Chapter 323
2013 -- H 5354 SUBSTITUTE A
Enacted 07/15/13
A N A C T
RELATING TO
INSURANCE - ORALLY ADMINISTERED ANTICANCER MEDICATION
Introduced
By: Representatives Amore, Kazarian,
Date Introduced: February 12, 2013
It is enacted by the
General Assembly as follows:
SECTION 1. Chapter 27-18 of the General Laws entitled
"Accident and Sickness
Insurance Policies" is
hereby amended by adding thereto the following section:
27-18-80. Orally administered anticancer medication - Cost-sharing
requirement. –
(a) Every individual or group hospital or medical
expense, insurance policy or individual or group
hospital or medical services plan contract, plan or
certificate of insurance delivered, issued for
delivery, or renewed in this state, on or after January 1,
2014, that offers both medical and
prescription drug coverage, and provides coverage for
intravenously administered anticancer
medication, shall provide coverage for prescribed, orally
administered anticancer medications
used to kill or slow the growth of cancerous cells on a
basis no less favorable than intravenously
administered or injected cancer medications that are covered as
medical benefits. An increase in
patient cost sharing for anticancer medications shall not be
allowed to achieve compliance with
this section. Notwithstanding the above, the requirements
shall not be construed to impose any
form of cap on cost-sharing.
(b) 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 disease indemnity; (8) Sickness or
bodily injury or death by accident or both; and (9) Other
limited benefit policies.
SECTION 2. Chapter 27-19 of the General Laws entitled
"Nonprofit Hospital Service
Corporations" is
hereby amended by adding thereto the following section:
27-19-71. Orally administered anticancer medication – Cost-sharing
requirement. –
(a) Every individual or group hospital or
medical expense, insurance policy or individual or group
hospital or medical services plan contract, plan or
certificate of insurance delivered, issued for
delivery, or renewed in this state, on or after January 1,
2014, that offers both medical and
prescription drug coverage, and provides coverage for
intravenously administered anticancer
medication, shall provide coverage for prescribed, orally
administered anticancer medications
used to kill or slow the growth of cancerous cells on a
basis no less favorable than intravenously
administered or injected cancer medications that are covered as
medical benefits. An increase in
patient cost sharing for anticancer medications shall not be
allowed to achieve compliance with
this section. Notwithstanding the above, the requirements
shall not be construed to impose any
form of cap on cost-sharing.
(b) 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 disease indemnity; (8) Sickness or
bodily injury or death by accident or both; and (9) Other
limited benefit policies.
SECTION 3. Chapter 27-20 of the General Laws entitled
"Nonprofit Medical Service
Corporations" is
hereby amended by adding thereto the following section:
27-20-67. Orally administered anticancer medication – Cost-sharing
requirement. –
(a) Every individual or group hospital or
medical expense, insurance policy or individual or group
hospital or medical services plan contract, plan or certificate
of insurance delivered, issued for
delivery, or renewed in this state, on or after January 1,
2014, that offers both medical and
prescription drug coverage, and provides coverage for
intravenously administered anticancer
medication, shall provide coverage for prescribed, orally
administered anticancer medications
used to kill or slow the growth of cancerous cells on a
basis no less favorable than intravenously
administered or injected cancer medications that are covered as
medical benefits. An increase in
patient cost sharing for anticancer medications shall not be
allowed to achieve compliance with
this section. Notwithstanding the above, the requirements
shall not be construed to impose any
form of cap on cost-sharing.
(b) 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 disease indemnity; (8) Sickness or
bodily injury or death by accident or both; and (9) Other
limited benefit policies.
SECTION 4. Chapter 27-41 of the General Laws entitled
"Health Maintenance
Organizations" is
hereby amended by adding thereto the following section:
27-41-84. Orally administered anticancer medication – Cost-sharing
requirement. –
(a) Every individual or group hospital or
medical expense, insurance policy or individual or group
hospital or medical services plan contract, plan or
certificate of insurance delivered, issued for
delivery, or renewed in this state, on or after January 1,
2014 ,that offers both medical and
prescription drug coverage, and provides coverage for
intravenously administered anticancer
medication, shall provide coverage for prescribed, orally
administered anticancer medications
used to kill or slow the growth of cancerous cells on a
basis no less favorable than intravenously
administered or injected cancer medications that are covered as
medical benefits. An increase in
patient cost sharing for anticancer medications shall not be
allowed to achieve compliance with
this section. Notwithstanding the above, the requirements
shall not be construed to impose any
form of cap on cost-sharing.
