2012 -- H 7909 SUBSTITUTE A

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LC02084/SUB A/2

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STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2012

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A N A C T

RELATING TO INSURANCE -- HEALTH INSURANCE - CONSUMER PROTECTION

     

     

     Introduced By: Representatives Kennedy, San Bento, E Coderre, Ferri, and Tanzi

     Date Introduced: March 07, 2012

     Referred To: House Corporations

It is enacted by the General Assembly as follows:

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     SECTION 1. Purpose and intent.

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     It is the purpose of this act to amend Rhode Island statutes so as to be consistent with

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health insurance consumer protections enacted in federal law. This act is intended to establish

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health insurance rules, standards, and policies pursuant to, and in furtherance of, the health

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insurance standards established in the federal Patient Protection and Affordable Care Act of 2010,

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as amended by the federal Health Care and Education Reconciliation Act of 2010.

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     SECTION 2. Chapter 27-18 of the General laws entitled "Accident and Sickness

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Insurance Policies" is hereby amended by adding thereto the following sections:

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     27-18-1.1. Definitions. – As used in this chapter:

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     (1) “Adverse benefit determination” means any of the following: a denial, reduction, or

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termination of, or a failure to provide or make payment (in whole or in part) for, a benefit,

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including any such denial, reduction, termination, or failure to provide or make payment that is

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based on a determination of an individual’s eligibility to participate in a plan or to receive

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coverage under a plan, and including, with respect to group health plans, a denial, reduction, or

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termination of, or a failure to provide or make payment (in whole or in part) for, a benefit

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resulting from the application of any utilization review, as well as a failure to cover an item or

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service for which benefits are otherwise provided because it is determined to be experimental or

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investigational or not medically necessary or appropriate. The term also includes a rescission of

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coverage determination.

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     (2) “Affordable Care Act” means the federal Patient Protection and Affordable Care Act

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of 2010, as amended by the federal Health Care and Education Reconciliation Act of 2010, and

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federal regulations adopted thereunder.

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     (3) “Commissioner” or “health insurance commissioner” means that individual appointed

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pursuant to section 42-14.5-1 of the general laws.

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     (4) “Essential health benefits” shall have the meaning set forth in section 1302(b) of the

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federal Affordable Care Act,

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     (5) “Grandfathered health plan” means any group health plan or health insurance

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coverage subject to 42 USC section 18011.

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     (6) “Group health insurance coverage” means, in connection with a group health plan,

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health insurance coverage offered in connection with such plan.

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     (7) “Group health plan” means an employee welfare benefit plan, as defined in 29 USC

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section 1002(1), to the extent that the plan provides health benefits to employees or their

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dependents directly or through insurance, reimbursement, or otherwise.

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     (8) “Health benefits” or “covered benefits” means coverage or benefits for the diagnosis,

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cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting

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any structure or function of the body including coverage or benefits for transportation primarily

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for and essential thereto, and including medical services as defined in R.I. Gen. Laws § 27-19-17;

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     (9) “Health care facility” means an institution providing health care services or a health

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care setting, including, but not limited to, hospitals and other licensed inpatient centers,

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ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers,

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diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health

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settings.

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     (10) “Health care professional” means a physician or other health care practitioner

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licensed, accredited or certified to perform specified health care services consistent with state

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law.

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     (11) “Health care provider” or "provider" means a health care professional or a health

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care facility.

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     (12) “Health care services” means services for the diagnosis, prevention, treatment, cure

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or relief of a health condition, illness, injury or disease.

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     (13) “Health insurance carrier” means a person, firm, corporation or other entity subject

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to the jurisdiction of the commissioner under this chapter. Such term does not include a group

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health plan.

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     (14) “Health plan” or “health benefit plan” means health insurance coverage and a group

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health plan, including coverage provided through an association plan if it covers Rhode Island

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residents. Except to the extent specifically provided by the federal Affordable Care Act, the term

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“health plan” shall not include a group health plan to the extent state regulation of the health plan

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is pre-empted under section 514 of the federal Employee Retirement Income Security Act of

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1974. The term also shall not include:

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     (A)(i) Coverage only for accident, or disability income insurance, or any combination

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thereof.

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     (ii) Coverage issued as a supplement to liability insurance.

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     (iii) Liability insurance, including general liability insurance and automobile liability

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insurance.

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     (iv) Workers’ compensation or similar insurance.

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     (v) Automobile medical payment insurance.

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     (vi) Credit-only insurance.

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     (vii) Coverage for on-site medical clinics.

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     (viii) Other similar insurance coverage, specified in federal regulations issued pursuant to

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Pub. L. No. 104-191, the federal health insurance portability and accountability act of 1996

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(“HIPAA”), under which benefits for medical care are secondary or incidental to other insurance

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benefits.

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     (B) The following benefits if they are provided under a separate policy, certificate or

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contract of insurance or are otherwise not an integral part of the plan:

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     (i) Limited scope dental or vision benefits.

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     (ii) Benefits for long-term care, nursing home care, home health care, community-based

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care, or any combination thereof.

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     (iii) Other excepted benefits specified in federal regulations issued pursuant to federal

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Pub. L. No. 104-191 (“HIPAA”).

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     (C) The following benefits if the benefits are provided under a separate policy, certificate

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or contract of insurance, there is no coordination between the provision of the benefits and any

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exclusion of benefits under any group health plan maintained by the same plan sponsor, and the

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benefits are paid with respect to an event without regard to whether benefits are provided with

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respect to such an event under any group health plan maintained by the same plan sponsor:

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     (i) Coverage only for a specified disease or illness.

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     (ii) Hospital indemnity or other fixed indemnity insurance.

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     (D) The following if offered as a separate policy, certificate or contract of insurance:

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     (i) Medicare supplement health insurance as defined under section 1882(g)(1) of the

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federal Social Security Act.

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     (ii) Coverage supplemental to the coverage provided under chapter 55 of title 10, United

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States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)).

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     (iii) Similar supplemental coverage provided to coverage under a group health plan.

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     (15) "Office of the health insurance commissioner" means the agency established under

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section 42-14.5-1 of the General laws.

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     (16) “Rescission" means a cancellation or discontinuance of coverage that has retroactive

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effect for reasons unrelated to timely payment of required premiums or contribution to costs of

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coverage.

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     27-18-2.1. Uniform explanation of benefits and coverage. – (a) A health insurance

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carrier shall provide a summary of benefits and coverage explanation and definitions to

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policyholders and others required by, and at the times and in the format required, by the federal

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regulations adopted under section 2715 of the Public Health Service Act, as amended by the

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federal Affordable Care Act. The forms required by this section shall be made available to the

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commissioner on request. Nothing in this section shall be construed to limit the authority of the

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commissioner under existing state law.

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

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

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

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benefit health; (7) specified disease indemnity; (8) sickness or bodily injury or death by accident

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

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     (c) If the commissioner of the office of the health insurance commissioner determines

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that the corresponding provision of the federal Patient Protection and Affordable Care Act has

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been declared invalid by a final judgment of the federal judicial branch or has been repealed by

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an act of Congress, on the date of the commissioner’s determination this section shall have its

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effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this

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section. Nothing in this section shall be construed to limit the authority of the commissioner

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under existing state law.

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     27-18-71. Prohibition on preexisting condition exclusions. – (a) A health insurance

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policy, subscriber contract, or health plan offered, issued, issued for delivery, or issued to cover a

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resident of this state by a health insurance company licensed pursuant to this title and/or chapter:

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     (1) Shall not limit or exclude coverage for an individual under the age of nineteen (19) by

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imposing a preexisting condition exclusion on that individual.

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     (2) For plan or policy years beginning on or after January 1, 2014, shall not limit or

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exclude coverage for any individual by imposing a preexisting condition exclusion on that

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individual.

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     (b) As used in this section:

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     (1) “Preexisting condition exclusion” means a limitation or exclusion of benefits,

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including a denial of coverage, based on the fact that the condition (whether physical or mental)

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was present before the effective date of coverage, or if the coverage is denied, the date of denial,

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under a health benefit plan whether or not any medical advice, diagnosis, care or treatment was

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recommended or received before the effective date of coverage.

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     (2) “Preexisting condition exclusion” means any limitation or exclusion of benefits,

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including a denial of coverage, applicable to an individual as a result of information relating to an

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individual’s health status before the individual’s effective date of coverage, or if the coverage is

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denied, the date of denial, under the health benefit plan, such as a condition (whether physical or

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mental) identified as a result of a pre-enrollment questionnaire or physical examination given to

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the individual, or review of medical records relating to the pre-enrollment period.

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     (c) This section shall not apply to grandfathered health plans providing individual health

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insurance coverage.

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

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

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

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

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     27-18-72. Prohibition on rescission of coverage. – (a)(1) Coverage under a health

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benefit plan subject to the jurisdiction of the commissioner under this chapter with respect to an

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individual, including a group to which the individual belongs or family coverage in which the

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individual is included, shall not be rescinded after the individual is covered under the plan,

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unless:

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     (A) The individual or a person seeking coverage on behalf of the individual, performs an

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act, practice or omission that constitutes fraud; or

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     (B) The individual makes an intentional misrepresentation of material fact, as prohibited

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by the terms of the plan or coverage.

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     (2) For purposes of paragraph (a)(1)(A), a person seeking coverage on behalf of an

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individual does not include an insurance producer or employee or authorized representative of the

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health carrier.

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     (b) At least thirty (30) days advance written notice shall be provided to each health

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benefit plan enrollee or, for individual health insurance coverage, primary subscriber, who would

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be affected by the proposed rescission of coverage before coverage under the plan may be

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rescinded in accordance with subsection (a) regardless of, in the case of group health insurance

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coverage, whether the rescission applies to the entire group or only to an individual within the

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group.

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     (c) For purposes of this section, “to rescind” means to cancel or to discontinue coverage

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with retroactive effect for reasons unrelated to timely payment of required premiums or

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contribution to costs of coverage.

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     (d) This section applies to grandfathered health plans.

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     27-18-73. Prohibition on annual and lifetime limits. – (a) Annual limits.

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     (1) For plan or policy years beginning prior to January 1, 2014, for any individual, a

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health insurance carrier and a health benefit plan subject to the jurisdiction of the commissioner

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under this chapter may establish an annual limit on the dollar amount of benefits that are essential

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health benefits provided the restricted annual limit is not less than the following:

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     (A) For a plan or policy year beginning after September 22, 2011, but before September

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23, 2012 – one million two hundred fifty thousand dollars ($1,250,000); and

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     (B) For a plan or policy year beginning after September 22, 2012, but before January 1,

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2014 – two million dollars ($2,000,000).

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     (2) For plan or policy years beginning on or after January 1, 2014, a health insurance

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carrier and a health benefit plan shall not establish any annual limit on the dollar amount of

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essential health benefits for any individual, except:

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     (A) A health flexible spending arrangement, as defined in Section 106(c)(2)(i) of the

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Federal Internal Revenue Code, a medical savings account, as defined in section 220 of the

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federal Internal Revenue Code, and a health savings account, as defined in Section 223 of the

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federal Internal Revenue Code are not subject to the requirements of subdivisions (1) and (2) of

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this subsection.

