmarried child
of any age who is financially dependent
upon the parent and medically determined to have a
physical or mental impairment which can be
expected to result in death or which has lasted or can
be expected to last for a continuous period
of not less than twelve (12) months. Such contract, plan or policy shall also
include a provision
that policyholders shall receive no less than thirty
(30) days notice from the accident and sickness
insurer that a child covered as a dependent by the
policy holder is about to lose his or her
coverage as a result of reaching the maximum age for a
dependent child, and that the child will
only continue to be covered upon documentation being
provided of current full or part-time
enrollment in a post-secondary educational institution
or that the child may purchase a conversion
policy if he or she is not an eligible student.
Nothing in this section prohibits an accident and
sickness insurer from requiring a policy holder to
annually provide proof of a child’s current full
or part-time enrollment in a post-secondary
educational institution in order to maintain the child’s
coverage. Provided, nothing in this section requires
coverage inconsistent with the membership
criteria in effect under the policyholder’s health
benefits coverage.
(2) With respect to a
child who has not attained twenty-six (26) years of age, a health
maintenance organization shall not define “dependent”
for purposes of eligibility for dependent
coverage of children other than the terms of a
relationship between a child and the plan
participant, or subscriber.
(3) A health
maintenance organization shall not deny or restrict coverage for a child who
has not attained twenty-six (26) years of age based on
the presence or absence of the child’s
financial dependency upon the participant, primary
subscriber or any other person, residency with
the participant and in the individual market the
primary subscriber, or with any other person,
marital status, student status, employment or any
combination of those factors. A health carrier
shall not deny or restrict coverage of a child based
on eligibility for other coverage, except as
provided in (b) (1) of this section.
(4) Nothing in this
section shall be construed to require a health maintenance
organization to make coverage available for the child
of a child receiving dependent coverage,
unless the grandparent becomes the legal guardian or
adoptive parent of that grandchild.
(5) The terms of
coverage in a health benefit plan offered by a health maintenance
organization providing dependent coverage of children
cannot vary based on age except for
children who are twenty-six (26) years of age or
older.
(b)(1) For plan years
beginning before January 1, 2014, a group health plan providing
group health insurance coverage that is a
grandfathered health plan and makes available
dependent coverage of children may exclude an adult
child who has not attained twenty-six (26)
years of age from coverage only if the adult child is
eligible to enroll in an eligible employer-
sponsored health benefit plan, as defined in section
5000A(f)(2) of the federal Internal Revenue
Code, other than the group health plan of a parent.
(2) For plan years,
beginning on or after January 1, 2014, a group health plan providing
group health insurance coverage that is a
grandfathered health plan shall comply with the
requirements of this section
(c) This section does
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
diseased indemnity; or (8) other limited
benefit policies.
SECTION
10. Chapter 27-41 of the General laws entitled "Health Maintenance
Organizations" is
hereby amended by adding thereto the following sections:
27-41-29.1.
Uniform explanation of benefits and coverage. -- (a) A health
maintenance
organization shall provide a summary of benefits and coverage
explanation and definitions to
policyholders and others required by, and at the times
and in the format required, by the federal
regulations adopted under section 2715 of the Public
Health Service Act, as amended by the
federal Affordable Care Act. The forms required by
this section shall be made available to the
commissioner on request. Nothing in this section shall
be construed to limit the authority of the
commissioner under existing state law.
(b) 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.
(c) If the
commissioner of the office of the health insurance commissioner determines
that the corresponding provision of the federal
Patient Protection and Affordable Care Act has
been declared invalid by a final judgment of the
federal judicial branch or has been repealed by
an act of Congress, on the date of the commissioner’s
determination this section shall have its
effectiveness suspended indefinitely, and the
commissioner shall take no action to enforce this
section. Nothing in this section shall be construed to
limit the authority of the commissioner
under existing state law.
27-41-29.2. Filing
of policy forms. – (a)
A health maintenance organization shall file all
policy forms and rates used by it in the state with
the commissioner, including the forms of any
rider, endorsement, application blank, and other
matter generally used or incorporated by
reference in its policies or contracts of insurance.
No such form shall be used if disapproved by
the commissioner under this section, or if the
commissioner’s approval has been withdrawn after
notice and an opportunity to be heard, or until the
expiration of sixty (60) days following the
filing of the form. Such a company shall comply with
its filed and approved forms. If the
commissioner finds from an examination of any form
that it is contrary to the public interest or
the requirements of this code or duly promulgated
regulations, he or she shall forbid its use, and
shall notify the corporation in writing.
(b) Each rate filing
shall include a certification by a qualified actuary that to the best of
the actuary's knowledge and judgment, the entire rate
filing is in compliance with applicable laws
and that the benefits offered or proposed to be
offered are reasonable in relation to the premium
to be charged. A health insurance carrier shall comply
with its filed and approved rates and
forms.
27-41-75.
Prohibition on rescission of coverage. -- (a)(1) Coverage under
a health plan
subject to the jurisdiction of the commissioner under
this chapter with respect to an individual,
including a group to which the individual belongs or
family coverage in which the individual is
included, shall not be rescinded after the individual
is covered under the plan, unless:
(A) The individual or
a person seeking coverage on behalf of the individual, performs an
act, practice or omission that constitutes fraud; or
(B) The individual
makes an intentional misrepresentation of material fact, as prohibited
by the terms of the plan or coverage.
(2) For purposes of
paragraph (1)(A), a person seeking coverage on behalf of an
individual does not include an insurance producer or
employee or authorized representative of the
health maintenance organization.
(b) At least thirty
(30) days advance written notice shall be provided to each plan enrollee
or, for individual health insurance coverage, primary
subscriber, who would be affected by the
proposed rescission of coverage before coverage under
the plan may be rescinded in accordance
with subsection (a) regardless of, in the case of
group health insurance coverage, whether the
rescission applies to the entire group or only to an
individual within the group.
(c) For purposes of
this section, “to rescind” means to cancel or to discontinue coverage
with retroactive effect for reasons unrelated to timely
payment of required premiums or
contribution to costs of coverage.
(d) This section
applies to grandfathered health plans.
27-41-76.
Prohibition on annual and lifetime limits. -- (a) Annual
limits.
(1) For plan or policy
years beginning prior to January 1, 2014, for any individual, a
health maintenance organization subject to the
jurisdiction of the commissioner under this chapter
may establish an annual limit on the dollar amount of
benefits that are essential health benefits
provided the restricted annual limit is not less than
the following:
(A) For a plan or
policy year beginning after September 22, 2011, but before September
23, 2012 – one million two hundred fifty thousand
dollars ($1,250,000); and
(B) For a plan or
policy year beginning after September 22, 2012, but before January 1,
2014 – two million dollars ($2,000,000).
(2 ) For plan or
policy years beginning on or after January 1, 2014, a health maintenance
organization shall not establish any annual limit on
the dollar amount of essential health benefits
for any individual, except:
(A) A health flexible
spending arrangement, as defined in section 106(c)(2)(i)
of the
federal Internal Revenue Code, a medical savings
account, as defined in section 220 of the federal
Internal Revenue Code, and a health savings account,
as defined in section 223 of the federal
Internal Revenue Code are not subject to the
requirements of subdivisions (1) and (2) of this
subsection .
(B) The provisions of
this subsection shall not prevent a health maintenance organization
from placing annual dollar limits for any individual
on specific covered benefits that are not
essential health benefits to the extent that such
limits are otherwise permitted under applicable
federal law or the laws and regulations of this state.
(3) In determining
whether an individual has received benefits that meet or exceed the
allowable limits, as provided in subdivision (1) of
this subsection, a health maintenance
organization shall take into account only essential
health benefits.
(b) Lifetime limits.
(1) A health
insurance carrier and health benefit plan offering group or individual health
insurance coverage shall not establish a lifetime
limit on the dollar value of essential health
benefits for any individual.
(2) Notwithstanding
subdivision (1) above, a health insurance carrier and health benefit
plan is not prohibited from placing lifetime dollar limits
for any individual on specific covered
benefits that are not essential health benefits in
accordance with federal laws and regulations.
(c)(1) The provisions
of this section relating to lifetime limits apply to any health
maintenance organization or health insurance carrier
providing coverage under an individual or
group health plan, including grandfathered health
plans.
(2) The provisions of
this section relating to annual limits apply to any health
maintenance organization or health insurance carrier
providing coverage under a group health
plan, including grandfathered health plans, but the
prohibition and limits on annual limits do not
apply to grandfathered health plans providing
individual health insurance coverage.
(d) This section
shall not apply to a plan or to policy years prior to January 1, 2014 for
which the Secretary of the
pursuant to 45 C.F.R. § 147.126(d)(3). This section
also 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.
(e) If the
commissioner of the office of the health insurance commissioner determines
that the corresponding provision of the federal
Patient Protection and Affordable Care Act has
been declared invalid by a final judgment of the
federal judicial branch or has been repealed by
an act of Congress, on the date of the commissioner’s
determination this section shall have its
effectiveness suspended indefinitely, and the
commissioner shall take no action to enforce this
section. Nothing in this subsection shall be construed
to limit the authority of the Commissioner
to regulate health insurance under existing state law.