(b) 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 disease indemnity; (8) Sickness or
bodily injury or death by accident or both; and (9) Other
limited benefit policies.
SECTION 5. Section 42-14.5-3 of the General Laws in Chapter
42-14.5 entitled "The
Rhode Island Health Care
Reform Act of 2004 - Health Insurance Oversight" is hereby amended
to read as follows:
42-14.5-3.
Powers and duties. [Contingent effective date; see
effective dates under
this section.] -- The health insurance commissioner shall have the following powers and
duties:
(a) To conduct quarterly
public meetings throughout the state, separate and distinct from
rate hearings pursuant to section 42-62-13, regarding the
rates, services and operations of insurers
licensed to provide health insurance in the state the effects
of such rates, services and operations
on consumers, medical care providers, patients, and the
market environment in which such
insurers operate and efforts to bring new health insurers into
the
not less than ten (10) days of said hearing(s) shall go
to the general assembly, the governor, the
Rhode Island Medical Society, the Hospital Association
of Rhode Island, the director of health,
the attorney general and the chambers of commerce. Public
notice shall be posted on the
department's web site and given in the newspaper of general
circulation, and to any entity in
writing requesting notice.
(b) To make
recommendations to the governor and the house of
representatives and
senate finance committees regarding health care insurance
and the regulations, rates, services,
administrative expenses, reserve requirements, and operations of
insurers providing health
insurance in the state, and to prepare or comment on, upon the
request of the governor, or
chairpersons of the house or senate finance committees, draft
legislation to improve the regulation
of health insurance. In making such recommendations, the
commissioner shall recognize that it is
the intent of the legislature that the maximum disclosure
be provided regarding the
reasonableness of individual administrative expenditures as well as
total administrative costs. The
commissioner shall also make recommendations on the levels of
reserves including consideration
of: targeted reserve levels; trends in the increase or
decrease of reserve levels; and insurer plans
for distributing excess reserves.
(c) To establish a
consumer/business/labor/medical advisory council to obtain
information and present concerns of consumers, business and
medical providers affected by
health insurance decisions. The council shall develop
proposals to allow the market for small
business health insurance to be affordable and fairer. The
council shall be involved in the
planning and conduct of the quarterly public meetings in
accordance with subsection (a) above.
The advisory council shall develop measures to inform
small businesses of an insurance
complaint process to ensure that small businesses that
experience rate increases in a given year
may request and receive a formal review by the
department. The advisory council shall assess
views of the health provider community relative to
insurance rates of reimbursement, billing and
reimbursement procedures, and the insurers' role in promoting
efficient and high quality health
care. The advisory council shall issue an annual report of
findings and recommendations to the
governor and the general assembly and present their findings
at hearings before the house and
senate finance committees. The advisory council is to be
diverse in interests and shall include
representatives of community consumer organizations; small
businesses, other than those
involved in the sale of insurance products; and hospital,
medical, and other health provider
organizations. Such representatives shall be nominated by their
respective organizations. The
advisory council shall be co-chaired by the health insurance
commissioner and a community
consumer organization or small business member to be elected
by the full advisory council.