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     (B) The provisions of this subsection shall not prevent a health insurance carrier and a

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health benefit plan from placing annual dollar limits for any individual on specific covered

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benefits that are not essential health benefits to the extent that such limits are otherwise permitted

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under applicable federal law or the laws and regulations of this state.

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     (3) In determining whether an individual has received benefits that meet or exceed the

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allowable limits, as provided in subdivision (1) of this subsection, a health insurance carrier and a

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health benefit plan shall take into account only essential health benefits.

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     (b) Lifetime limits.

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     (1) A health insurance carrier and health benefit plan offering group or individual health

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insurance coverage shall not establish a lifetime limit on the dollar value of essential health

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benefits for any individual.

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     (2) Notwithstanding subdivision (1) above, a health insurance carrier and health benefit

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plan is not prohibited from placing lifetime dollar limits for any individual on specific covered

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benefits that are not essential health benefits, in accordance with federal laws and regulations.

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     (c)(1) The provisions of this section relating to lifetime limits apply to any health

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insurance carrier providing coverage under an individual or group health plan, including

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grandfathered health plans.

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     (2) The provisions of this section relating to annual limits apply to any health insurance

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carrier providing coverage under a group health plan, including grandfathered health plans, but

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the prohibition and limits on annual limits do not apply to grandfathered health plans providing

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individual health insurance coverage.

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     (d) This section shall not apply to a plan or to policy years prior to January 1, 2014 for

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which the Secretary of the U.S. Department of Health and Human Services issued a waiver

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pursuant to 45 C.F.R. § 147.126(d)(3). This section also shall not apply to insurance coverage

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providing benefits for: (1) hospital confinement indemnity; (2) disability income; (3) accident

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only; (4) long term care; (5) Medicare supplement; (6) limited benefit health; (7) specified disease

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indemnity; (8) sickness or bodily injury or death by accident or both; and (9) other limited benefit

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policies.

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     (e) If the commissioner of the office of the health insurance commissioner determines

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that the corresponding provision of the federal Patient Protection and Affordable Care Act has

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been declared invalid by a final judgment of the federal judicial branch or has been repealed by

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an act of Congress, on the date of the commissioner’s determination this section shall have its

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effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this

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section. Nothing in this subsection shall be construed to limit the authority of the Commissioner

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to regulate health insurance under existing state law.

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     27-18-74. Coverage for individuals participating in approved clinical trials. – (a) As

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used in this section,

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     (1) “Approved clinical trial” means a phase I, phase II, phase III or phase IV clinical trial

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that is conducted in relation to the prevention, detection or treatment of cancer or a life-

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threatening disease or condition and is described in any of the following:

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     (A) The study or investigation is approved or funded, which may include funding through

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in-kind contributions, by one or more of the following:

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     (i) The federal National Institutes of Health;

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     (ii) The federal Centers for Disease Control and Prevention;

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     (iii) The federal Agency for Health Care Research and Quality;

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     (iv) The federal Centers for Medicare & Medicaid Services;

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     (v) A cooperative group or center of any of the entities described in items (i) through (iv)

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or the U.S. Department of Defense or the U.S. Department of Veteran Affairs;

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     (vi) A qualified non-governmental research entity identified in the guidelines issued by

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the federal National Institutes of Health for center support grants; or

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     (vii) A study or investigation conducted by the U.S. Department of Veteran Affairs, the

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U.S. Department of Defense, or the U.S. Department of Energy, if the study or investigation has

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been reviewed and approved through a system of peer review that the Secretary of U.S.

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Department of Health and Human Services determines:

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     (I) Is comparable to the system of peer review of studies and investigations used by the

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federal National Institutes of Health; and

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     (II) Assures unbiased review of the highest scientific standards by qualified individuals

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who have no interest in the outcome of the review.

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     (B) The study or investigation is conducted under an investigational new drug application

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reviewed by the U.S. Food and Drug Administration; or

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     (C) The study or investigation is a drug trial that is exempt from having such an

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investigational new drug application.

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     (2) “Participant” has the meaning stated in section 3(7) of federal ERISA.

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     (3) “Participating provider” means a health care provider that, under a contract with the

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health carrier or with its contractor or subcontractor, has agreed to provide health care services to

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covered persons with an expectation of receiving payment, other than coinsurance, copayments or

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deductibles, directly or indirectly from the health carrier.

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     (4) “Qualified individual” means a participant or beneficiary who meets the following

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conditions:

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     (A) The individual is eligible to participate in an approved clinical trial according to the

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trial protocol with respect to the treatment of cancer or other life-threatening disease or condition;

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and

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     (B)(i) The referring health care professional is a participating provider and has concluded

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that the individual’s participation in such trial would be appropriate based on the individual

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meeting the conditions described in subdivision (A) of this subdivision (3); or

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     (ii) The participant or beneficiary provides medical and scientific information

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establishing the individual’s participation in such trial would be appropriate based on the

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individual meeting the conditions described in subdivision (A) of this subdivision (3).

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     (5) “Life-threatening condition” means any disease or condition from which the

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likelihood of death is probable unless the course of the disease or condition is interrupted.

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     (b)(1) If a health insurance carrier offering group or individual health insurance coverage

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provides coverage to a qualified individual, the health insurance carrier:

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     (A) Shall not deny the individual participation in an approved clinical trial.

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     (B) Subject to subdivision (3) of this subsection, shall not deny or limit or impose

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additional conditions on the coverage of routine patient costs for items and services furnished in

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connection with participation in the approved clinical trial; and

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     (C) Shall not discriminate against the individual on the basis of the individual’s

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participation in the approved clinical trial.

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     (2)(A) Subject to subdivision (B) of this subdivision (2), routine patient costs include all

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items and services consistent with the coverage typically covered for a qualified individual who is

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not enrolled in an approved clinical trial.

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     (B) For purposes of subdivision (B) of this subdivision (2), routine patient costs do not

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include:

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     (i) The investigational item, device or service itself;

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     (ii) Items and services that are provided solely to satisfy data collection and analysis

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needs and that are not used in the direct clinical management of the patient; or

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     (iii) A service that is clearly inconsistent with widely accepted and established standards

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of care for a particular diagnosis.

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     (3) If one or more participating providers are participating in a clinical trial, nothing in

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subdivision (1) of this subsection shall be construed as preventing a health carrier from requiring

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that a qualified individual participate in the trial through such a participating provider if the

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provider will accept the individual as a participant in the trial.

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     (4) Notwithstanding subdivision (3) of this subsection, subdivision (1) of this subsection

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shall apply to a qualified individual participating in an approved clinical trial that is conducted

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outside this state.

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     (5) This section shall not be construed to require a health insurance carrier offering group

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or individual health insurance coverage to provide benefits for routine patient care services

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provided outside of the coverage’s health care provider network unless out-of-network benefits

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are otherwise provided under the coverage.

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     (6) Nothing in this section shall be construed to limit a health insurance carrier’s

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coverage with respect to clinical trials.

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     (c) The requirements of this section shall be in addition to the requirements of Rhode

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Island general laws sections 27-18-36 through 27-18-36.3.

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

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

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

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

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and (9) other limited benefit policies.

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     (e) This section shall be effective for plan years beginning on or after January 1, 2014.

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     27-18-75. Medical loss ratio reporting and rebates. – (a) A health insurance carrier

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offering group or individual health insurance coverage of a health benefit plan, including a

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grandfathered health plan, shall comply with the provisions of Section 2718 of the Public Health

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Services Act as amended by the federal Affordable Care Act, in accordance with regulations

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adopted thereunder.

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     (b) Health insurance carriers required to report medical loss ratio and rebate calculations

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and other medical loss ratio and rebate information to the U.S. Department of Health and Human

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Services shall concurrently file such information with the commissioner.

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     27-18-76. Emergency services. – (a) As used in this section:

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     (1) “Emergency medical condition” means a medical condition manifesting itself by

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

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

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

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

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impairment to bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or

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part.

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

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

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

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hospital, including ancillary services routinely available to the emergency department to evaluate

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such emergency medical condition, and

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

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

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

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

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

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

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

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emergency services in compliance with this section.

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

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following manner:

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

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

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     (2) Without regard to whether the health care provider furnishing the emergency services

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is a participating network provider with respect to the services;

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

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

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

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

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

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

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     (A) The exclusion of or coordination of benefits;

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

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

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     (C) Applicable cost-sharing.

11-87

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

11-88

rate imposed with respect to a participant or beneficiary for out-of-network emergency services

11-89

cannot exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if

11-90

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

11-91

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

11-92

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

11-93

subdivision (1) of this subsection. A health insurance carrier complies with the requirements of

11-94

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

11-95

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

11-96

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

11-97

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

11-98

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

11-99

participant or beneficiary. If there is more than one amount negotiated with in-network providers

11-100

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

11-101

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

11-102

participant or beneficiary. In determining the median described in the preceding sentence, the

12-1

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

12-2

same amount is paid to more than one provider). If there is no per-service amount negotiated with

12-3

in-network providers (such as under a capitation or other similar payment arrangement), the

12-4

amount under this subdivision (A) is disregarded.

12-5

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

12-6

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

12-7

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

12-8

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

12-9

determined without reduction for out-of-network cost-sharing that generally applies under the

12-10

plan or health insurance coverage with respect to out-of-network services.

12-11

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

12-12

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

12-13

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

12-14

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

12-15

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

12-16

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

12-17

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

12-18

services only as part of a deductible that generally applies to out-of-network benefits. If an out-of-

12-19

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

12-20

apply to out-of-network emergency services.

12-21

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

12-22

23, 2010.

12-23

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

12-24

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

12-25

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

12-26

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

12-27

and (9) other limited benefit policies.

12-28

     27-18-77. Internal and external appeal of adverse benefit determinations. – (a) The

12-29

commissioner shall adopt regulations to implement standards and procedures with respect to

12-30

internal claims and appeals of adverse benefit determinations, and with respect to external appeals

12-31

of adverse benefit determinations.

12-32

     (b) The regulations adopted by the commissioner shall apply only to those adverse

12-33

benefit determinations which are not subject to the jurisdiction of the department of health

12-34

pursuant to R.I. Gen. Laws § 23-17.12 et seq. (Utilization Review Act).

13-1

     (c) This section shall not apply to insurance coverage providing benefits for: (1) hospital

13-2

confinement indemnity; (2) disability income; (3) accident only; (4) long term care; (5) Medicare

13-3

supplement; (6) limited benefit health; (7) specified disease indemnity; (8) sickness or bodily

13-4

injury or death by accident or both; and (9) other limited benefit policies. This section also shall

13-5

not apply to grandfathered health plans.