27-41-77. Coverage
for individual participating in approved clinical trials. -- (a)
As
used in this section.
(1) “Approved
clinical trial” means a phase I, phase II, phase III or phase IV clinical trial
that is conducted in relation to the prevention,
detection or treatment of cancer or a life-
threatening disease or condition and is described in
any of the following:
(A) The study or
investigation is approved or funded, which may include funding through
in-kind contributions, by one or more of the
following:
(i)
The federal National Institutes of Health;
(ii) The federal
Centers for Disease Control and Prevention;
(iii) The federal
Agency for Health Care Research and Quality;
(iv) The federal
Centers for Medicare & Medicaid Services;
(v) A cooperative
group or center of any of the entities described in items (i)
through (iv)
or the
(vi) A qualified
non-governmental research entity identified in the guidelines issued by
the federal National Institutes of Health for center
support grants; or
(vii) A study or
investigation conducted by the
U.S. Department of Defense, or the U.S. Department of
Energy, if the study or investigation has
been reviewed and approved through a system of peer
review that the Secretary of
Department of Health and Human Services determines:
(I) Is comparable to
the system of peer review of studies and investigations used by the
federal National Institutes of Health; and
(II) Assures unbiased
review of the highest scientific standards by qualified individuals
who have no interest in the outcome of the review.
(B) The study or
investigation is conducted under an investigational new drug application
reviewed by the
(C) The study or
investigation is a drug trial that is exempt from having such an
investigational new drug application.
(2) “Participant” has
the meaning stated in section 3(7) of federal ERISA.
(3) “Participating
provider” means a health care provider that, under a contract with the
health carrier or with its contractor or
subcontractor, has agreed to provide health care services to
covered persons with an expectation of receiving
payment, other than coinsurance, copayments or
deductibles, directly or indirectly from the health
carrier.
(4) “Qualified
individual” means a participant or beneficiary who meets the following
conditions:
(A) The individual is
eligible to participate in an approved clinical trial according to the
trial protocol with respect to the treatment of cancer
or other life-threatening disease or condition;
and
(B)(i) The referring health care professional is a
participating provider and has concluded
that the individual’s participation in such trial
would be appropriate based on the individual
meeting the conditions described in subdivision (A) of
this subdivision (3); or
(ii) The participant
or beneficiary provides medical and scientific information
establishing the individual’s participation in such
trial would be appropriate based on the
individual meeting the conditions described in
subdivision (A) of this subdivision (3).
(5) “Life-threatening
condition” means any disease or condition from which the
likelihood of death is probable unless the course of
the disease or condition is interrupted.
(b)(1) If a health
maintenance organization offering group or individual health insurance
coverage provides coverage to a qualified individual,
it:
(A) Shall not deny
the individual participation in an approved clinical trial.
(B) Subject to
subdivision (3) of this subsection, shall not deny or limit or impose
additional conditions on the coverage of routine
patient costs for items and services furnished in
connection with participation in the approved clinical
trial; and
(C) Shall not
discriminate against the individual on the basis of the individual’s
participation in the approved clinical trial.
(2)(A) Subject to
subdivision (B) of this subdivision (2), routine patient costs include all
items and services consistent with the coverage
typically covered for a qualified individual who is
not enrolled in an approved clinical trial.
(B) For purposes of
subdivision (B) of this subdivision (2), routine patient costs do not
include:
(i)
The investigational item, device or service itself;
(ii) Items and
services that are provided solely to satisfy data collection and analysis
needs and that are not used in the direct clinical
management of the patient; or
(iii) A service that
is clearly inconsistent with widely accepted and established standards
of care for a particular diagnosis.
(3) If one or more participating
providers is participating in a clinical trial, nothing in
subdivision (1) of this subsection shall be construed
as preventing a health maintenance
organization from requiring that a qualified
individual participate in the trial through such a
participating provider if the provider will accept the
individual as a participant in the trial.
(4) Notwithstanding
subdivision (3) of this subsection, subdivision (1) of this subsection
shall apply to a qualified individual participating in
an approved clinical trial that is conducted
outside this state.
(5) This section
shall not be construed to require a health maintenance organization
offering group or individual health insurance coverage
to provide benefits for routine patient care
services provided outside of the coverage’s health
care provider network unless out-of-network
benefits are other provided under the coverage.
(6) Nothing in this
section shall be construed to limit a health maintenance organization’s
coverage with respect to clinical trials.
(c) The requirements
of this section shall be in addition to the requirements of Rhode
Island general laws sections 27-41-41 through
27-41-41.3.
(d) 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.
27-41-78. Medical
loss ratio reporting and rebates. -- (a) A health maintenance
organization offering group or individual health
insurance coverage of a health benefit plan,
including a grandfathered health plan, shall comply
with the provisions of Section 2718 of the
Public Health Services Act as amended by the federal
Affordable Care Act, in accordance with
regulations adopted thereunder.
(b) Health
maintenance organizations required to report medical loss ratio and rebate
calculations and any other medical loss ratio or
rebate information to the
Health and Human Services shall concurrently file such
information with the commissioner.
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. 1395 dd)
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. 1395 dd) 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.1395 dd(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 health care 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 plan or
health maintenance organization is required
to pay under subdivision (1) of this subsection. 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.
(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.
27-41-80. Internal
and external appeal of adverse benefit determinations. -- (a)
The
commissioner shall adopt regulations to implement
standards and procedures with respect to
internal claims and appeals of adverse benefit
determinations, and with respect to external appeals
of adverse benefit determinations.
(b) The regulations
adopted by the commissioner shall apply only to those adverse
benefit determinations within the jurisdiction of the
department of health pursuant to R.I. Gen.
Laws § 23-17.12 et seq. (Utilization Review Act).
(c) 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. This section also
shall not apply to grandfathered health plans.
27-41-81.
Prohibition on preexisting condition exclusions. -- (a) A
health insurance
policy, subscriber contract, or health plan offered,
issued, issued for delivery, or issued to cover a
resident of this state by a health insurance company
licensed pursuant to this title and/or chapter:
(1) Shall not limit
or exclude coverage for an individual under the age of nineteen (19) by
imposing a preexisting condition exclusion on that
individual.
(2) For plan or
policy years beginning on or after January 1, 2014, shall not limit or
exclude coverage for any individual by imposing a
preexisting condition exclusion on that
individual.
(b) As used in this
section:
(1) “Preexisting
condition exclusion” means a limitation or exclusion of benefits,
including a denial of coverage, based on the fact that
the condition (whether physical or mental)
was present before the effective date of coverage, or
if the coverage is denied, the date of denial,
under a health benefit plan whether or not any medical
advice, diagnosis, care or treatment was
recommended or received before the effective date of
coverage.
(2) “Preexisting
condition exclusion” means any limitation or exclusion of benefits,
including a denial of coverage, applicable to an
individual as a result of information relating to an
individual’s health status before the individual’s effective
date of coverage, or if the coverage is
denied, the date of denial, under the health benefit
plan, such as a condition (whether physical or
mental) identified as a result of a pre-enrollment
questionnaire or physical examination given to
the individual, or review of medical records relating
to the pre-enrollment period.
(c) This section
shall not apply to grandfathered health plans providing individual health
insurance coverage.
(d) 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
11. Sections 27-50-3 and 27-50-7 of the General Laws in Chapter 27-50
entitled "Small
Employer Health Insurance Availability Act" are hereby amended to read as
follows:
27-50-3.
Definitions. [Effective December 31, 2010.] -- (a) "Actuarial
certification"
means a written statement signed by a member of the
individual acceptable to the director that a small
employer carrier is in compliance with the
provisions of section 27-50-5, based upon the person's
examination and including a review of the
appropriate records and the actuarial assumptions and
methods used by the small employer carrier
in establishing premium rates for applicable health
benefit plans.
(b) "Adjusted
community rating" means a method used to develop a carrier's premium
which spreads financial risk across the carrier's
entire small group population in accordance with
the requirements in section 27-50-5.
(c)
"Affiliate" or "affiliated" means any entity or person who
directly or indirectly
through one or more intermediaries controls or is
controlled by, or is under common control with,
a specified entity or person.
(d) "Affiliation
period" means a period of time that must expire before health insurance
coverage provided by a carrier becomes effective, and
during which the carrier is not required to
provide benefits.
(e) "Bona fide
association" means, with respect to health benefit plans offered in this
state, an association which:
(1) Has been actively
in existence for at least five (5) years;
(2) Has been formed and
maintained in good faith for purposes other than obtaining
insurance;
(3) Does not condition
membership in the association on any health-status related factor
relating to an individual (including an employee of an
employer or a dependent of an employee);
(4) Makes health
insurance coverage offered through the association available to all
members regardless of any health status-related factor
relating to those members (or individuals
eligible for coverage through a member);
(5) Does not make
health insurance coverage offered through the association available
other than in connection with a member of the
association;
(6) Is composed of
persons having a common interest or calling;
(7) Has a constitution
and bylaws; and
(8) Meets any
additional requirements that the director may prescribe by regulation.