(d) To establish and
provide guidance and assistance to a subcommittee ("The
Professional Provider-Health Plan Work Group") of
the advisory council created pursuant to
subsection (c) above, composed of health care providers and
Rhode
This subcommittee shall include in its annual report
and presentation before the house and senate
finance committees the following information:
(i)
A method whereby health plans shall disclose to contracted providers the fee
schedules used to provide payment to those providers for
services rendered to covered patients;
(ii) A standardized
provider application and credentials verification process, for the
purpose of verifying professional qualifications of
participating health care providers;
(iii) The uniform health
plan claim form utilized by participating providers;
(iv)
Methods for health maintenance organizations as defined by section
27-41-1, and
nonprofit hospital or medical service corporations as defined
by chapters 27-19 and 27-20, to
make facility-specific data and other medical
service-specific data available in reasonably
consistent formats to patients regarding quality and costs. This
information would help consumers
make informed choices regarding the facilities and/or
clinicians or physician practices at which to
seek care. Among the items considered would be the unique
health services and other public
goods provided by facilities and/or clinicians or physician
practices in establishing the most
appropriate cost comparisons.
(v) All activities
related to contractual disclosure to participating providers of the
mechanisms for resolving health plan/provider disputes; and
(vi)
The uniform process being utilized for confirming in real time patient
insurance
enrollment status, benefits coverage, including co-pays and
deductibles.
(vii) Information
related to temporary credentialing of providers seeking to participate in
the plan's network and the impact of said activity on
health plan accreditation;
(viii) The feasibility
of regular contract renegotiations between plans and the providers
in their networks.
(ix) Efforts conducted
related to reviewing impact of silent PPOs on
physician practices.
(e) To enforce the
provisions of Title 27 and Title 42 as set forth in section 42-14-5(d).
(f) To provide analysis
of the
The fund shall be used to effectuate the provisions of
sections 27-18.5-8 and 27-50-17.
(g) To analyze the
impact of changing the rating guidelines and/or merging the
individual health insurance market as defined in chapter 27-18.5
and the small employer health
insurance market as defined in chapter 27-50 in accordance with
the following:
(i)
The analysis shall forecast the likely rate increases required to effect the
changes
recommended pursuant to the preceding subsection (g) in the
direct pay market and small
employer health insurance market over the next five (5) years,
based on the current rating
structure, and current products.
(ii) The analysis shall
include examining the impact of merging the individual and small
employer markets on premiums charged to individuals and small
employer groups.
(iii) The analysis
shall include examining the impact on rates in each of the individual
and small employer health insurance markets and the
number of insureds in the context of
possible changes to the rating guidelines used for small
employer groups, including: community
rating principles; expanding small employer rate bonds
beyond the current range; increasing the
employer group size in the small group market; and/or adding
rating factors for broker and/or
tobacco use.
(iv)
The analysis shall include examining the adequacy of current statutory and
regulatory oversight of the rating process and factors employed
by the participants in the
proposed new merged market.
(v) The analysis shall
include assessment of possible reinsurance mechanisms and/or
federal high-risk pool structures and funding to support the
health insurance market in Rhode
Island by reducing the risk of adverse selection and
the incremental insurance premiums charged
for this risk, and/or by making health insurance
affordable for a selected at-risk population.
(vi)
The health insurance commissioner shall work with an insurance market
merger task
force to assist with the analysis. The task force shall be
chaired by the health insurance
commissioner and shall include, but not be limited to,
representatives of the general assembly, the
business community, small employer carriers as defined in
section 27-50-3, carriers offering
coverage in the individual market in
general public.
(vii) For the purposes
of conducting this analysis, the commissioner may contract with
an outside organization with expertise in fiscal
analysis of the private insurance market. In
conducting its study, the organization shall, to the extent
possible, obtain and use actual health
plan data. Said data shall be subject to state and federal
laws and regulations governing
confidentiality of health care and proprietary information.
(viii) The task force
shall meet as necessary and include their findings in the annual
report and the commissioner shall include the information in
the annual presentation before the
house and senate finance committees.
(h) To establish and
convene a workgroup representing health care providers and health
insurers for the purpose of coordinating the development of
processes, guidelines, and standards
to streamline health care administration that are to be
adopted by payors and providers of health
care services operating in the state. This workgroup shall
include representatives with expertise
that would contribute to the streamlining of health care
administration and that are selected from
hospitals, physician practices, community behavioral health
organizations, each health insurer
and other affected entities. The workgroup shall also
include at least one designee each from the
Organizations, the
(1) Establishing a
consistent standard for electronic eligibility and coverage verification.