13-6

     SECTION 3. Sections 27-18-8, 27-18-44 and 27-18-59 of the General laws in Chapter

13-7

27-18 entitled "Accident and Sickness Insurance Policies" are hereby amended to read as follows:

13-8

     27-18-8. Filing of accident and sickness insurance policy forms. – (a) Any insurance

13-9

company authorized to do an accident and sickness business within this state in accordance with

13-10

the provisions of this title shall file all accident and sickness insurance policy forms and rates

13-11

used by it in the state with the insurance commissioner, including the forms of any rider,

13-12

endorsement, application blank, and other matter generally used or incorporated by reference in

13-13

its policies or contracts of insurance. No such form shall be used if disapproved by the

13-14

commissioner under this section, or if the commissioner’s approval has been withdrawn under

13-15

section 27-18-8.3, or until the expiration of the waiting period established under section 27-18-

13-16

8.3. Such a company shall comply with its filed and approved forms. If the commissioner finds

13-17

from a examination of any form that it is contrary to the public interest, or the requirements of

13-18

this code or duly promulgated regulations, he or she shall forbid its use, and shall notify the

13-19

company in writing as provided in section 27-18-8.2. Each form shall include a certification by a

13-20

qualified actuary that to the best of the actuary's knowledge and judgment, the entire rate is in

13-21

compliance with applicable laws and that the benefits are reasonable in relation to the premium to

13-22

be charged.

13-23

     (b) Each rate filing shall include a certification by a qualified actuary that to the best of

13-24

the actuary's knowledge and judgment, the entire rate filing is in compliance with applicable laws

13-25

and that the benefits offered or proposed to be offered are reasonable in relation to the premium

13-26

to be charged. A health insurance carrier shall comply with its filed and approved rates and forms.

13-27

     27-18-44. Primary and preventive obstetric and gynecological care. – (a) Any insurer

13-28

or health plan, nonprofit health medical service plan, or nonprofit hospital service plan that

13-29

provides coverage for obstetric and gynecological care for issuance or delivery in the state to any

13-30

group or individual on an expense-incurred basis, including a health plan offered or issued by a

13-31

health insurance carrier or a health maintenance organization, shall permit a woman to receive an

13-32

annual visit to an in-network obstetrician/gynecologist for routine gynecological care without

13-33

requiring the woman to first obtain a referral from a primary care provider.

14-34

     (b)(1)(A) Any health plan, nonprofit medical service plan or nonprofit hospital service

14-35

plan, including a health insurance carrier or a health maintenance organization which requires or

14-36

provides for the designation by a covered person of a participating primary health care

14-37

professional shall permit each covered person to:

14-38

     (i) Designate any participating primary care health care professional who is available to

14-39

accept the covered person; and

14-40

     (ii) For a child, designate any participating physician who specializes in pediatrics as the

14-41

child’s primary care health care professional and is available to accept the child.

14-42

     (2) The provisions of subdivision (1) of this subsection shall not be construed to waive

14-43

any exclusions of coverage under the terms and conditions of the health benefit plan with respect

14-44

to coverage of pediatric care.

14-45

     (c)(1) If a health plan, nonprofit medical service plan or nonprofit hospital service plan,

14-46

including a health insurance carrier or a health maintenance organization, provides coverage for

14-47

obstetrical or gynecological care and requires the designation by a covered person of a

14-48

participating primary care health care professional, then it:

14-49

     (A) Shall not require any person’s, including a primary care health care professional’s,

14-50

prior authorization or referral in the case of a female covered person who seeks coverage for

14-51

obstetrical or gynecological care provided by a participating health care professional who

14-52

specializes in obstetrics or gynecology; and

14-53

     (B) Shall treat the provision of obstetrical and gynecological care, and the ordering of

14-54

related obstetrical and gynecological items and services, pursuant to subdivision (A) of this

14-55

subdivision (c)(1), by a participating health care professional who specializes in obstetrics or

14-56

gynecology as the authorization of the primary care health care professional.

14-57

     (2)(A) A health plan, nonprofit medical service plan or nonprofit hospital service plan,

14-58

including a health insurance carrier or a health maintenance organization may require the health

14-59

care professional to agree to otherwise adhere to its policies and procedures, including procedures

14-60

relating to referrals, obtaining prior authorization, and providing services in accordance with a

14-61

treatment plan, if any, approved by the plan, carrier or health maintenance organization.

14-62

     (B)For purposes of subdivision (A) of this subdivision (c)(1), a health care professional,

14-63

who specializes in obstetrics or gynecology, means any individual, including an individual other

14-64

than a physician, who is authorized under state law to provide obstetrical or gynecological care.

14-65

     (3) The provisions of subdivision (A) of this subdivision (c)(1) shall not be construed to:

14-66

     (A) Waive any exclusions of coverage under the terms and conditions of the health

14-67

benefit plan with respect to coverage of obstetrical or gynecological care; or

15-68

     (B) Preclude the health plan, nonprofit medical service plan or nonprofit hospital service

15-69

plan, including a health insurance carrier or a health maintenance organization involved from

15-70

requiring that the participating health care professional providing obstetrical or gynecological

15-71

care notify the primary care health care professional or the plan, carrier or health maintenance

15-72

organization of treatment decisions.

15-73

     (d) Notice Requirements:

15-74

     (1) A health plan, nonprofit medical service plan or nonprofit hospital service plan,

15-75

including a health insurance carrier or a health maintenance organization subject to this section

15-76

shall provide notice to covered persons of the terms and conditions of the plan related to the

15-77

designation of a participating health care professional and of a covered person’s rights with

15-78

respect to those provisions.

15-79

     (2)(A) In the case of group health insurance coverage, the notice described in subdivision

15-80

(1) of this subsection shall be included whenever the a participant is provided with a summary

15-81

plan description or other similar description of benefits under the health benefit plan.

15-82

     (B) In the case of individual health insurance coverage, the notice described in

15-83

subdivision (1) of this subsection shall be included whenever the primary subscriber is provided

15-84

with a policy, certificate or contract of health insurance.

15-85

     (C) A health plan, nonprofit medical service plan or nonprofit hospital service plan,

15-86

including a health insurance carrier or a health maintenance organization, may use the model

15-87

language in federal regulation 45 CFR section 147.138(a)(4)(iii) to satisfy the requirements of

15-88

this subsection.

15-89

     (e) The requirements of subsections (b), (c), and (d) shall not apply to grandfathered

15-90

health plans. This section shall not apply to insurance coverage providing benefits for: (1)

15-91

hospital confinement indemnity; (2) disability income; (3) accident only; (4) long term care; (5)

15-92

Medicare supplement; (6) limited benefit health; (7) specified disease indemnity; (8) sickness or

15-93

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

15-94

     27-18-59. Termination of children's benefits Eligibility for children’s benefits. --

15-95

(a)(1) Every individual health insurance contract, plan, or policy health benefit plan delivered,

15-96

issued for delivery, or renewed in this state and every group health insurance contract, plan, or

15-97

policy delivered, issued for delivery or renewed in this state which provides medical health

15-98

benefits coverage for dependent children that includes coverage for physician services in a

15-99

physician's office, and every policy which provides major medical or similar comprehensive type

15-100

coverage dependents, except for supplemental policies which only provide coverage for specified

15-101

diseases and other supplemental policies, shall provide make coverage available of an unmarried

15-102

child under the age of nineteen (19) years, an unmarried child who is a student under the age of

16-1

twenty-five (25) years and who is financially dependent upon the parent and an unmarried child

16-2

of any age who is financially dependent upon the parent and medically determined to have a

16-3

physical or mental impairment which can be expected to result in death or which has lasted or can

16-4

be expected to last for a continuous period of not less than twelve (12) months for children until

16-5

attainment of twenty-six (26) years of age, and an unmarried child of any age who is financially

16-6

dependent upon the parent and medically determined to have a physical or mental impairment

16-7

which can be expected to result in death or which has lasted or can be expected to last for a

16-8

continuous period of not less than twelve (12) months. Such contract, plan or policy shall also

16-9

include a provision that policyholders shall receive no less than thirty (30) days notice from the

16-10

accident and sickness insurer that a child covered as a dependent by the policy holder is about to

16-11

lose his or her coverage as a result of reaching the maximum age for a dependent child, and that

16-12

the child will only continue to be covered upon documentation being provided of current full or

16-13

part-time enrollment in a post-secondary educational institution or that the child may purchase a

16-14

conversion policy if he or she is not an eligible student. Nothing in this section prohibits an

16-15

accident and sickness insurer from requiring a policyholder to annually provide proof of a child's

16-16

current full or part-time enrollment in a post-secondary educational institution in order to

16-17

maintain the child's coverage. Provided, nothing in this section requires coverage inconsistent

16-18

with the membership criteria in effect under the policyholder's health benefits coverage.

16-19

     (2) With respect to a child who has not attained twenty-six (26) years of age, a health

16-20

insurance carrier shall not define “dependent” for purposes of eligibility for dependent coverage

16-21

of children other than the terms of a relationship between a child and the plan participant, or

16-22

subscriber.

16-23

     (3) A health insurance carrier shall not deny or restrict coverage for a child who has not

16-24

attained twenty-six (26) years of age based on the presence or absence of the child’s financial

16-25

dependency upon the participant, primary subscriber or any other person, residency with the

16-26

participant and in the individual market the primary subscriber, or with any other person, marital

16-27

status, student status, employment or any combination of those factors. A health carrier shall not

16-28

deny or restrict coverage of a child based on eligibility for other coverage, except as provided in

16-29

subparagraph (b)(1) of this section.

16-30

     (4) Nothing in this section shall be construed to require a health insurance carrier to make

16-31

coverage available for the child of a child receiving dependent coverage, unless the grandparent

16-32

becomes the legal guardian or adoptive parent of that grandchild.

16-33

     (5) The terms of coverage in a health benefit plan offered by a health insurance carrier

16-34

providing dependent coverage of children cannot vary based on age except for children who are

17-1

twenty-six (26) years of age or older.

17-2

     (b)(1) For plan years beginning before January 1, 2014, a health insurance carrier

17-3

providing group health insurance coverage that is a grandfathered health plan and makes

17-4

available dependent coverage of children may exclude an adult child who has not attained twenty-

17-5

six (26) years of age from coverage only if the adult child is eligible to enroll in an eligible

17-6

employer-sponsored health benefit plan, as defined in section 5000A(f)(2) of the federal Internal

17-7

Revenue Code, other than the group health plan of a parent.

17-8

     (2) For plan years, beginning on or after January 1, 2014, a health insurance carrier

17-9

providing group health insurance coverage that is a grandfathered health plan shall comply with

17-10

the requirements of subsections (a) through (e) of this section.

17-11

     (b)(c)This section does not apply to insurance coverage providing benefits for: (1)

17-12

hospital confinement indemnity; (2) disability income; (3) accident only; (4) long term care; (5)

17-13

Medicare supplement; (6) limited benefit health; (7) specified diseased indemnity; or (8) sickness

17-14

or bodily injury or death by accident or both; or (9) other limited benefit policies.