(f) "Carrier"
or "small employer carrier" means all entities licensed, or required
to be
licensed, in this state that offer health benefit
plans covering eligible employees of one or more
small employers pursuant to this chapter. For the purposes
of this chapter, carrier includes an
insurance company, a nonprofit hospital or medical
service corporation, a fraternal benefit
society, a health maintenance organization as defined
in chapter 41 of this title or as defined in
chapter 62 of title 42, or any other entity subject to
state insurance regulation that provides
medical care as defined in subsection (y) that is paid
or financed for a small employer by such
entity on the basis of a periodic premium, paid
directly or through an association, trust, or other
intermediary, and issued, renewed, or delivered within
or without
employer pursuant to the laws of this or any other
jurisdiction, including a certificate issued to an
eligible employee which evidences coverage under a
policy or contract issued to a trust or
association.
(g) "Church
plan" has the meaning given this term under section 3(33) of the Employee
Retirement Income Security Act of 1974 [29 U.S.C.
section 1002(33)_.
(h) "Control"
is defined in the same manner as in chapter 35 of this title.
(i)
(1) "Creditable coverage" means, with respect to an individual,
health benefits or
coverage provided under any of the following:
(i)
A group health plan;
(ii) A health benefit
plan;
(iii) Part A or part B
of Title XVIII of the Social Security Act, 42 U.S.C. section 1395c
et seq., or 42 U.S.C. section 1395j et seq.,
(Medicare);
(iv) Title XIX of the
Social Security Act, 42 U.S.C. section 1396 et seq., (Medicaid),
other than coverage consisting solely of benefits
under 42 U.S.C. section 1396s (the program for
distribution of pediatric vaccines);
(v) 10 U.S.C. section
1071 et seq., (medical and dental care for members and certain
former members of the uniformed services, and for
their dependents)(Civilian Health and
Medical Program of the Uniformed Services)(CHAMPUS).
For purposes of 10 U.S.C. section
1071 et seq., "uniformed services" means the
armed forces and the commissioned corps of the
National Oceanic and Atmospheric Administration and of
the Public Health Service;
(vi) A medical care
program of the Indian Health Service or of a tribal organization;
(vii) A state health
benefits risk pool;
(viii) A health plan
offered under 5 U.S.C. section 8901 et seq., (Federal Employees
Health Benefits Program (FEHBP));
(ix) A public health
plan, which for purposes of this chapter, means a plan established or
maintained by a state, county, or other political
subdivision of a state that provides health
insurance coverage to individuals enrolled in the
plan; or
(x) A health benefit
plan under section 5(e) of the Peace Corps Act (22 U.S.C. section
2504(e)).
(2) A period of
creditable coverage shall not be counted, with respect to enrollment of an
individual under a group health plan, if, after the
period and before the enrollment date, the
individual experiences a significant break in
coverage.
(j)
"Dependent" means a spouse, an unmarried child under the age of
nineteen (19)
twenty-six (26)
years, an unmarried child who is a student under the age of twenty-five (25)
years, and
an unmarried child of any age who is financially dependent upon, the parent and
is
medically determined to have a physical or mental
impairment which can be expected to result in
death or which has lasted or can be expected to last
for a continuous period of not less than
twelve (12) months.
(k)
"Director" means the director of the department of business
regulation.
(l) [Deleted by P.L.
2006, ch. 258, section 2, and P.L. 2006, ch. 296, section 2.]
(m) "Eligible
employee" means an employee who works on a full-time basis with a
normal work week of thirty (30) or more hours, except
that at the employer's sole discretion, the
term shall also include an employee who works on a
full-time basis with a normal work week of
anywhere between at least seventeen and one-half
(17.5) and thirty (30) hours, so long as this
eligibility criterion is applied uniformly among all
of the employer's employees and without
regard to any health status-related factor. The term
includes a self-employed individual, a sole
proprietor, a partner of a partnership, and may
include an independent contractor, if the self-
employed individual, sole proprietor, partner, or
independent contractor is included as an
employee under a health benefit plan of a small
employer, but does not include an employee who
works on a temporary or substitute basis or who works
less than seventeen and one-half (17.5)
hours per week. Any retiree under contract with any
independently incorporated fire district is
also included in the definition of eligible employee,
as well as any former employee of an
employer who retired before normal retirement age, as
defined by 42 U.S.C. 18002(a)(2)(c) while
the employer participates in the early retiree
reinsurance program defined by that chapter. Persons
covered under a health benefit plan pursuant to the
Consolidated Omnibus Budget Reconciliation
Act of 1986 shall not be considered "eligible employees"
for purposes of minimum participation
requirements pursuant to section 27-50-7(d)(9).
(n) "Enrollment
date" means the first day of coverage or, if there is a waiting period,
the
first day of the waiting period, whichever is earlier.
(o) "Established
geographic service area" means a geographic area, as approved by the
director and based on the carrier's certificate of
authority to transact insurance in this state, within
which the carrier is authorized to provide coverage.
(p) "Family
composition" means:
(1) Enrollee;
(2) Enrollee, spouse
and children;
(3) Enrollee and
spouse; or
(4) Enrollee and
children.
(q) "Genetic
information" means information about genes, gene products, and inherited
characteristics that may derive from the individual or
a family member. This includes information
regarding carrier status and information derived from
laboratory tests that identify mutations in
specific genes or chromosomes, physical medical
examinations, family histories, and direct
analysis of genes or chromosomes.
(r) "Governmental
plan" has the meaning given the term under section 3(32) of the
Employee Retirement Income Security Act of 1974, 29
U.S.C. section 1002(32), and any federal
governmental plan.
(s) (1) "Group
health plan" means an employee welfare benefit plan as defined in section
3(1) of the Employee Retirement Income Security Act of
1974, 29 U.S.C. section 1002(1), to the
extent that the plan provides medical care, as defined
in subsection (y) of this section, and
including items and services paid for as medical care
to employees or their dependents as defined
under the terms of the plan directly or through
insurance, reimbursement, or otherwise.
(2) For purposes of
this chapter:
(i)
Any plan, fund, or program that would not be, but for PHSA Section 2721(e), 42
U.S.C. section 300gg(e), as added by P.L. 104-191, an
employee welfare benefit plan and that is
established or maintained by a partnership, to the extent
that the plan, fund or program provides
medical care, including items and services paid for as
medical care, to present or former partners
in the partnership, or to their dependents, as defined
under the terms of the plan, fund or program,
directly or through insurance, reimbursement or
otherwise, shall be treated, subject to paragraph
(ii) of this subdivision, as an employee welfare
benefit plan that is a group health plan;
(ii) In the case of a
group health plan, the term "employer" also includes the partnership
in relation to any partner; and
(iii) In the case of a
group health plan, the term "participant" also includes an individual
who is, or may become, eligible to receive a benefit
under the plan, or the individual's beneficiary
who is, or may become, eligible to receive a benefit
under the plan, if:
(A) In connection with
a group health plan maintained by a partnership, the individual is
a partner in relation to the partnership; or
(B) In connection with a
group health plan maintained by a self-employed individual,
under which one or more employees are participants,
the individual is the self-employed
individual.
(t) (1) "Health
benefit plan" means any hospital or medical policy or certificate, major
medical expense insurance, hospital or medical service
corporation subscriber contract, or health
maintenance organization subscriber contract. Health
benefit plan includes short-term and
catastrophic health insurance policies, and a policy
that pays on a cost-incurred basis, except as
otherwise specifically exempted in this definition.
(2) "Health
benefit plan" does not include one or more, or any combination of, the
following:
(i)
Coverage only for accident or disability income insurance, or any combination
of
those;
(ii) Coverage issued as
a supplement to liability insurance;
(iii) Liability
insurance, including general liability insurance and automobile liability
insurance;
(iv) Workers'
compensation or similar insurance;
(v) Automobile medical
payment insurance;
(vi) Credit-only
insurance;
(vii) Coverage for
on-site medical clinics; and
(viii) Other similar
insurance coverage, specified in federal regulations issued pursuant
to Pub. L. No. 104-191, under which benefits for
medical care are secondary or incidental to other
insurance benefits.
(3) "Health
benefit plan" does not include the following benefits if they are provided
under a separate policy, certificate, or contract of
insurance or are otherwise not an integral part
of the plan:
(i)
Limited scope dental or vision benefits;
(ii) Benefits for
long-term care, nursing home care, home health care, community-based
care, or any combination of those; or
(iii) Other similar,
limited benefits specified in federal regulations issued pursuant to
Pub. L. No. 104-191.
(4) "Health
benefit plan" does not include the following benefits if the benefits are
provided under a separate policy, certificate or contract
of insurance, there is no coordination
between the provision of the benefits and any
exclusion of benefits under any group health plan
maintained by the same plan sponsor, and the benefits
are paid with respect to an event without
regard to whether benefits are provided with respect
to such an event under any group health plan
maintained by the same plan sponsor:
(i)
Coverage only for a specified disease or illness; or
(ii) Hospital indemnity
or other fixed indemnity insurance.