Such standard shall:
(i) Include standards for eligibility inquiry and
response and, wherever possible, be
consistent with the standards adopted by nationally recognized
organizations, such as the centers
for Medicare and Medicaid services;
(ii) Enable providers
and payors to exchange eligibility requests and
responses on a
system-to-system basis or using a payor
supported web browser;
(iii) Provide
reasonably detailed information on a consumer's eligibility for health care
coverage, scope of benefits, limitations and exclusions
provided under that coverage, cost-sharing
requirements for specific services at the specific time of the
inquiry, current deductible amounts,
accumulated or limited benefits, out-of-pocket maximums, any
maximum policy amounts, and
other information required for the provider to collect the
patient's portion of the bill;
(iv)
Reflect the necessary limitations imposed on payors
by the originator of the
eligibility and benefits information;
(v) Recommend a
standard or common process to protect all providers from the costs of
services to patients who are ineligible for insurance coverage
in circumstances where a payor
provides eligibility verification based on best information
available to the payor at the date of the
request of eligibility.
(2) Developing implementation
guidelines and promoting adoption of such guidelines
for:
(i)
The use of the national correct coding initiative code edit policy by payors and
providers in the state;
(ii) Publishing any
variations from codes and mutually exclusive codes by payors
in a
manner that makes for simple retrieval and implementation by
providers;
(iii)
Use of health insurance portability and accountability act standard group
codes,
reason codes, and remark codes by payors
in electronic remittances sent to providers;
(iv)
The processing of corrections to claims by providers and payors.
(v) A standard payor denial review process for providers when they request
a
reconsideration of a denial of a claim that results from differences
in clinical edits where no
single, common standards body or process exists and multiple
conflicting sources are in use by
payors and providers.
(vi)
Nothing in this section or in the guidelines developed shall inhibit an
individual
payor's ability to employ, and not disclose to providers,
temporary code edits for the purpose of
detecting and deterring fraudulent billing activities. The
guidelines shall require that each payor
disclose to the provider its adjudication decision on a claim
that was denied or adjusted based on
the application of such edits and that the provider have
access to the payor's review and appeal
process to challenge the payor's
adjudication decision.
(vii) Nothing in this
subsection shall be construed to modify the rights or obligations of
payors or providers with respect to procedures relating to
the investigation, reporting, appeal, or
prosecution under applicable law of potentially fraudulent
billing activities.
(3) Developing and
promoting widespread adoption by payors and providers
of
guidelines to:
(i)
Ensure payors do not automatically deny claims for
services when extenuating
circumstances make it impossible for the provider to obtain a
preauthorization before services are
performed or notify a payor within an
appropriate standardized timeline of a patient's admission;
(ii) Require payors to use common and consistent processes and time
frames when
responding to provider requests for medical management
approvals. Whenever possible, such
time frames shall be consistent with those established by
leading national organizations and be
based upon the acuity of the patient's need for care or
treatment. For the purposes of this section,
medical management includes prior authorization of services,
preauthorization of services,
precertification of services, post service review, medical necessity
review, and benefits advisory;
(iii) Develop,
maintain, and promote widespread adoption of a single common website
where providers can obtain payors'
preauthorization, benefits advisory, and preadmission
requirements;
(iv)
Establish guidelines for payors to develop and
maintain a website that providers can
use to request a preauthorization, including a
prospective clinical necessity review; receive an
authorization number; and transmit an admission notification.
(i)
To issue an ANTI-CANCER MEDICATION REPORT. Not later than June 30, 2014
and annually thereafter, the office of the health
insurance commissioner (OHIC) shall provide the
senate committee on health and human services, and the house
committee on corporations, with:
(1) Information on the availability in the commercial
market of coverage for anti-cancer
medication options; (2) For the state employee's health benefit
plan, the costs of various cancer
treatment options; (3) The changes in drug prices over the
prior thirty-six (36) months; and (4)
Member utilization and
cost-sharing expense.
SECTION 6. This act shall take effect upon passage.
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LC01019/SUB A/5
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