17-15

     SECTION 4. Chapter 27-18.5 of the General Laws entitled “Individual Health Insurance

17-16

Coverage” is hereby amended by adding thereto the following section:

17-17

     27-18.5-10. Prohibition on preexisting condition exclusions. -- (a) A health insurance

17-18

policy, subscriber contract, or health plan offered, issued, issued for delivery, or issued to cover a

17-19

resident of this state by a health insurance company licensed pursuant to this title and/or chapter:

17-20

     (1) Shall not limit or exclude coverage for an individual under the age of nineteen (19) by

17-21

imposing a preexisting condition exclusion on that individual.

17-22

     (2) For plan or policy years beginning on or after January 1, 2014, shall not limit or

17-23

exclude coverage for any individual by imposing a preexisting condition exclusion on that

17-24

individual.

17-25

     (b) As used in this section:

17-26

     (1) “Preexisting condition exclusion” means a limitation or exclusion of benefits,

17-27

including a denial of coverage, based on the fact that the condition (whether physical or mental)

17-28

was present before the effective date of coverage, or if the coverage is denied, the date of denial,

17-29

under a health benefit plan whether or not any medical advice, diagnosis, care or treatment was

17-30

recommended or received before the effective date of coverage.

17-31

     (2) “Preexisting condition exclusion” means any limitation or exclusion of benefits,

17-32

including a denial of coverage, applicable to an individual as a result of information relating to an

17-33

individual’s health status before the individual’s effective date of coverage, or if the coverage is

17-34

denied, the date of denial, under the health benefit plan, such as a condition (whether physical or

18-1

mental) identified as a result of a pre-enrollment questionnaire or physical examination given to

18-2

the individual, or review of medical records relating to the pre-enrollment period.

18-3

     (c) This section shall not apply to grandfathered health plans providing individual health

18-4

insurance coverage.

18-5

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

18-6

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

18-7

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

18-8

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

18-9

     SECTION 5. Sections 27-19-1 and 27-19-50 of the General laws in Chapter 27-19

18-10

entitled "Nonprofit Hospital Service Corporations" are hereby amended to read as follows:

18-11

     27-19-1. Definitions. -- As used in this chapter:

18-12

     (1) "Contracting hospital" means an eligible hospital which has contracted with a

18-13

nonprofit hospital service corporation to render hospital care to subscribers to the nonprofit

18-14

hospital service plan operated by the corporation;

18-15

     (2) "Adverse benefit determination" means any of the following: a denial, reduction, or

18-16

termination of, or a failure to provide or make payment (in whole or in part) for, a benefit,

18-17

including any such denial, reduction, termination, or failure to provide or make payment that is

18-18

based on a determination of an individual's eligibility to participate in a plan or to receive

18-19

coverage under a plan, and including, with respect to group health plans, a denial, reduction, or

18-20

termination of, or a failure to provide or make payment (in whole or in part) for, a benefit

18-21

resulting from the application of any utilization review, as well as a failure to cover an item or

18-22

service for which benefits are otherwise provided because it is determined to be experimental or

18-23

investigational or not medically necessary or appropriate. The term also includes a rescission of

18-24

coverage determination.

18-25

     (3) "Affordable Care Act" means the federal Patient Protection and Affordable Care Act

18-26

of 2010, as amended by the federal Health Care and Education Reconciliation Act of 2010, and

18-27

federal regulations adopted thereunder;

18-28

     (4) “Commissioner” or “health insurance commissioner” means that individual appointed

18-29

pursuant to section 42-14.5-1 of the General laws;

18-30

     (5) "Eligible hospital" is one which is maintained either by the state or by any of its

18-31

political subdivisions or by a corporation organized for hospital purposes under the laws of this

18-32

state or of any other state or of the United States, which is designated as an eligible hospital by a

18-33

majority of the directors of the nonprofit hospital service corporation;

19-34

     (6) "Essential health benefits" shall have the meaning set forth in section 1302(b) of the

19-35

federal Affordable Care Act.

19-36

     (7) “Grandfathered health plan” means any group health plan or health insurance

19-37

coverage subject to 42 USC section 18011;

19-38

     (8) “Group health insurance coverage” means, in connection with a group health plan,

19-39

health insurance coverage offered in connection with such plan;

19-40

     (9) “Group health plan” means an employee welfare benefit plan as defined 29 USC

19-41

section 1002(1), to the extent that the plan provides health benefits to employees or their

19-42

dependents directly or through insurance, reimbursement, or otherwise;

19-43

     (10) “Health benefits” or “covered benefits” means coverage or benefits for the

19-44

diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose

19-45

of affecting any structure or function of the body including coverage or benefits for transportation

19-46

primarily for and essential thereto, and including medical services as defined in R.I. Gen. Laws §

19-47

27-19-17;

19-48

     (11) “Health care facility” means an institution providing health care services or a health

19-49

care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory

19-50

surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic,

19-51

laboratory and imaging centers, and rehabilitation and other therapeutic health settings;

19-52

     (12) "Health care professional" means a physician or other health care practitioner

19-53

licensed, accredited or certified to perform specified health care services consistent with state

19-54

law;

19-55

     (13) "Health care provider" or "provider" means a health care professional or a health

19-56

care facility;

19-57

     (14) "Health care services" means services for the diagnosis, prevention, treatment, cure

19-58

or relief of a health condition, illness, injury or disease;

19-59

     (15) “Health insurance carrier” means a person, firm, corporation or other entity subject

19-60

to the jurisdiction of the commissioner under this chapter, and includes nonprofit hospital service

19-61

corporations. Such term does not include a group health plan. The use of this term shall not be

19-62

construed to subject a nonprofit hospital service corporation to the insurance laws of this state

19-63

other than as set forth in R.I. Gen. Laws § 27-19-2;

19-64

     (16) "Health plan" or "health benefit plan" means health insurance coverage and a group

19-65

health plan, including coverage provided through an association plan if it covers Rhode Island

19-66

residents. Except to the extent specifically provided by the federal Affordable Care Act, the term

19-67

“health plan” shall not include a group health plan to the extent state regulation of the health plan

19-68

is pre- empted under section 514 of the federal Employee Retirement Income Security Act of

20-1

1974. The term also shall not include:

20-2

     (A)(i) Coverage only for accident, or disability income insurance, or any combination

20-3

thereof.

20-4

     (ii) Coverage issued as a supplement to liability insurance.

20-5

     (iii) Liability insurance, including general liability insurance and automobile liability

20-6

insurance.

20-7

     (iv) Workers’ compensation or similar insurance.

20-8

     (v) Automobile medical payment insurance.

20-9

     (vi) Credit-only insurance.

20-10

     (vii) Coverage for on-site medical clinics.

20-11

     (viii) Other similar insurance coverage, specified in federal regulations issued pursuant to

20-12

federal Pub. L. No. 104-191, the federal health insurance portability and accountability act of

20-13

1996 (“HIPAA”), under which benefits for medical care are secondary or incidental to other

20-14

insurance benefits.

20-15

     (B) The following benefits if they are provided under a separate policy, certificate or

20-16

contract of insurance or are otherwise not an integral part of the plan:

20-17

     (i) Limited scope dental or vision benefits.

20-18

     (ii) Benefits for long-term care, nursing home care, home health care, community-based

20-19

care, or any combination thereof.

20-20

     (iii) Other excepted benefits specified in federal regulations issued pursuant to federal

20-21

Pub. L. No. 104-191 (“HIPAA”).

20-22

     (C) The following benefits if the benefits are provided under a separate policy, certificate

20-23

or contract of insurance, there is no coordination between the provision of the benefits and any

20-24

exclusion of benefits under any group health plan maintained by the same plan sponsor, and the

20-25

benefits are paid with respect to an event without regard to whether benefits are provided with

20-26

respect to such an event under any group health plan maintained by the same plan sponsor:

20-27

     (i) Coverage only for a specified disease or illness.

20-28

     (ii) Hospital indemnity or other fixed indemnity insurance.

20-29

     (D) The following if offered as a separate policy, certificate or contract of insurance:

20-30

     (i) Medicare supplement health insurance as defined under section 1882(g)(1) of the

20-31

federal Social Security Act.

20-32

     (ii) Coverage supplemental to the coverage provided under chapter 55 of title 10, United

20-33

States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)).

21-34

     (iii) Similar supplemental coverage provided to coverage under a group health plan.

21-35

      (17) "Nonprofit hospital service corporation" means any corporation organized pursuant

21-36

to this chapter for the purpose of establishing, maintaining, and operating a nonprofit hospital

21-37

service plan;

21-38

     (18) "Nonprofit hospital service plan" means a plan by which specified hospital care is to

21-39

be provided to subscribers to the plan by a contracting hospital; 

21-40

     (19) "Office of the health insurance commissioner" means the agency established under

21-41

section 42-14.5-1 of the General Law;

21-42

     (20) “Rescission" means a cancellation or discontinuance of coverage that has retroactive

21-43

effect for reasons unrelated to timely payment of required premiums or contribution to costs of

21-44

coverage; and

21-45

     (21) "Subscribers" mean those persons, whether or not residents of this state, who have

21-46

contracted with a nonprofit hospital service corporation for hospital care pursuant to a nonprofit

21-47

hospital service plan operated by the corporation.

21-48

     27-19-50. Termination of children’s benefits Eligibility for children's benefits. --

21-49

 (a)(1) Every individual health insurance contract, plan, or policy health benefit plan delivered,

21-50

issued for delivery, or renewed in this state which provides medical health benefits coverage for

21-51

dependent children that includes coverage for physician services in a physician’s office, and

21-52

every policy which provides major medical or similar comprehensive type coverage dependents,

21-53

except for supplemental policies which only provide coverage for specified diseases and other

21-54

supplemental policies, shall provide make coverage available of an unmarried child under the age

21-55

of nineteen (19) years, an unmarried child who is a student under the age of twenty-five (25)

21-56

years and who is financially dependent upon the parent and an unmarried child of any age who is

21-57

financially dependent upon the parent and medically determined to have a physical or mental

21-58

impairment which can be expected to result in death or which has lasted or can be expected to last

21-59

for a continuous period of not less than twelve (12) months for children until attainment of

21-60

twenty-six (26) years of age, and an unmarried child of any age who is financially dependent

21-61

upon the parent and medically determined to have a physical or mental impairment which can be

21-62

expected to result in death or which has lasted or can be expected to last for a continuous period

21-63

of not less than twelve (12) months. Such contract, plan or policy shall also include a provision

21-64

that policyholders shall receive no less than thirty (30) days notice from the accident and sickness

21-65

insurer that a child covered as a dependent by the policy holder is about to lose his or her

21-66

coverage as a result of reaching the maximum age for a dependent child, and that the child will

21-67

only continue to be covered upon documentation being provided of current full or part-time

21-68

enrollment in a post-secondary educational institution or that the child may purchase a conversion

22-1

policy if he or she is not an eligible student.