(5) "Health
benefit plan" does not include the following if offered as a separate
policy,
certificate, or contract of insurance:
(i)
Medicare supplemental health insurance as defined under section 1882(g)(1) of
the
Social Security Act, 42 U.S.C. section 1395ss(g)(1);
(ii) Coverage
supplemental to the coverage provided under 10 U.S.C. section 1071 et
seq.; or
(iii) Similar
supplemental coverage provided to coverage under a group health plan.
(6) A carrier offering
policies or certificates of specified disease, hospital confinement
indemnity, or limited benefit health insurance shall
comply with the following:
(i)
The carrier files on or before March 1 of each year a certification with the
director
that contains the statement and information described
in paragraph (ii) of this subdivision;
(ii) The certification
required in paragraph (i) of this subdivision shall
contain the
following:
(A) A statement from
the carrier certifying that policies or certificates described in this
paragraph are being offered and marketed as
supplemental health insurance and not as a substitute
for hospital or medical expense insurance or major
medical expense insurance; and
(B) A summary
description of each policy or certificate described in this paragraph,
including the average annual premium rates (or range
of premium rates in cases where premiums
vary by age or other factors) charged for those
policies and certificates in this state; and
(iii) In the case of a
policy or certificate that is described in this paragraph and that is
offered for the first time in this state on or after
July 13, 2000, the carrier shall file with the
director the information and statement required in paragraph
(ii) of this subdivision at least thirty
(30) days prior to the date the policy or certificate
is issued or delivered in this state.
(u) "Health
maintenance organization" or "HMO" means a health maintenance
organization licensed under chapter 41 of this title.
(v) "Health
status-related factor" means any of the following factors:
(1) Health status;
(2) Medical condition,
including both physical and mental illnesses;
(3) Claims experience;
(4) Receipt of health
care;
(5) Medical history;
(6) Genetic
information;
(7) Evidence of
insurability, including conditions arising out of acts of domestic
violence; or
(8) Disability.
(w) (1) "Late
enrollee" means an eligible employee or dependent who requests
enrollment in a health benefit plan of a small
employer following the initial enrollment period
during which the individual is entitled to enroll
under the terms of the health benefit plan,
provided that the initial enrollment period is a
period of at least thirty (30) days.
(2) "Late
enrollee" does not mean an eligible employee or dependent:
(i)
Who meets each of the following provisions:
(A) The individual was
covered under creditable coverage at the time of the initial
enrollment;
(B) The individual lost
creditable coverage as a result of cessation of employer
contribution, termination of employment or
eligibility, reduction in the number of hours of
employment, involuntary termination of creditable
coverage, or death of a spouse, divorce or
legal separation, or the individual and/or dependents
are determined to be eligible for RIteCare
under chapter 5.1 of title 40 or chapter 12.3 of title
42 or for RIteShare under chapter 8.4 of title
40; and
(C) The individual
requests enrollment within thirty (30) days after termination of the
creditable coverage or the change in conditions that
gave rise to the termination of coverage;
(ii) If, where provided
for in contract or where otherwise provided in state law, the
individual enrolls during the specified bona fide open
enrollment period;
(iii) If the individual
is employed by an employer which offers multiple health benefit
plans and the individual elects a different plan
during an open enrollment period;
(iv) If a court has
ordered coverage be provided for a spouse or minor or dependent child
under a covered employee's health benefit plan and a
request for enrollment is made within thirty
(30) days after issuance of the court order;
(v) If the individual
changes status from not being an eligible employee to becoming an
eligible employee and requests enrollment within
thirty (30) days after the change in status;
(vi) If the individual
had coverage under a COBRA continuation provision and the
coverage under that provision has been exhausted; or
(vii) Who meets the
requirements for special enrollment pursuant to section 27-50-7 or
27-50-8.
(x) "Limited
benefit health insurance" means that form of coverage that pays stated
predetermined amounts for specific services or
treatments or pays a stated predetermined amount
per day or confinement for one or more named
conditions, named diseases or accidental injury.
(y) "Medical
care" means amounts paid for:
(1) The diagnosis,
care, mitigation, treatment, or prevention of disease, or amounts paid
for the purpose of affecting any structure or function
of the body;
(2) Transportation
primarily for and essential to medical care referred to in subdivision
(1); and
(3) Insurance covering
medical care referred to in subdivisions (1) and (2) of this
subsection.
(z) "Network
plan" means a health benefit plan issued by a carrier under which the
financing and delivery of medical care, including items
and services paid for as medical care, are
provided, in whole or in part, through a defined set
of providers under contract with the carrier.
(aa)
"Person" means an individual, a corporation, a partnership, an
association, a joint
venture, a joint stock company, a trust, an
unincorporated organization, any similar entity, or any
combination of the foregoing.
(bb) "Plan
sponsor" has the meaning given this term under section 3(16)(B) of the
Employee Retirement Income Security Act of 1974, 29
U.S.C. section 1002(16)(B).
(cc) (1)
"Preexisting condition" means a condition, regardless of the cause of
the
condition, for which medical advice, diagnosis, care,
or treatment was recommended or received
during the six (6) months immediately preceding the
enrollment date of the coverage.
(2) "Preexisting
condition" does not mean a condition for which medical advice,
diagnosis, care, or treatment was recommended or
received for the first time while the covered
person held creditable coverage and that was a covered
benefit under the health benefit plan,
provided that the prior creditable coverage was
continuous to a date not more than ninety (90)
days prior to the enrollment date of the new coverage.
(3) Genetic information
shall not be treated as a condition under subdivision (1) of this
subsection for which a preexisting condition exclusion
may be imposed in the absence of a
diagnosis of the condition related to the information.
(dd)
"Premium" means all moneys paid by a small employer and eligible
employees as a
condition of receiving coverage from a small employer
carrier, including any fees or other
contributions associated with the health benefit plan.
(ee)
"Producer" means any insurance producer licensed under chapter 2.4 of
this title.
(ff) "Rating
period" means the calendar period for which premium rates established by a
small employer carrier are assumed to be in effect.
(gg)
"Restricted network provision" means any provision of a health
benefit plan that
conditions the payment of benefits, in whole or in
part, on the use of health care providers that
have entered into a contractual arrangement with the
carrier pursuant to provide health care
services to covered individuals.
(hh)
"Risk adjustment mechanism" means the mechanism established pursuant
to section
27-50-16.
(ii)
"Self-employed individual" means an individual or sole proprietor who
derives a
substantial portion of his or her income from a trade
or business through which the individual or
sole proprietor has attempted to earn taxable income
and for which he or she has filed the
appropriate Internal Revenue Service Form 1040,
Schedule C or F, for the previous taxable year.
(jj)
"Significant break in coverage" means a period of ninety (90)
consecutive days
during all of which the individual does not have any
creditable coverage, except that neither a
waiting period nor an affiliation period is taken into
account in determining a significant break in
coverage.
(kk)
"Small employer" means, except for its use in section 27-50-7, any
person, firm,
corporation, partnership, association, political
subdivision, or self-employed individual that is
actively engaged in business including, but not
limited to, a business or a corporation organized
under the Rhode Island Non-Profit Corporation Act,
chapter 6 of title 7, or a similar act of
another state that, on at least fifty percent (50%) of
its working days during the preceding
calendar quarter, employed no more than fifty (50)
eligible employees, with a normal work week
of thirty (30) or more hours, the majority of whom
were employed within this state, and is not
formed primarily for purposes of buying health
insurance and in which a bona fide employer-
employee relationship exists. In determining the
number of eligible employees, companies that
are affiliated companies, or that are eligible to file
a combined tax return for purposes of taxation
by this state, shall be considered one employer.
Subsequent to the issuance of a health benefit
plan to a small employer and for the purpose of
determining continued eligibility, the size of a
small employer shall be determined annually. Except as
otherwise specifically provided,
provisions of this chapter that apply to a small
employer shall continue to apply at least until the
plan anniversary following the date the small employer
no longer meets the requirements of this
definition. The term small employer includes a
self-employed individual.
(ll
) "Waiting period" means, with respect to a group health plan and an
individual who
is a potential enrollee in the plan, the period that
must pass with respect to the individual before
the individual is eligible to be covered for benefits
under the terms of the plan. For purposes of
calculating periods of creditable coverage pursuant to
subsection (j)(2) of this section, a waiting
period shall not be considered a gap in coverage.
(mm) "Wellness
health benefit plan" means a plan developed pursuant to section 27-50-
10.
(nn)
"Health insurance commissioner" or "commissioner" means
that individual
appointed pursuant to section 42-14.5-1 of the general
laws and afforded those powers and duties
as set forth in sections 42-14.5-2 and 42-14.5-3 of
title 42.
(oo)
"Low-wage firm" means those with average wages that fall within the
bottom
quartile of all
(pp) "Wellness
health benefit plan" means the health benefit plan offered by each small
employer carrier pursuant to section 27-50-7.
(qq)
"Commissioner" means the health insurance commissioner.
27-50-7.
Availability of coverage. -- (a) Until October 1, 2004, for purposes of
this
section, "small employer" includes any
person, firm, corporation, partnership, association, or
political subdivision that is actively engaged in
business that on at least fifty percent (50%) of its
working days during the preceding calendar quarter,
employed a combination of no more than
fifty (50) and no less than two (2) eligible employees
and part-time employees, the majority of
whom were employed within this state, and is not
formed primarily for purposes of buying health
insurance and in which a bona fide employer-employee
relationship exists. After October 1, 2004,
for the purposes of this section, "small
employer" has the meaning used in section 27-50-3(kk).
(b) (1) Every small
employer carrier shall, as a condition of transacting business in this
state with small employers, actively offer to small
employers all health benefit plans it actively
markets to small employers in this state including a
wellness health benefit plan. A small
employer carrier shall be considered to be actively
marketing a health benefit plan if it offers that
plan to any small employer not currently receiving a
health benefit plan from the small employer
carrier.
(2) Subject to
subdivision (1) of this subsection, a small employer carrier shall issue any
health benefit plan to any eligible small employer
that applies for that plan and agrees to make the
required premium payments and to satisfy the other
reasonable provisions of the health benefit
plan not inconsistent with this chapter. However, no
carrier is required to issue a health benefit
plan to any self-employed individual who is covered
by, or is eligible for coverage under, a health
benefit plan offered by an employer.
(c) (1) A small
employer carrier shall file with the director, in a format and manner
prescribed by the director, the health benefit plans
to be used by the carrier. A health benefit plan
filed pursuant to this subdivision may be used by a
small employer carrier beginning thirty (30)
days after it is filed unless the director disapproves
its use.
(2) The director may at
any time may, after providing notice and an opportunity for a
hearing to the small employer carrier, disapprove the
continued use by a small employer carrier of
a health benefit plan on the grounds that the plan does
not meet the requirements of this chapter.
(d) Health benefit
plans covering small employers shall comply with the following
provisions:
(1) A health benefit
plan shall not deny, exclude, or limit benefits for a covered
individual for losses incurred more than six (6)
months following the enrollment date of the
individual's coverage due to a preexisting condition,
or the first date of the waiting period for
enrollment if that date is earlier than the enrollment
date. A health benefit plan shall not define a
preexisting condition more restrictively than as
defined in section 27-50-3.
(2) (i) Except as provided in subdivision (3) of this
subsection, a small employer carrier
shall reduce the period of any preexisting condition
exclusion by the aggregate of the periods of
creditable coverage without regard to the specific
benefits covered during the period of creditable
coverage, provided that the last period of creditable
coverage ended on a date not more than
ninety (90) days prior to the enrollment date of new
coverage.
(ii) The aggregate
period of creditable coverage does not include any waiting period or
affiliation period for the effective date of the new
coverage applied by the employer or the carrier,
or for the normal application and enrollment process
following employment or other triggering
event for eligibility.
(iii) A carrier that
does not use preexisting condition limitations in any of its health
benefit plans may impose an affiliation period that:
(A) Does not exceed
sixty (60) days for new entrants and not to exceed ninety (90) days
for late enrollees;
(B) During which the
carrier charges no premiums and the coverage issued is not
effective; and
(C) Is applied uniformly,
without regard to any health status-related factor.
(iv) This section does
not preclude application of any waiting period applicable to all
new enrollees under the health benefit plan, provided
that any carrier-imposed waiting period is
no longer than sixty (60) days.
(3) (i) Instead of as provided in paragraph (2)(i) of this subsection, a small employer
carrier may elect to reduce the period of any
preexisting condition exclusion based on coverage of
benefits within each of several classes or categories
of benefits specified in federal regulations.
(ii) A small employer
electing to reduce the period of any preexisting condition
exclusion using the alternative method described in
paragraph (i) of this subdivision shall:
(A) Make the election
on a uniform basis for all enrollees; and
(B) Count a period of
creditable coverage with respect to any class or category of
benefits if any level of benefits is covered within
the class or category.
(iii) A small employer
carrier electing to reduce the period of any preexisting condition
exclusion using the alternative method described under
paragraph (i) of this subdivision shall:
(A) Prominently state
that the election has been made in any disclosure statements
concerning coverage under the health benefit plan to
each enrollee at the time of enrollment under
the plan and to each small employer at the time of the
offer or sale of the coverage; and
(B) Include in the
disclosure statements the effect of the election.
(4) (i) A health benefit plan shall accept late enrollees, but
may exclude coverage for late
enrollees for preexisting conditions for a period not
to exceed twelve (12) months.
(ii) A small employer
carrier shall reduce the period of any preexisting condition
exclusion pursuant to subdivision (2) or (3) of this
subsection.
(5) A small employer
carrier shall not impose a preexisting condition exclusion:
(i)
Relating to pregnancy as a preexisting condition; or
(ii) With regard to a
child who is covered under any creditable coverage within thirty
(30) days of birth, adoption, or placement for
adoption, provided that the child does not
experience a significant break in coverage, and
provided that the child was adopted or placed for
adoption before attaining eighteen (18) years of age.
(6) A small employer
carrier shall not impose a preexisting condition exclusion in the
case of a condition for which medical advice, diagnosis,
care or treatment was recommended or
received for the first time while the covered person
held creditable coverage, and the medical
advice, diagnosis, care or treatment was a covered
benefit under the plan, provided that the
creditable coverage was continuous to a date not more
than ninety (90) days prior to the
enrollment date of the new coverage.
(7) (i) A small employer carrier shall permit an employee or a
dependent of the
employee, who is eligible, but not enrolled, to enroll
for coverage under the terms of the group
health plan of the small employer during a special
enrollment period if:
(A) The employee or
dependent was covered under a group health plan or had coverage
under a health benefit plan at the time coverage was previously
offered to the employee or
dependent;
(B) The employee stated
in writing at the time coverage was previously offered that
coverage under a group health plan or other health
benefit plan was the reason for declining
enrollment, but only if the plan sponsor or carrier,
if applicable, required that statement at the
time coverage was previously offered and provided
notice to the employee of the requirement and
the consequences of the requirement at that time;
(C) The employee's or
dependent's coverage described under subparagraph (A) of this
paragraph:
(I) Was under a COBRA
continuation provision and the coverage under this provision
has been exhausted; or
(II) Was not under a
COBRA continuation provision and that other coverage has been
terminated as a result of loss of eligibility for
coverage, including as a result of a legal separation,
divorce, death, termination of employment, or
reduction in the number of hours of employment or
employer contributions towards that other coverage
have been terminated; and
(D) Under terms of the
group health plan, the employee requests enrollment not later
than thirty (30) days after the date of exhaustion of
coverage described in item (C)(I) of this
paragraph or termination of coverage or employer
contribution described in item (C)(II) of this
paragraph.
(ii) If an employee
requests enrollment pursuant to subparagraph (i)(D)
of this
subdivision, the enrollment is effective not later than
the first day of the first calendar month
beginning after the date the completed request for
enrollment is received.
(8) (i) A small employer carrier that makes coverage available
under a group health plan
with respect to a dependent of an individual shall
provide for a dependent special enrollment
period described in paragraph (ii) of this subdivision
during which the person or, if not enrolled,
the individual may be enrolled under the group health
plan as a dependent of the individual and,
in the case of the birth or adoption of a child, the
spouse of the individual may be enrolled as a
dependent of the individual if the spouse is eligible
for coverage if:
(A) The individual is a
participant under the health benefit plan or has met any waiting
period applicable to becoming a participant under the
plan and is eligible to be enrolled under the
plan, but for a failure to enroll during a previous
enrollment period; and
(B) A person becomes a
dependent of the individual through marriage, birth, or adoption
or placement for adoption.
(ii) The special
enrollment period for individuals that meet the provisions of paragraph
(i) of this subdivision is a
period of not less than thirty (30) days and begins on the later of:
(A) The date dependent
coverage is made available; or
(B) The date of the
marriage, birth, or adoption or placement for adoption described in
subparagraph (i)(B) of this
subdivision.
(iii) If an individual
seeks to enroll a dependent during the first thirty (30) days of the
dependent special enrollment period described under
paragraph (ii) of this subdivision, the
coverage of the dependent is effective:
(A) In the case of
marriage, not later than the first day of the first month beginning after
the date the completed request for enrollment is
received;
(B) In the case of a
dependent's birth, as of the date of birth; and
(C) In the case of a
dependent's adoption or placement for adoption, the date of the
adoption or placement for adoption.
(9) (i) Except as provided in this subdivision, requirements
used by a small employer
carrier in determining whether to provide coverage to
a small employer, including requirements
for minimum participation of eligible employees and minimum
employer contributions, shall be
applied uniformly among all small employers applying
for coverage or receiving coverage from
the small employer carrier.
(ii) For health benefit
plans issued or renewed on or after October 1, 2000, a small
employer carrier shall not require a minimum
participation level greater than seventy-five percent
(75%) of eligible employees.
(iii) In applying
minimum participation requirements with respect to a small employer, a
small employer carrier shall not consider employees or
dependents who have creditable coverage
in determining whether the applicable percentage of
participation is met.
(iv) A small employer
carrier shall not increase any requirement for minimum employee
participation or modify any requirement for minimum
employer contribution applicable to a small
employer at any time after the small employer has been
accepted for coverage.