22-2

     (b) Nothing in this section prohibits a nonprofit hospital service corporation from

22-3

requiring a policyholder to annually provide proof of a child's current full or part-time enrollment

22-4

in a post-secondary educational institution in order to maintain the child's coverage. Provided,

22-5

nothing in this section requires coverage inconsistent with the membership criteria in effect under

22-6

the policyholder's health benefits coverage.

22-7

     (2) With respect to a child who has not attained twenty-six (26) years of age, a health

22-8

insurance carrier shall not define “dependent” for purposes of eligibility for dependent coverage

22-9

of children other than the terms of a relationship between a child and the plan participant or

22-10

subscriber.

22-11

     (3) A health insurance carrier shall not deny or restrict coverage for a child who has not

22-12

attained twenty-six (26) years of age based on the presence or absence of the child’s financial

22-13

dependency upon the participant, primary subscriber or any other person, residency with the

22-14

participant and in the individual market the primary subscriber, or with any other person, marital

22-15

status, student status, employment or any combination of those factors. A health carrier shall not

22-16

deny or restrict coverage of a child based on eligibility for other coverage, except as provided in

22-17

(b)(1) of this section.

22-18

     (4) Nothing in this section shall be construed to require a health insurance carrier to make

22-19

coverage available for the child of a child receiving dependent coverage, unless the grandparent

22-20

becomes the legal guardian or adoptive parent of that grandchild.

22-21

     (5) The terms of coverage in a health benefit plan offered by a health insurance carrier

22-22

providing dependent coverage of children cannot vary based on age except for children who are

22-23

twenty-six (26) years of age or older.

22-24

     (b)(1) For plan years beginning before January 1, 2014, a group health plan providing

22-25

group health insurance coverage that is a grandfathered health plan and makes available

22-26

dependent coverage of children may exclude an adult child who has not attained twenty-six (26)

22-27

years of age from coverage only if the adult child is eligible to enroll in an eligible employer-

22-28

sponsored health benefit plan, as defined in section 5000A(f)(2) of the federal Internal Revenue

22-29

Code, other than the group health plan of a parent.

22-30

     (2) For plan years, beginning on or after January 1, 2014, a group health plan providing

22-31

group health insurance coverage that is a grandfathered health plan shall comply with the

22-32

requirements of this section.

22-33

     (c) This section does not apply to insurance coverage providing benefits for: (1) Hospital

22-34

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

23-1

Medicare supplement; (6) Limited benefit health; (7) Specified diseased indemnity; or (8) Other

23-2

limited benefit policies.

23-3

     SECTION 6. Chapter 27-19 of the General laws entitled "Nonprofit Hospital Service

23-4

Corporations" is hereby amended by adding thereto the following sections:

23-5

     27-19-7.1. Uniform explanation of benefits and coverage.   (a) A nonprofit hospital

23-6

service corporation shall provide a summary of benefits and coverage explanation and definitions

23-7

to policyholders and others required by, and at the times and in the format required, by the federal

23-8

regulations adopted under section 2715 of the Public Health Service Act, as amended by the

23-9

federal Affordable Care Act. The forms required by this section shall be made available to the

23-10

commissioner on request. Nothing in this section shall be construed to limit the authority of the

23-11

commissioner under existing state law.

23-12

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

23-13

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

23-14

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

23-15

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

23-16

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

23-17

     (c) If the commissioner of the office of the health insurance commissioner determines

23-18

that the corresponding provision of the federal Patient Protection and Affordable Care Act has

23-19

been declared invalid by a final judgment of the federal judicial branch or has been repealed by

23-20

an act of Congress, on the date of the commissioner’s determination this section shall have its

23-21

effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this

23-22

section. Nothing in this section shall be construed to limit the authority of the commissioner

23-23

under existing state law.

23-24

     27-19-7.2. Filing of policy forms. – A nonprofit hospital service corporation shall file all

23-25

policy forms and rates used by it in the state with the commissioner, including the forms of any

23-26

rider, endorsement, application blank, and other matter generally used or incorporated by

23-27

reference in its policies or contracts of insurance. No such form shall be used if disapproved by

23-28

the commissioner under this section, or if the commissioner’s approval has been withdrawn after

23-29

notice and an opportunity to be heard, or until the expiration of sixty (60) days following the

23-30

filing of the form. Such a company shall comply with its filed and approved forms . If the

23-31

commissioner finds from an examination of any form that it is contrary to the public interest, or

23-32

the requirements of this code or duly promulgated regulations, he or she shall forbid its use, and

23-33

shall notify the corporation in writing.

24-34

     (b) Each rate filing shall include a certification by a qualified actuary that to the best of

24-35

the actuary's knowledge and judgment, the entire rate filing is in compliance with applicable laws

24-36

and that the benefits offered or proposed to be offered are reasonable in relation to the premium

24-37

to be charged. A health insurance carrier shall comply with its filed and approved rates and

24-38

forms.

24-39

     27-19-62. Prohibition on rescission of coverage. – (a)(1) Coverage under a health plan

24-40

subject to the jurisdiction of the commissioner under this chapter with respect to an individual,

24-41

including a group to which the individual belongs or family coverage in which the individual is

24-42

included, shall not be rescinded after the individual is covered under the plan, unless:

24-43

     (A) The individual or a person seeking coverage on behalf of the individual, performs an

24-44

act, practice or omission that constitutes fraud; or

24-45

     (B) The individual makes an intentional misrepresentation of material fact, as prohibited

24-46

by the terms of the plan or coverage.

24-47

     (2) For purposes of paragraph (1)(A), a person seeking coverage on behalf of an

24-48

individual does not include an insurance producer or employee or authorized representative of the

24-49

health carrier.

24-50

     (b) At least thirty (30) days advance written notice shall be provided to each health

24-51

benefit plan enrollee or, for individual health insurance coverage, primary subscriber, who would

24-52

be affected by the proposed rescission of coverage before coverage under the plan may be

24-53

rescinded in accordance with subsection (a) regardless of, in the case of group health insurance

24-54

coverage, whether the rescission applies to the entire group or only to an individual within the

24-55

group.

24-56

     (c) For purposes of this section, “to rescind” means to cancel or to discontinue coverage

24-57

with retroactive effect for reasons unrelated to timely payment of required premiums or

24-58

contribution to costs of coverage.

24-59

     (d) This section applies to grandfathered health plans.

24-60

     27-19-63. Prohibition on annual and lifetime limits. – (a) Annual limits. (1) For plan or

24-61

policy years beginning prior to January 1, 2014, for any individual, a health insurance carrier and

24-62

health benefit plan subject to the jurisdiction of the commissioner under this chapter may

24-63

establish an annual limit on the dollar amount of benefits that are essential health benefits

24-64

provided the restricted annual limit is not less than the following:

24-65

     (A) For a plan or policy year beginning after September 22, 2011, but before September

24-66

23, 2012 – one million two hundred fifty thousand dollars ($1,250,000); and

24-67

     (B) For a plan or policy year beginning after September 22, 2012, but before January 1,

24-68

2014 – two million dollars ($2,000,000).

25-1

     (2) For plan or policy years beginning on or after January 1, 2014, a health insurance

25-2

carrier and health benefit plan shall not establish any annual limit on the dollar amount of

25-3

essential health benefits for any individual, except:

25-4

     (A) A health flexible spending arrangement, as defined in Section 106(c)(2)(i) of the

25-5

federal Internal Revenue Code, a medical savings account, as defined in Section 220 of the

25-6

federal Internal Revenue Code, and a health savings account, as defined in Section 223 of the

25-7

federal Internal Revenue Code, are not subject to the requirements of subdivisions (1) and (2) of

25-8

this subsection.

25-9

     (B) The provisions of this subsection shall not prevent a health insurance carrier and

25-10

health benefit plan from placing annual dollar limits for any individual on specific covered

25-11

benefits that are not essential health benefits to the extent that such limits are otherwise permitted

25-12

under applicable federal law or the laws and regulations of this state.

25-13

     (3) In determining whether an individual has received benefits that meet or exceed the

25-14

allowable limits, as provided in subdivision (1) of this subsection, a health insurance carrier and

25-15

health benefit plan shall take into account only essential health benefits.

25-16

     (b) Lifetime limits.

25-17

     (1) A health insurance carrier and health benefit plan offering group or individual health

25-18

insurance coverage shall not establish a lifetime limit on the dollar value of essential health

25-19

benefits for any individual.

25-20

     (2) Notwithstanding subdivision (1) above, a health insurance carrier and health benefit

25-21

plan is not prohibited from placing lifetime dollar limits for any individual on specific covered

25-22

benefits that are not essential health benefits in accordance with federal laws and regulations.

25-23

     (c)(1) The provisions of this section relating to lifetime limits apply to any health

25-24

insurance carrier providing coverage under an individual or group health plan, including

25-25

grandfathered health plans.

25-26

     (2) The provisions of this section relating to annual limits apply to any health insurance

25-27

carrier providing coverage under a group health plan, including grandfathered health plans, but

25-28

the prohibition and limits on annual limits do not apply to grandfathered health plans providing

25-29

individual health insurance coverage.

25-30

     (d) This section shall not apply to a plan or to policy years prior to January 1, 2014 for

25-31

which the Secretary of the U.S. Department of Health and Human Services issued a waiver

25-32

pursuant to 45 C.F.R. § 147.126(d)(3)This section also shall not apply to insurance coverage

25-33

providing benefits for: (1) Hospital confinement indemnity; (2) Disability income; (3) Accident

25-34

only; (4) Long-term care; (5) Medicare supplement; (6) Limited benefit health; (7) Specified

26-1

disease indemnity; (8) Sickness or bodily injury or death by accident or both; and (9) Other

26-2

limited benefit policies.

26-3

     (e) If the commissioner of the office of the health insurance commissioner determines

26-4

that the corresponding provision of the federal Patient Protection and Affordable Care Act has

26-5

been declared invalid by a final judgment of the federal judicial branch or has been repealed by

26-6

an act of Congress, on the date of the commissioner’s determination this section shall have its

26-7

effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this

26-8

section. Nothing in this subsection shall be construed to limit the authority of the Commissioner

26-9

to regulate health insurance under existing state law.