(10) (i) If a small employer carrier offers coverage to a small
employer, the small
employer carrier shall offer coverage to all of the
eligible employees of a small employer and
their dependents who apply for enrollment during the
period in which the employee first becomes
eligible to enroll under the terms of the plan. A
small employer carrier shall not offer coverage to
only certain individuals or dependents in a small
employer group or to only part of the group.
(ii) A small employer
carrier shall not place any restriction in regard to any health status-
related factor on an eligible employee or dependent
with respect to enrollment or plan
participation.
(iii) Except as
permitted under subdivisions (1) and (4) of this subsection, a small
employer carrier shall not modify a health benefit
plan with respect to a small employer or any
eligible employee or dependent, through riders,
endorsements, or otherwise, to restrict or exclude
coverage or benefits for specific diseases, medical
conditions, or services covered by the plan.
(e) (1) Subject to
subdivision (3) of this subsection, a small employer carrier is not
required to offer coverage or accept applications
pursuant to subsection (b) of this section in the
case of the following:
(i)
To a small employer, where the small employer does not have eligible
individuals
who live, work, or reside in the established
geographic service area for the network plan;
(ii) To an employee,
when the employee does not live, work, or reside within the
carrier's established geographic service area; or
(iii) Within an area where
the small employer carrier reasonably anticipates, and
demonstrates to the satisfaction of the director, that
it will not have the capacity within its
established geographic service area to deliver
services adequately to enrollees of any additional
groups because of its obligations to existing group
policyholders and enrollees.
(2) A small employer
carrier that cannot offer coverage pursuant to paragraph (1)(iii) of
this subsection may not offer coverage in the
applicable area to new cases of employer groups
until the later of one hundred and eighty (180) days
following each refusal or the date on which
the carrier notifies the director that it has regained
capacity to deliver services to new employer
groups.
(3) A small employer
carrier shall apply the provisions of this subsection uniformly to all
small employers without regard to the claims
experience of a small employer and its employees
and their dependents or any health status-related
factor relating to the employees and their
dependents.
(f) (1) A small
employer carrier is not required to provide coverage to small employers
pursuant to subsection (b) of this section if:
(i)
For any period of time the director determines the small employer carrier does
not
have the financial reserves necessary to underwrite
additional coverage; and
(ii) The small employer
carrier is applying this subsection uniformly to all small
employers in the small group market in this state
consistent with applicable state law and without
regard to the claims experience of a small employer
and its employees and their dependents or
any health status-related factor relating to the
employees and their dependents.
(2) A small employer
carrier that denies coverage in accordance with subdivision (1) of
this subsection may not offer coverage in the small
group market for the later of:
(i)
A period of one hundred and eighty (180) days after the date the coverage is
denied;
or
(ii) Until the small
employer has demonstrated to the director that it has sufficient
financial reserves to underwrite additional coverage.
(g) (1) A small
employer carrier is not required to provide coverage to small employers
pursuant to subsection (b) of this section if the small
employer carrier elects not to offer new
coverage to small employers in this state.
(2) A small employer
carrier that elects not to offer new coverage to small employers
under this subsection may be allowed, as determined by
the director, to maintain its existing
policies in this state.
(3) A small employer
carrier that elects not to offer new coverage to small employers
under subdivision (g)(1) shall provide at least one
hundred and twenty (120) days notice of its
election to the director and is prohibited from
writing new business in the small employer market
in this state for a period of five (5) years beginning
on the date the carrier ceased offering new
coverage in this state.
(h) No small group
carrier may impose a pre-existing condition exclusion pursuant to the
provisions of subdivisions 27-50-7(d)(1),
27-50-7(d)(2), 27-50-7(d)(3), 27-50-7(d)(4), 27-50-
7(d)(5) and 27-50-7(d)(6) with regard to an individual
that is less than nineteen (19) years of age.
With respect to health benefit plans issued on and
after January 1, 2014 a small employer carrier
shall offer and issue coverage to small employers and
eligible individuals notwithstanding any
pre-existing condition of an employee, member, or
individual, or their dependents.
SECTION
12. Section 27-18.6-3 of the General laws in Chapter 27-18.6 entitled
"Large
Group Health Insurance
Coverage" is hereby amended to read as follows:
27-18.6-3.
Limitation on preexisting condition exclusion. -- (a) (1)
Notwithstanding
any of the provisions of this title to the contrary, a
group health plan and a health insurance
carrier offering group health insurance
coverage shall not deny, exclude, or limit benefits with
respect to a participant or beneficiary because of a
preexisting condition exclusion except if:
(i)
The exclusion relates to a condition (whether physical or mental), regardless
of the
cause of the condition, for which medical advice,
diagnosis, care, or treatment was recommended
or received within the six (6) month period ending on
the enrollment date;
(ii) The exclusion
extends for a period of not more than twelve (12) months (or eighteen
(18) months in the case of a late enrollee) after the
enrollment date; and
(iii) The period of the preexisting
condition exclusion is reduced by the aggregate of the
periods of creditable coverage, if any, applicable to
the participant or the beneficiary as of the
enrollment date.
(2) For purposes of this
section, genetic information shall not be treated as a preexisting
condition in the absence of a diagnosis of the
condition related to that information.
(b) With respect to
paragraph (a)(1)(iii) of this section, a period of creditable coverage
shall not be counted, with respect to enrollment of an
individual under a group health plan, if,
after that period and before the enrollment date,
there was a sixty-three (63) day period during
which the individual was not covered under any
creditable coverage.
(c) Any period that an
individual is in a waiting period for any coverage under a group
health plan or for group health insurance or is in an
affiliation period shall not be taken into
account in determining the continuous period under
subsection (b) of this section.
(d) Except as otherwise
provided in subsection (e) of this section, for purposes of
applying paragraph (a)(1)(iii) of this section, a
group health plan and a health insurance carrier
offering group health insurance coverage shall count a
period of creditable coverage without
regard to the specific benefits covered during the
period.
(e) (1) A group health
plan or a health insurance carrier offering group health insurance
may elect to apply paragraph (a)(1)(iii) of this
section based on coverage of benefits within each
of several classes or categories of benefits. Those
classes or categories of benefits are to be
determined by the secretary of the United States
Department of Health and Human Services
pursuant to regulation. The election shall be made on
a uniform basis for all participants and
beneficiaries. Under the election, a group health plan
or carrier shall count a period of creditable
coverage with respect to any class or category of
benefits if any level of benefits is covered
within the class or category.
(2) In the case of an
election under this subsection with respect to a group health plan
(whether or not health insurance coverage is provided
in connection with that plan), the plan
shall:
(i)
Prominently state in any disclosure statements concerning the plan, and state
to each
enrollee under the plan, that the plan has made the
election; and
(ii) Include in the
statements a description of the effect of this election.
(3) In the case of an election
under this subsection with respect to health insurance
coverage offered by a carrier in the large group
market, the carrier shall:
(i)
Prominently state in any disclosure statements concerning the coverage, and to
each
employer at the time of the offer or sale of the
coverage, that the carrier has made the election;
and
(ii) Include in the
statements a description of the effect of the election.
(f) (1) A group health
plan and a health insurance carrier offering group health insurance
coverage may not impose any preexisting condition
exclusion in the case of an individual who, as
of the last day of the thirty (30) day period
beginning with the date of birth, is covered under
creditable coverage.
(2) Subdivision (1) of
this subsection shall no longer apply to an individual after the end
of the first sixty-three (63) day period during all of
which the individual was not covered under
any creditable coverage. Moreover, any period that an
individual is in a waiting period for any
coverage under a group health plan (or for group
health insurance coverage) or is in an affiliation
period shall not be taken into account in determining
the continuous period for purposes of
determining creditable coverage.
(g) (1) A group health
plan and a health insurance carrier offering group health insurance
coverage may not impose any preexisting condition
exclusion in the case of a child who is
adopted or placed for adoption before attaining
eighteen (18) years of age and who, as of the last
day of the thirty (30) day period beginning on the
date of the adoption or placement for adoption,
is covered under creditable coverage. The previous
sentence does not apply to coverage before
the date of the adoption or placement for adoption.
(2) Subdivision (1) of
this subsection shall no longer apply to an individual after the end
of the first sixty-three (63) day period during all of
which the individual was not covered under
any creditable coverage. Any period that an individual
is in a waiting period for any coverage
under a group health plan (or for group health
insurance coverage) or is in an affiliation period
shall not be taken into account in determining the
continuous period for purposes of determining
creditable coverage.
(h) A group health plan
and a health insurance carrier offering group health insurance
coverage may not impose any preexisting condition
exclusion relating to pregnancy as a
preexisting condition or with regard to an
individual who is under nineteen (19) years of age.
(i)
(1) Periods of creditable coverage with respect to an individual shall be
established
through presentation of certifications. A group health
plan and a health insurance carrier offering
group health insurance coverage shall provide
certifications:
(i)
At the time an individual ceases to be covered under the plan or becomes
covered
under a COBRA continuation provision;
(ii) In the case of an
individual becoming covered under a continuation provision, at the
time the individual ceases to be covered under that
provision; and
(iii) On the request of
an individual made not later than twenty-four (24) months after the
date of cessation of the coverage described in
paragraph (i) or (ii) of this subdivision, whichever
is later.