26-10

     27-19-64. Coverage for individuals participating in approved clinical trials. – (a) As

26-11

used in this section:

26-12

     (1) “Approved clinical trial” means a phase I, phase II, phase III or phase IV clinical trial

26-13

that is conducted in relation to the prevention, detection or treatment of cancer or a life-

26-14

threatening disease or condition and is described in any of the following:

26-15

     (A) The study or investigation is approved or funded, which may include funding through

26-16

in-kind contributions, by one or more of the following:

26-17

     (i) The federal National Institutes of Health;

26-18

     (ii) The federal Centers for Disease Control and Prevention;

26-19

     (iii) The federal Agency for Health Care Research and Quality;

26-20

     (iv) The federal Centers for Medicare & Medicaid Services;

26-21

     (v) A cooperative group or center of any of the entities described in items (i) through (iv)

26-22

or the U.S. Department of Defense or the U.S. Department of Veterans’ Affairs;

26-23

     (vi) A qualified non-governmental research entity identified in the guidelines issued by

26-24

the federal National Institutes of Health for center support grants; or

26-25

     (vii) A study or investigation conducted by the U.S. Department of Veterans’ Affairs, the

26-26

     U.S. Department of Defense, or the U.S. Department of Energy, if the study or

26-27

investigation has been reviewed and approved through a system of peer review that the Secretary

26-28

of U.S. Department of Health and Human Services determines:

26-29

     (I) Is comparable to the system of peer review of studies and investigations used by the

26-30

Federal National Institutes of Health; and

26-31

     (II) Assures unbiased review of the highest scientific standards by qualified individuals

26-32

who have no interest in the outcome of the review.

26-33

     (B) The study or investigation is conducted under an investigational new drug application

26-34

reviewed by the U.S. Food and Drug Administration; or

27-1

     (C) The study or investigation is a drug trial that is exempt from having such an

27-2

investigational new drug application.

27-3

     (2) “Participant” has the meaning stated in section 3(7) of federal ERISA.

27-4

     (3) “Participating provider” means a health care provider that, under a contract with the

27-5

health carrier or with its contractor or subcontractor, has agreed to provide health care services to

27-6

covered persons with an expectation of receiving payment, other than coinsurance, copayments or

27-7

deductibles, directly or indirectly from the health carrier.

27-8

     (4) “Qualified individual” means a participant or beneficiary who meets the following

27-9

conditions:

27-10

     (A) The individual is eligible to participate in an approved clinical trial according to the

27-11

trial protocol with respect to the treatment of cancer or other life-threatening disease or condition;

27-12

and

27-13

     (B)(i) The referring health care professional is a participating provider and has concluded

27-14

that the individual’s participation in such trial would be appropriate based on the individual

27-15

meeting the conditions described in subdivision (A) of this subdivision (3); or

27-16

     (ii) The participant or beneficiary provides medical and scientific information

27-17

establishing the individual’s participation in such trial would be appropriate based on the

27-18

individual meeting the conditions described in subdivision (A) of this subdivision (3).

27-19

     (5) “Life-threatening condition” means any disease or condition from which the

27-20

likelihood of death is probable unless the course of the disease or condition is interrupted.

27-21

     (b)(1) If a health insurance carrier offering group or individual health insurance coverage

27-22

provides coverage to a qualified individual, the health carrier:

27-23

     (A) Shall not deny the individual participation in an approved clinical trial.

27-24

     (B) Subject to subdivision (3) of this subsection, shall not deny or limit or impose

27-25

additional conditions on the coverage of routine patient costs for items and services furnished in

27-26

connection with participation in the approved clinical trial; and

27-27

     (C) Shall not discriminate against the individual on the basis of the individual’s

27-28

participation in the approved clinical trial.

27-29

     (2)(A) Subject to subdivision (B) of this subdivision (2), routine patient costs include all

27-30

items and services consistent with the coverage typically covered for a qualified individual who is

27-31

not enrolled in an approved clinical trial.

27-32

     (B) For purposes of subdivision (B) of this subdivision (2), routine patient costs do not

27-33

include:

28-34

     (i) The investigational item, device or service itself;

28-35

     (ii) Items and services that are provided solely to satisfy data collection and analysis

28-36

needs and that are not used in the direct clinical management of the patient; or

28-37

     (iii) A service that is clearly inconsistent with widely accepted and established standards

28-38

of care for a particular diagnosis.

28-39

     (3) If one or more participating providers are participating in a clinical trial, nothing in

28-40

subdivision (1) of this subsection shall be construed as preventing a health carrier from requiring

28-41

that a qualified individual participate in the trial through such a participating provider if the

28-42

provider will accept the individual as a participant in the trial.

28-43

     (4) Notwithstanding subdivision (3) of this subsection, subdivision (1) of this subsection

28-44

shall apply to a qualified individual participating in an approved clinical trial that is conducted

28-45

outside this state.

28-46

     (5) This section shall not be construed to require a health carrier offering group or

28-47

individual health insurance coverage to provide benefits for routine patient care services provided

28-48

outside of the coverage’s health care provider network unless out-of-network benefits are

28-49

otherwise provided under the coverage.

28-50

     (6) Nothing in this section shall be construed to limit a health carrier’s coverage with

28-51

respect to clinical trials.

28-52

     (c) The requirements of this section shall be in addition to the requirements of Rhode

28-53

Island general laws sections 27-18-32 through 27-19-32.2.

28-54

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

28-55

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

28-56

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

28-57

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

28-58

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

28-59

     (e) This section shall be effective for plan years beginning on or after January 1, 2014.

28-60

     27-19-65. Medical loss ratio reporting and rebates. – (a) A nonprofit hospital service

28-61

corporation offering group or individual health insurance coverage of a health benefit plan,

28-62

including a grandfathered health plan, shall comply with the provisions of Section 2718 of the

28-63

Public Health Services Act as amended by the federal Affordable Care Act, in accordance with

28-64

regulations adopted thereunder.

28-65

     (b) Health insurance carriers required to report medical loss ratio and rebate calculations

28-66

and other medical loss ratio and rebate information to the U.S. Department of Health and Human

28-67

Services shall concurrently file such information with the commissioner.

29-68

     27-19-66. Emergency services. – (a) As used in this section:

29-69

     (1) “Emergency medical condition” means a medical condition manifesting itself by

29-70

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

29-71

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

29-72

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

29-73

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

29-74

impairment to bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or

29-75

part.

29-76

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

29-77

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

29-78

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

29-79

hospital, including ancillary services routinely available to the emergency department to evaluate

29-80

such emergency medical condition, and

29-81

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

29-82

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

29-83

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

29-84

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

29-85

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

29-86

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

29-87

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

29-88

services consistent with the rules of this section.

29-89

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

29-90

services in the following manner:

29-91

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

29-92

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

29-93

     (2) Without regard to whether the health care provider furnishing the emergency services

29-94

is a participating network provider with respect to the services;

29-95

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

29-96

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

29-97

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

29-98

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

29-99

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

29-100

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

29-101

     (A) The exclusion of or coordination of benefits;

30-102

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

30-103

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

30-104

     (C) Applicable cost sharing.

30-105

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

30-106

rate imposed with respect to a participant or beneficiary for out-of-network emergency services

30-107

cannot exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if

30-108

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

30-109

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

30-110

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

30-111

subdivision (1) of this subsection. A group health plan or health insurance carrier complies with

30-112

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

30-113

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

30-114

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

30-115

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

30-116

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

30-117

participant or beneficiary. If there is more than one amount negotiated with in-network providers

30-118

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

30-119

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

30-120

participant or beneficiary. In determining the median described in the preceding sentence, the

30-121

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

30-122

same amount is paid to more than one provider). If there is no per-service amount negotiated with

30-123

in-network providers (such as under a capitation or other similar payment arrangement), the

30-124

amount under this subdivision (A) is disregarded.

30-125

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

30-126

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

30-127

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

30-128

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

30-129

determined without reduction for out-of-network cost sharing that generally applies under the

30-130

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

30-131

plan generally pays seventy percent (70%) of the usual, customary, and reasonable amount for

30-132

out-of-network services, the amount in this subdivision (B) for an emergency service is the total,

30-133

that is, one hundred percent (100%), of the usual, customary, and reasonable amount for the

30-134

service, not reduced by the thirty percent (30%) coinsurance that would generally apply to out-of-

30-135

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

30-136

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

31-1

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

31-2

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

31-3

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

31-4

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

31-5

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

31-6

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

31-7

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

31-8

services only as part of a deductible that generally applies to out-of-network benefits. If an out-of-

31-9

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

31-10

apply to out-of-network emergency services.

31-11

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

31-12

23, 2010.

31-13

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

31-14

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

31-15

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

31-16

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

31-17

     27-19-67. Internal and external appeal of adverse benefit determinations. – (a) The

31-18

commissioner shall adopt regulations to implement standards and procedures with respect to

31-19

internal claims and appeals of adverse benefit determinations, and with respect to external appeals

31-20

of adverse benefit determinations.

31-21

     (b) The regulations adopted by the commissioner shall apply only to those adverse

31-22

benefit determinations which are not subject to the jurisdiction of the department of health

31-23

pursuant to R.I. Gen. Laws § 23-17.12 et seq. (Utilization Review Act).

31-24

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

31-25

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

31-26

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

31-27

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

31-28

shall not apply to grandfathered health plans.

31-29

     27-19-68. Prohibition on preexisting condition exclusions. -- (a) A health insurance

31-30

policy, subscriber contract, or health plan offered, issued, issued for delivery, or issued to cover a

31-31

resident of this state by a health insurance company licensed pursuant to this title and/or chapter:

31-32

     (1) Shall not limit or exclude coverage for an individual under the age of nineteen (19) by

31-33

imposing a preexisting condition exclusion on that individual.

32-34

     (2) For plan or policy years beginning on or after January 1, 2014, shall not limit or

32-35

exclude coverage for any individual by imposing a preexisting condition exclusion on that

32-36

individual.

32-37

     (b) As used in this section:

32-38

     (1) “Preexisting condition exclusion” means a limitation or exclusion of benefits,

32-39

including a denial of coverage, based on the fact that the condition (whether physical or mental)

32-40

was present before the effective date of coverage, or if the coverage is denied, the date of denial,

32-41

under a health benefit plan whether or not any medical advice, diagnosis, care or treatment was

32-42

recommended or received before the effective date of coverage.

32-43

     (2) “Preexisting condition exclusion” means any limitation or exclusion of benefits,

32-44

including a denial of coverage, applicable to an individual as a result of information relating to an

32-45

individual’s health status before the individual’s effective date of coverage, or if the coverage is

32-46

denied, the date of denial, under the health benefit plan, such as a condition (whether physical or

32-47

mental) identified as a result of a pre-enrollment questionnaire or physical examination given to

32-48

the individual, or review of medical records relating to the pre-enrollment period.

32-49

     (c) This section shall not apply to grandfathered health plans providing individual health

32-50

insurance coverage.

32-51

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

32-52

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

32-53

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

32-54

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

32-55

     SECTION 7. Sections 27-20-1 and 27-20-45 of the General laws in Chapter 27-20

32-56

entitled "Nonprofit Medical Service Corporations" are hereby amended to read as follows:

32-57

     27-20-1. Definitions. -- As used in this chapter:

32-58

     (1) “Adverse benefit determination" means any of the following: a denial, reduction, or

32-59

termination of, or a failure to provide or make payment (in whole or in part) for, a benefit,

32-60

including any such denial, reduction, termination, or failure to provide or make payment that is

32-61

based on a determination of a an individual’s eligibility to participate in a plan or to receive

32-62

coverage under a plan, and including, with respect to group health plans, a denial, reduction, or

32-63

termination of, or a failure to provide or make payment (in whole or in part) for, a benefit

32-64

resulting from the application of any utilization review, as well as a failure to cover an item or

32-65

service for which benefits are otherwise provided because it is determined to be experimental or

32-66

investigational or not medically necessary or appropriate. The term also includes a rescission of

32-67

coverage determination.