(2) The certification
under this subsection may be provided, to the extent practicable, at a
time consistent with notices required under any
applicable COBRA continuation provision.
(3) The certification
described in this subsection is a written certification of:
(i)
The period of creditable coverage of the individual under the plan and the
coverage (if
any) under the COBRA continuation provision; and
(ii) The waiting period
(if any) (and affiliation period, if applicable) imposed with respect
to the individual for any coverage under the plan.
(4) To the extent that
medical care under a group health plan consists of group health
insurance coverage, the plan is deemed to have
satisfied the certification requirement under this
subsection if the health insurance carrier offering
the coverage provides for the certification in
accordance with this subsection.
(5) In the case of an
election taken pursuant to subsection (e) of this section by a group
health plan or a health insurance carrier, if the plan
or carrier enrolls an individual for coverage
under the plan and the individual provides a
certification of creditable coverage, upon request of
the plan or carrier, the entity which issued the
certification shall promptly disclose to the
requisition plan or carrier information on coverage of
classes and categories of health benefits
available under that entity's plan or coverage, and
the entity may charge the requesting plan or
carrier for the reasonable cost of disclosing the
information.
(6) Failure of an entity
to provide information under this subsection with respect to
previous coverage of an individual so as to adversely
affect any subsequent coverage of the
individual under another group health plan or health
insurance coverage, as determined in
accordance with rules and regulations established by
the secretary of the
Department of Health and Human Services, is a
violation of this chapter.
(j) A group health plan
and a health insurance carrier offering group health insurance
coverage in connection with a group health plan shall
permit an employee who is eligible, but not
enrolled, for coverage under the terms of the plan (or
a dependent of an employee if the
dependent is eligible, but not enrolled, for coverage
under the terms) to enroll for coverage under
the terms of the plan if each of the following
conditions are met:
(1) The employee or
dependent was covered under a group health plan or had health
insurance coverage at the time coverage was previously
offered to the employee or dependent;
(2) The employee stated
in writing at the time that coverage under a group health plan or
health insurance coverage was the reason for declining
enrollment, but only if the plan sponsor or
carrier (if applicable) required a statement at the
time and provided the employee with notice of
that requirement (and the consequences of the
requirement) at the time;
(3) The employee's or
dependent's coverage described in subsection (j)(1):
(i)
Was under a COBRA continuation provision and the coverage under that provision
was exhausted; or
(ii) Was not under a
continuation provision and either the coverage was terminated as a
result of loss of eligibility for the coverage
(including as a result of legal separation, divorce,
death, termination of employment, or reduction in the
number of hours of employment) or
employer contributions towards the coverage were
terminated; and
(4) Under the terms of
the plan, the employee requests enrollment not later than thirty
(30) days after the date of exhaustion of coverage
described in paragraph (3)(i) of this subsection
or termination of coverage or employer contribution
described in paragraph (3)(ii) of this
subsection.
(k) (1) If a group
health plan makes coverage available with respect to a dependent of an
individual, the individual is a participant under the
plan (or has met any waiting period applicable
to becoming a participant under the plan and is
eligible to be enrolled under the plan but for a
failure to enroll during a previous enrollment
period), and a person becomes a dependent of the
individual through marriage, birth, or adoption or
placement through adoption, the group health
plan shall provide for a dependent special enrollment
period during which the person (or, if not
enrolled, the individual) may be enrolled under the
plan as a dependent of the individual, and in
the case of the birth or adoption of a child, the
spouse of the individual may be enrolled as a
dependent of the individual if the spouse is eligible
for coverage.
(2) A dependent special
enrollment period shall be a period of not less than thirty (30)
days and shall begin on the later of:
(i)
The date dependent coverage is made available; or
(ii) The date of the
marriage, birth, or adoption or placement for adoption (as the case
may be).
(3) If an individual
seeks to enroll a dependent during the first thirty (30) days of a
dependent special enrollment period, the coverage of
the dependent shall become effective:
(i)
In the case of marriage, not later than the first day of the first month
beginning after
the date the completed request for enrollment is
received;
(ii) In the case of a
dependent's birth, as of the date of the birth; or
(iii) In the case of a
dependent's adoption or placement for adoption, the date of the
adoption or placement for adoption.
(l) (1) A health
maintenance organization which offers health insurance coverage in
connection with a group health plan and which does not
impose any preexisting condition
exclusion allowed under subsection (a) of this section
with respect to any particular coverage
option may impose an affiliation period for the
coverage option, but only if that period is applied
uniformly without regard to any health status-related
factors, and the period does not exceed two
(2) months (or three (3) months in the case of a late
enrollee).
(2) For the purposes of
this subsection, an affiliation shall begin on the enrollment date.
(3) An affiliation
period under a plan shall run concurrently with any waiting period
under the plan.
(4) The director may approve
alternative methods from those described under this
subsection to address adverse selection.
(m) For the purpose of
determining creditable coverage pursuant to this chapter, no
period before July 1, 1996, shall be taken into
account. Individuals who need to establish
creditable coverage for periods before July 1, 1996,
and who would have the coverage credited
but for the prohibition in the preceding sentence may
be given credit for creditable coverage for
those periods through the presentation of documents or
other means in accordance with any rule
or regulation that may be established by the secretary
of the United States Department of Health
and Human Services.
(n) In the case of an
individual who seeks to establish creditable coverage for any period
for which certification is not required because it
relates to an event occurring before June 30,
1996, the individual may present other credible
evidence of coverage in order to establish the
period of creditable coverage. The group health plan
and a health insurance carrier shall not be
subject to any penalty or enforcement action with
respect to the plan's or carrier's crediting (or not
crediting) the coverage if the plan or carrier has
sought to comply in good faith with the
applicable requirements of this section.
(o) Notwithstanding
the provisions of any general or public law to the contrary, for plan
or policy years beginning on and after January 1,
2014, a group health plan and a health insurance
carrier offering group health insurance coverage shall
not deny, exclude, or limit benefits with
respect to a participant or beneficiary because of a
preexisting condition exclusion.
SECTION.
13 Applicability and Construction.
(a) This act shall
apply only to health insurance policies, subscriber contracts, and any
other health benefit contract issued on and after July
1, 2012 notwithstanding any other provision
of this act.
(b) In its
construction and enforcement of the provisions of this act, and in the interests
of
promoting uniform national rules for health insurance
carriers, the office of the health insurance
commissioner shall give due deference to the
construction, enforcement policies, and guidance of
the federal government with respect to federal law
substantially similar to the provisions of this
act.
SECTION
14. Sections 27-18-36, 27-18-36.1, 27-18-36.2 and 27-18-36.3 of the General
Laws in Chapter 27-18
entitled "Accident and Sickness Insurance Policies" are hereby
repealed
on the effective date of RI
General Law 27-18-80.
27-18-36. New
cancer therapies -- Under investigation. -- Every individual or
group
hospital or medical expense insurance policy or
individual or group hospital or medical service
plan contract delivered, issued for delivery or
renewed in this state, except policies which only
provide coverage for specified diseases other than
cancer, fixed indemnity, disability income,
accident only, long-term care Medicare supplement
limited benefit health, sickness or bodily
injury or death by accident or both, or other limited
benefit policies, shall provide coverage for
new cancer therapies still under investigation as
outlined in this chapter.
27-18-36.1.
"Reliable evidence" defined. -- "Reliable
evidence" means:
(1) Evidence
including published reports and articles in authoritative, peer reviewed
medical and scientific literature;
(2) A written
informed consent used by the treating facility or by another facility
studying substantially the same service; or
(3) A written
protocol or protocols used by the treating facility or protocols of another
facility studying substantially the same service.
27-18-36.2.
Conditions of coverage. -- As provided in section 27-18-36,
coverage shall
be extended to new cancer therapies still under
investigation when the following circumstances
are present:
(1) Treatment is
being provided pursuant to a phase II, III or IV clinical trial which has
been approved by the National Institutes of Health
(NIH) in cooperation with the National Cancer
Institute (NCI), Community clinical oncology programs;
the Food and Drug Administration in the
form of an Investigational New Drug (IND) exemption;
the Department of Veterans' Affairs; or a
qualified nongovernmental research entity as
identified in the guidelines for NCI cancer center
support grants;
(2) The proposed
therapy has been reviewed and approved by a qualified institutional
review board (IRB);
(3) The facility and
personnel providing the treatment are capable of doing so by virtue
of their experience, training, and volume of patients
treated to maintain expertise;
(4) The patients
receiving the investigational treatment meet all protocol requirements;
(5) There is no
clearly superior, noninvestigational alternative to
the protocol treatment;
(6) The available
clinical or preclinical data provide a reasonable expectation that the
protocol treatment will be at least as efficacious as
the noninvestigational alternative; and
(7) The coverage of
new cancer therapy treatment provided pursuant to a Phase II
clinical trial shall not be required for only that
portion of that treatment provided as part of the
phase II clinical trial and is otherwise funded by a
national agency, such as the National Cancer
Institute, the Veteran's Administration, the
Department of Defense, or funded by commercial
organizations such as the biotechnical and/or
pharmaceutical industry or manufacturers of
medical devices. Any portions of a Phase II trial
which are customarily funded by government,
biotechnical and/or pharmaceutical and/or medical
device industry sources in
other states shall continue to be so funded in
shall supplement, not supplant, customary funding.