33-68

     (2) "Affordable Care Act" means the federal Patient Protection and Affordable Care Act

33-69

of 2010, as amended by the federal Health Care and Education Reconciliation Act of 2010, and

33-70

federal regulations adopted thereunder;

33-71

     (1)(3) "Certified registered nurse practitioners" is an expanded role utilizing independent

33-72

knowledge of physical assessment and management of health care and illnesses. The practice

33-73

includes collaboration with other licensed health care professionals including, but not limited to,

33-74

physicians, pharmacists, podiatrists, dentists, and nurses;

33-75

     (4) “Commissioner” or “health insurance commissioner” means that individual appointed

33-76

pursuant to section 42-14.5-1 of the General laws.

33-77

     (2)(5) "Counselor in mental health" means a person who has been licensed pursuant to

33-78

section 5-63.2-9.

33-79

     (6) "Essential health benefits" shall have the meaning set forth in section 1302(b) of the

33-80

federal Affordable Care Act.

33-81

     (7) “Grandfathered health plan” means any group health plan or health insurance

33-82

coverage subject to 42 USC section 18011.

33-83

     (8) “Group health insurance coverage” means, in connection with a group health plan,

33-84

health insurance coverage offered in connection with such plan.

33-85

     (9) “Group health plan” means an employee welfare benefit plan as defined in 29 USC

33-86

section 1002(1) to the extent that the plan provides health benefits to employees or their

33-87

dependents directly or through insurance, reimbursement, or otherwise.

33-88

     (10) “Health benefits” or “covered benefits” means coverage or benefits for the

33-89

diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose

33-90

of affecting any structure or function of the body including coverage or benefits for transportation

33-91

primarily for and essential thereto, and including medical services as defined in R.I. Gen. Laws §

33-92

27-19-17;

33-93

     (11) “Health care facility” means an institution providing health care services or a health

33-94

care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory

33-95

surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic,

33-96

laboratory and imaging centers, and rehabilitation and other therapeutic health settings.

33-97

     (12) "Health care professional" means a physician or other health care practitioner

33-98

licensed, accredited or certified to perform specified health care services consistent with state

33-99

law.

33-100

     (13) "Health care provider" or "provider" means a health care professional or a health

33-101

care facility.

34-102

     (14) "Health care services" means services for the diagnosis, prevention, treatment, cure

34-103

or relief of a health condition, illness, injury or disease.

34-104

     (15) “Health insurance carrier” means a person, firm, corporation or other entity subject

34-105

to the jurisdiction of the commissioner under this chapter, and includes a nonprofit medical

34-106

service corporation. Such term does not include a group health plan.

34-107

     (16) "Health plan" or “health benefit plan” means health insurance coverage and a group

34-108

health plan, including coverage provided through an association plan if it covers Rhode Island

34-109

residents. Except to the extent specifically provided by the federal Affordable Care Act, the term

34-110

‘‘health plan’’ shall not include a group health plan to the extent state regulation of the health

34-111

plan is pre- empted under section 514 of the federal Employee Retirement Income Security Act of

34-112

1974. The term also shall not include:

34-113

     (A)(i) Coverage only for accident, or disability income insurance, or any combination

34-114

thereof.

34-115

     (ii) Coverage issued as a supplement to liability insurance.

34-116

     (iii) Liability insurance, including general liability insurance and automobile liability

34-117

insurance.

34-118

     (iv) Workers’ compensation or similar insurance.

34-119

     (v) Automobile medical payment insurance.

34-120

     (vi) Credit-only insurance.

34-121

     (vii) Coverage for on-site medical clinics.

34-122

     (viii) Other similar insurance coverage, specified in federal regulations issued pursuant to

34-123

Federal Pub. L. No. 104-191, the federal health insurance portability and accountability act of

34-124

1996 (“HIPAA”), under which benefits for medical care are secondary or incidental to other

34-125

insurance benefits.

34-126

     (B) The following benefits if they are provided under a separate policy, certificate or

34-127

contract of insurance or are otherwise not an integral part of the plan:

34-128

     (i) Limited scope dental or vision benefits.

34-129

     (ii) Benefits for long-term care, nursing home care, home health care, community-based

34-130

care, or any combination thereof.

34-131

     (iii) Other excepted benefits specified in federal regulations issued pursuant to federal

34-132

Pub. L. No. 104-191 (“HIPAA”).

34-133

     (C) The following benefits if the benefits are provided under a separate policy, certificate

34-134

or contract of insurance, there is no coordination between the provision of the benefits and any

34-135

exclusion of benefits under any group health plan maintained by the same plan sponsor, and the

34-136

benefits are paid with respect to an event without regard to whether benefits are provided with

35-1

respect to such an event under any group health plan maintained by the same plan sponsor:

35-2

     (i) Coverage only for a specified disease or illness.

35-3

     (ii) Hospital indemnity or other fixed indemnity insurance.

35-4

     (D) The following if offered as a separate policy, certificate or contract of insurance:

35-5

     (i) Medicare supplement health insurance as defined under section 1882(g)(1) of the

35-6

federal Social Security Act.

35-7

     (ii) Coverage supplemental to the coverage provided under chapter 55 of title 10, United

35-8

States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)).

35-9

     (iii) Similar supplemental coverage provided to coverage under a group health plan.

35-10

     (3)(17)"Licensed midwife" means any midwife licensed under section 23-13-9;

35-11

     (4)(18) "Medical services" means those professional services rendered by persons duly

35-12

licensed under the laws of this state to practice medicine, surgery, chiropractic, podiatry, and

35-13

other professional services rendered by a licensed midwife, certified registered nurse

35-14

practitioners, and psychiatric and mental health nurse clinical specialists, and appliances, drugs,

35-15

medicines, supplies, and nursing care necessary in connection with the services, or the expense

35-16

indemnity for the services, appliances, drugs, medicines, supplies, and care, as may be specified

35-17

in any nonprofit medical service plan. Medical service shall not be construed to include hospital

35-18

services;

35-19

      (5)(19) "Nonprofit medical service corporation" means any corporation organized

35-20

pursuant hereto for the purpose of establishing, maintaining, and operating a nonprofit medical

35-21

service plan;

35-22

      (6)(20) "Nonprofit medical service plan" means a plan by which specified medical

35-23

service is provided to subscribers to the plan by a nonprofit medical service corporation;

35-24

     (21) "Office of the health insurance commissioner" means the agency established under

35-25

section 42-14.5-1 of the General laws.

35-26

      (7)(22) "Psychiatric and mental health nurse clinical specialist" is an expanded role

35-27

utilizing independent knowledge and management of mental health and illnesses. The practice

35-28

includes collaboration with other licensed health care professionals, including, but not limited to,

35-29

psychiatrists, psychologists, physicians, pharmacists, and nurses;

35-30

     (23) “Rescission" means a cancellation or discontinuance of coverage that has retroactive

35-31

effect for reasons unrelated to timely payment of required premiums or contribution to costs of

35-32

coverage.

35-33

      (8)(24) "Subscribers" means those persons or groups of persons who contract with a

35-34

nonprofit medical service corporation for medical service pursuant to a nonprofit medical service

36-1

plan; and

36-2

      (9)(25) "Therapist in marriage and family practice" means a person who has been

36-3

licensed pursuant to section 5-63.2-10.

36-4

     27-20-45. Termination of children's benefits Eligibility for children's benefits. --

36-5

(a)(1) Every individual health insurance contract, plan, or policy health benefit plan delivered,

36-6

issued for delivery, or renewed in this state and every group health insurance contract, plan, or

36-7

policy delivered, issued for delivery or renewed in this state which provides medical health

36-8

benefits coverage for dependent children that includes coverage for physician services in a

36-9

physician's office, and every policy which provides major medical or similar comprehensive type

36-10

coverage dependents, except for supplemental policies which only provide coverage for specified

36-11

diseases and other supplemental policies, shall provide make coverage available of an unmarried

36-12

child under the age of nineteen (19) years, an unmarried child who is a student under the age of

36-13

twenty-five (25) years and who is financially dependent upon the parent and an unmarried child

36-14

of any age who is financially dependent upon the parent and medically determined to have a

36-15

physical or mental impairment which can be expected to result in death or which has lasted or can

36-16

be expected to last for a continuous period of not less than twelve (12) months for children until

36-17

attainment of twenty-six (26) years of age, and an unmarried child of any age who is financially

36-18

dependent upon the parent and medically determined to have a physical or mental impairment

36-19

which can be expected to result in death or which has lasted or can be expected to last for a

36-20

continuous period of not less than twelve (12) months. Such contract, plan or policy shall also

36-21

include a provision that policyholders shall receive no less than thirty (30) days notice from the

36-22

accident and sickness insurer that a child covered as a dependent by the policy holder is about to

36-23

lose his or her coverage as a result of reaching the maximum age for a dependent child, and that

36-24

the child will only continue to be covered upon documentation being provided of current full or

36-25

part-time enrollment in a post-secondary educational institution or that the child may purchase a

36-26

conversion policy if he or she is not an eligible student.

36-27

     (b) Nothing in this section prohibits a nonprofit medical service corporation from

36-28

requiring a policyholder to annually provide proof of a child’s current full or part-time enrollment

36-29

in a post-secondary educational institution in order to maintain the child’s coverage.

36-30

     (2) With respect to a child who has not attained twenty-six (26) years of age, a nonprofit

36-31

medical service corporation shall not define “dependent” for purposes of eligibility for dependent

36-32

coverage of children other than the terms of a relationship between a child and the plan

36-33

participant or subscriber.

37-34

     (3) A nonprofit medical service corporation shall not deny or restrict coverage for a child

37-35

who has not attained twenty-six (26) years of age based on the presence or absence of the child’s

37-36

financial dependency upon the participant, primary subscriber or any other person, residency with

37-37

the participant and in the individual market the primary subscriber, or with any other person,

37-38

marital status, student status, employment or any combination of those factors. A nonprofit

37-39

medical service corporation shall not deny or restrict coverage of a child based on eligibility for

37-40

other coverage, except as provided in (b)(1) of this section.

37-41

     (4) Nothing in this section shall be construed to require a health insurance carrier to make

37-42

coverage available for the child of a child receiving dependent coverage, unless the grandparent

37-43

becomes the legal guardian or adoptive parent of that grandchild.

37-44

     (5) The terms of coverage in a health benefit plan offered by a nonprofit medical service

37-45

corporation or providing dependent coverage of children cannot vary based on age except for

37-46

children who are twenty-six (26) years of age or older.