27-18-36.3.
Managed care. -- Nothing in this chapter shall preclude the
conducting of
managed care reviews and medical necessity reviews by
an insurer, hospital or medical service
corporation, or health maintenance organization.
SECTION
15. Sections 27-19-32, 27-19-32.1, 27-19-32.2 and 27-19-32.3 of the General
Laws in Chapter 27-19
entitled "Nonprofit Hospital Service Corporations" are hereby
repealed on
the effective date of RI
General Law 27-19-64.
27-19-32. New
cancer therapies -- Under investigation. -- Every individual or
group
hospital or medical expense insurance policy or
individual or group hospital or medical service
plan contract delivered, issued for delivery or
renewed in this state shall provide coverage for new
cancer therapies still under investigation as outlined
in this chapter.
27-19-32.1.
"Reliable evidence" defined. -- "Reliable
evidence" means:
(1) Evidence
including published reports and articles in authoritative, peer reviewed
medical and scientific literature;
(2) A written
informed consent used by the treating facility or by another facility
studying substantially the same service; or
(3) A written
protocol or protocols used by the treating facility or protocols of another
facility studying substantially the same service.
27-19-32.2.
Conditions of coverage. -- As provided in section 27-19-32,
coverage shall
be extended to new cancer therapies still under
investigation when the following circumstances
are present:
(1) Treatment is
being provided pursuant to a phase II, III or IV clinical trial which has
been approved by the National Institutes of Health
(NIH) in cooperation with the National Cancer
Institute (NCI), community clinical oncology programs;
the Food and Drug Administration in the
form of an investigation new drug (
qualified nongovernmental research entity as
identified in the guidelines for NCI cancer center
support grants;
(2) The proposed
therapy has been reviewed and approved by a qualified institutional
review board (IRB);
(3) The facility and
personnel providing the treatment are capable of doing so by virtue
of their experience, training, and volume of patients
treated to maintain expertise;
(4) The patients
receiving the investigational treatment meet all protocol requirements;
(5) There is no
clearly superior, noninvestigational alternative to
the protocol treatment;
(6) The available
clinical or preclinical data provide a reasonable expectation that the
protocol treatment will be at least as efficacious as
the noninvestigational alternative; and
(7) The coverage of
new cancer therapy treatment provided pursuant to a phase II
clinical trial shall not be required for that portion
of that treatment that is provided as part of the
phase II clinical trial and is funded by a national
agency, such as the National Cancer Institute,
the Veteran's Administration, the Department of
Defense, or funded by commercial organizations
such as the biotechnical and/or pharmaceutical
industry or manufacturers of medical devices. Any
portions of a phase II trial which are customarily
funded by government, biotechnical and/or
pharmaceutical and/or medical device industry sources
in
continue to be funded in
supplant, customary funding.
27-19-32.3.
Managed care. -- Nothing in this chapter shall preclude the
conducting of
managed care reviews and medical necessity reviews by
an insurer, hospital or medical service
corporation, or health maintenance corporation.
SECTION
16. Sections 27-20-27, 27-20-27.1, 27-20-27.2 and 27-20-27.3 of the General
Laws in Chapter 27-20
entitled "Nonprofit Medical Service Corporations" are hereby repealed
on
the effective date of RI General
Law 27-20-64.
27-20-27. New
cancer therapies -- Under investigation. -- Every individual or
group
hospital or medical expense insurance policy or
individual or group hospital or medical service
plan contract delivered, issued for delivery or renewed
in this state shall provide coverage for new
cancer therapies still under investigation as outlined
in this chapter.
27-20-27.1.
"Reliable evidence" defined. -- "Reliable
evidence" means:
(1) Evidence including
published reports and articles in authoritative, peer reviewed
medical and scientific literature;
(2) A written
informed consent used by the treating facility or by another facility
studying substantially the same service; or
(3) A written
protocol or protocols used by the treating facility or protocols of another
facility studying substantially the same service.
27-20-27.2.
Conditions of coverage. -- As provided in section 27-20-27,
coverage shall
be extended to new cancer therapies still under
investigation when the following circumstances
are present:
(1) Treatment is
being provided pursuant to a phase II, III or IV clinical trial which has
been approved by the National Institutes of Health (NIH)
in cooperation with the National Cancer
Institute (NCI), community clinical oncology programs;
the Food and Drug Administration in the
form of an investigational new drug (
qualified nongovernmental research entity as
identified in the guidelines for NCI cancer center
support grants;
(2) The proposed
therapy has been reviewed and approved by a qualified institutional
review board (IRB);
(3) The facility and
personnel providing the treatment are capable of doing so by virtue
of their experience, training, and volume of patients
treated to maintain expertise;
(4) The patients
receiving the investigational treatment meet all protocol requirements;
(5) There is no
clearly superior, noninvestigational alternative to
the protocol treatment;
(6) The available
clinical or preclinical data provide a reasonable expectation that the
protocol treatment will be at least as efficacious as
the noninvestigational alternative; and
(7) The coverage of
new cancer therapy treatment provided pursuant to a phase II
clinical trial is not required for only that portion
of that treatment that is provided as part of the
phase II clinical trial and is funded by a national
agency, such as the National Cancer Institute,
the Veteran's Administration, the Department of
Defense, or funded by commercial organizations
such as the biotechnical and/or pharmaceutical
industry or manufacturers of medical devices. Any
portions of a phase II trial which are customarily
funded by government, biotechnical and/or
pharmaceutical and/or medical device industry sources
in
continue to be funded in
not supplant customary funding.
27-20-27.3.
Managed care. -- Nothing in this chapter shall preclude the
conducting of
managed care reviews and medical necessity reviews by
an insurer, hospital or medical service
corporation, or health maintenance organization. A
nonprofit medical service corporation may, as
a condition of coverage, require its members to obtain
new cancer therapies still under
investigation as outlined in this chapter from
providers and facilities designated by the nonprofit
medical service corporation to render these new cancer
therapies.
SECTION
17. Sections 27-41-41, 27-41-41.1, 27-41-41.2 and 27-41-41.3 of the General
Laws in Chapter 27-41
entitled "Health Maintenance Organizations" are hereby repealed on
the
effective date of RI
General Law 27-41-77.
27-41-41. New
cancer therapies -- Under investigation. -- Every individual or
group
hospital or medical expense insurance policy or
individual or group hospital or medical service
plan contract delivered, issued for delivery or
renewed in this state shall provide coverage for new
cancer therapies still under investigation as outlined
in this chapter.
27-41-41.1.
"Reliable evidence" defined. -- "Reliable
evidence" means:
(1) Evidence
including published reports and articles in authoritative, peer reviewed
medical and scientific literature;
(2) A written
informed consent used by the treating facility or by another facility
studying substantially the same service; or
(3) A written
protocol or protocols used by the treating facility or protocols of another
facility studying substantially the same service.
27-41-41.2.
Conditions of coverage. -- As provided in section 27-41-41,
coverage shall
be extended to new cancer therapies still under
investigation when the following circumstances
are present:
(1) Treatment is
being provided pursuant to a phase II, III or IV clinical trial which has
been approved by the National Institutes of Health (NIH)
in cooperation with the National Cancer
Institute (NCI), community clinical oncology programs;
the food and drug administration in the
form of an investigational new drug (
qualified nongovernmental research entity as
identified in the guidelines for NCI cancer center
support grants;
(2) The proposed
therapy has been reviewed and approved by a qualified institutional
review board (IRB);
(3) The facility and
personnel providing the treatment are capable of doing so by virtue
of their experience, training, and volume of patients
treated to maintain expertise;
(4) The patients
receiving the investigational treatment meet all protocol requirements;
(5) There are no
clearly superior, noninvestigational alternatives to
the protocol
treatment;
(6) The available
clinical or preclinical data provide a reasonable expectation that the
protocol treatment will be at least as efficacious as
the noninvestigational alternative; and
(7) The coverage of
new cancer therapy treatment provided pursuant to a phase II
clinical trial is not required for only the portion of
that treatment that is provided as part of the
phase II clinical trial and is funded by a national
agency, such as the National Cancer Institute,
the Veteran's Administration, the Department of
Defense, or funded by commercial organizations
such as the biotechnical and/or pharmaceutical
industry or manufacturers of medical devices. Any
portions of a phase II trial which are customarily
funded by government, biotechnical and/or
pharmaceutical and/or medical device industry sources
in
continue to be funded in
does not supplant, that customary funding.
27-41-41.3.
Managed care. -- Nothing in this chapter shall preclude the
conducting of
managed care reviews and medical necessity reviews by
an insurer, hospital or medical service
corporation, or health maintenance organization. A
health maintenance organization may as a
condition of coverage require its members to obtain
these new cancer therapies still under
investigation from providers and facilities designated
by the health maintenance organization to
render these new cancer therapies.
SECTION
18. This act shall take effect upon passage.
=======
LC02084/SUB A/2
=======