37-47

     (b)(1) For plan years beginning before January 1, 2014, a group health plan providing

37-48

group health insurance coverage that is a grandfathered health plan and makes available

37-49

dependent coverage of children may exclude an adult child who has not attained twenty-six (26)

37-50

years of age from coverage only if the adult child is eligible to enroll in an eligible employer-

37-51

sponsored health benefit plan, as defined in section 5000A(f)(2) of the federal Internal Revenue

37-52

Code, other than the group health plan of a parent.

37-53

     (2) For plan years, beginning on or after January 1, 2014, a health insurance carrier

37-54

providing group health insurance coverage that is a grandfathered health plan shall comply with

37-55

the requirements of this section.

37-56

     (c)This section does not apply to insurance coverage providing benefits for: (1) hospital

37-57

confinement indemnity; (2) disability income; (3) accident only; (4) long term care; (5) Medicare

37-58

supplement; (6) limited benefit health; (7) specified diseased indemnity; or (8) other limited

37-59

benefit policies.

37-60

     SECTION 8. Chapter 27-20 of the General laws entitled "Nonprofit Medical Service

37-61

Corporations" is hereby amended by adding thereto the following sections:

37-62

     27-20-6.1. Uniform explanation of benefits and coverage.   (a) A nonprofit medical

37-63

service corporation shall provide a summary of benefits and coverage explanation and definitions

37-64

to policyholders and others required by, and at the times and in the format required, by the federal

37-65

regulations adopted under section 2715 of the Public Health Service Act, as amended by the

37-66

federal Affordable Care Act. The forms required by this section shall be made available to the

37-67

commissioner on request. Nothing in this section shall be construed to limit the authority of the

37-68

commissioner under existing state law.

38-1

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

38-2

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

38-3

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

38-4

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

38-5

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

38-6

     (c) If the commissioner of the office of the health insurance commissioner determines

38-7

that the corresponding provision of the federal Patient Protection and Affordable Care Act has

38-8

been declared invalid by a final judgment of the federal judicial branch or has been repealed by

38-9

an act of Congress, on the date of the commissioner’s determination this section shall have its

38-10

effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this

38-11

section. Nothing in this section shall be construed to limit the authority of the commissioner

38-12

under existing state law.

38-13

     27-20-6.2. Filing of policy forms. – (a) A nonprofit medical service corporation shall file

38-14

all policy forms and rates used by it in the state with the commissioner, including the forms of

38-15

any rider, endorsement, application blank, and other matter generally used or incorporated by

38-16

reference in its policies or contracts of insurance. No such form shall be used if disapproved by

38-17

the commissioner under this section, or if the commissioner’s approval has been withdrawn after

38-18

notice and an opportunity to be heard, or until the expiration of sixty (60) days following the

38-19

filing of the form. Such a company shall comply with its filed and approved forms.  If the

38-20

commissioner finds from an examination of any form that it is contrary to the public interest, or

38-21

the requirements of this code or duly promulgated regulations, he or she shall forbid its use, and

38-22

shall notify the corporation in writing.

38-23

     (b) Each rate filing shall include a certification by a qualified actuary that to the best of

38-24

the actuary's knowledge and judgment, the entire rate filing is in compliance with applicable laws

38-25

and that the benefits offered or proposed to be offered are reasonable in relation to the premium

38-26

to be charged. A health insurance carrier shall comply with its filed and approved rates and forms.

     

38-28

     27-20-57. Prohibition on preexisting condition exclusions. -- (a) A health insurance

38-29

policy, subscriber contract, or health plan offered, issued, issued for delivery, or issued to cover a

38-30

resident of this state by a health insurance company licensed pursuant to this title and/or chapter:

38-31

     (1) Shall not limit or exclude coverage for an individual under the age of nineteen (19) by

38-32

imposing a preexisting condition exclusion on that individual.

38-33

     (2) For plan or policy years beginning on or after January 1, 2014, shall not limit or

38-34

exclude coverage for any individual by imposing a preexisting condition exclusion on that

39-1

individual.

39-2

     (b) As used in this section:

39-3

     (1) “Preexisting condition exclusion” means a limitation or exclusion of benefits,

39-4

including a denial of coverage, based on the fact that the condition (whether physical or mental)

39-5

was present before the effective date of coverage, or if the coverage is denied, the date of denial,

39-6

under a health benefit plan whether or not any medical advice, diagnosis, care or treatment was

39-7

recommended or received before the effective date of coverage.

39-8

     (2) “Preexisting condition exclusion” means any limitation or exclusion of benefits,

39-9

including a denial of coverage, applicable to an individual as a result of information relating to an

39-10

individual’s health status before the individual’s effective date of coverage, or if the coverage is

39-11

denied, the date of denial, under the health benefit plan, such as a condition (whether physical or

39-12

mental) identified as a result of a pre-enrollment questionnaire or physical examination given to

39-13

the individual, or review of medical records relating to the pre-enrollment period.

39-14

     (c) This section shall not apply to grandfathered health plans providing individual health

39-15

insurance coverage.

39-16

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

39-17

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

39-18

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

39-19

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

39-20

     27-20-58. Prohibition on rescission of coverage. – (a)(1) Coverage under a health

39-21

benefit plan subject to the jurisdiction of the commissioner under this chapter with respect to an

39-22

individual, including a group to which the individual belongs or family coverage in which the

39-23

individual is included, shall not be subject to rescission after the individual is covered under the

39-24

plan, unless:

39-25

     (A)The individual or a person seeking coverage on behalf of the individual, performs an

39-26

act, practice or omission that constitutes fraud; or

39-27

     (B)The individual makes an intentional misrepresentation of material fact, as prohibited

39-28

by the terms of the plan or coverage.

39-29

     (2) For purposes of paragraph (1)(A), a person seeking coverage on behalf of an

39-30

individual does not include an insurance producer or employee or authorized representative of the

39-31

health carrier.

39-32

     (b) At least thirty (30) days advance written notice shall be provided to each plan enrollee

39-33

or, for individual health insurance coverage, primary subscriber, who would be affected by the

39-34

proposed rescission of coverage before coverage under the plan may be rescinded in accordance

40-1

with subsection (a) regardless of, in the case of group health insurance coverage, whether the

40-2

rescission applies to the entire group or only to an individual within the group.

40-3

     (c) This section applies to grandfathered health plans.

40-4

     27-20-59. Annual and lifetime limits. – (a) Annual limits.

40-5

     (1) For plan or policy years beginning prior to January 1, 2014, for any individual, a

40-6

health insurance carrier and health benefit plan subject to the jurisdiction of the commissioner

40-7

under this chapter may establish an annual limit on the dollar amount of benefits that are essential

40-8

health benefits provided the restricted annual limit is not less than the following:

40-9

     (A) For a plan or policy year beginning after September 22, 2011, but before September

40-10

23, 2012 – one million two hundred fifty thousand dollars ($1,250,000); and

40-11

     (B) For a plan or policy year beginning after September 22, 2012, but before January 1,

40-12

2014 – two million dollars ($2,000,000).

40-13

     (2) For plan or policy years beginning on or after January 1, 2014, a health insurance

40-14

carrier and health benefit plan shall not establish any annual limit on the dollar amount of

40-15

essential health benefits for any individual, except:

40-16

     (A) A health flexible spending arrangement, as defined in section 106(c)(2)(i) of the

40-17

federal Internal Revenue Code, a medical savings account, as defined in section 220 of the federal

40-18

Internal Revenue Code, and a health savings account, as defined in section 223 of the federal

40-19

Internal Revenue Code are not subject to the requirements of subdivisions (1) and (2) of this

40-20

subsection.

40-21

     (B) The provisions of this subsection shall not prevent a health insurance carrier from

40-22

placing annual dollar limits for any individual on specific covered benefits that are not essential

40-23

health benefits to the extent that such limits are otherwise permitted under applicable federal law

40-24

or the laws and regulations of this state.

40-25

     (3) In determining whether an individual has received benefits that meet or exceed the

40-26

allowable limits, as provided in subdivision (1) of this subsection, a health insurance carrier shall

40-27

take into account only essential health benefits.

40-28

     (b) Lifetime limits.

40-29

     (1) A health insurance carrier and health benefit plan offering group or individual health

40-30

insurance coverage shall not establish a lifetime limit on the dollar value of essential health

40-31

benefits for any individual.

40-32

     (2) Notwithstanding subdivision (1) above, a health insurance carrier and health benefit

40-33

plan is not prohibited from placing lifetime dollar limits for any individual on specific covered

40-34

benefits that are not essential health benefits, as designated pursuant to a state determination and

41-1

in accordance with federal laws and regulations.

41-2

     (c)(1) Except as provided in subdivision (2) of this subsection, this section applies to any

41-3

health insurance carrier providing coverage under an individual or group health plan.

41-4

     (2)(A) The prohibition on lifetime limits applies to grandfathered health plans.

41-5

     (B) The prohibition and limits on annual limits apply to grandfathered health plans

41-6

providing group health insurance coverage, but the prohibition and limits on annual limits do not

41-7

apply to grandfathered health plans providing individual health insurance coverage.

41-8

     (d) This section shall not apply to a plan or to policy years prior to January 1, 2014 for

41-9

which the Secretary of the U.S. Department of Health and Human Services issued a waiver

41-10

pursuant to 45 C.F.R. §147.126(d)(3). This section also shall not apply to insurance coverage

41-11

providing benefits for: (1) Hospital confinement indemnity; (2) Disability income; (3) Accident

41-12

only; (4) Long-term care; (5) Medicare supplement; (6) Limited benefit health; (7) Specified

41-13

disease indemnity; (8) Sickness or bodily injury or death by accident or both; and (9) Other

41-14

limited benefit policies.

41-15

     (e) If the commissioner of the office of the health insurance commissioner determines

41-16

that the corresponding provision of the federal Patient Protection and Affordable Care Act has

41-17

been declared invalid by a final judgment of the federal judicial branch or has been repealed by

41-18

an act of Congress, on the date of the commissioner’s determination this section shall have its

41-19

effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this

41-20

section. Nothing in this subsection shall be construed to limit the authority of the Commissioner

41-21

to regulate health insurance under existing state law.

41-22

     27-20-60. Coverage for individuals participating in approved clinical trials. – (a) As

41-23

used in this section,

41-24

     (1) “Approved clinical trial” means a phase I, phase II, phase III or phase IV clinical trial

41-25

that is conducted in relation to the prevention, detection or treatment of cancer or a life-

41-26

threatening disease or condition and is described in any of the following:

41-27

     (A) The study or investigation is approved or funded, which may include funding through

41-28

in-kind contributions, by one or more of the following:

41-29

     (i) The federal National Institutes of Health;

41-30

     (ii) The federal Centers for Disease Control and Prevention;

41-31

     (iii) The federal Agency for Health Care Research and Quality;

41-32

     (iv) The federal Centers for Medicare & Medicaid Services;

41-33

     (v) A cooperative group or center of any of the entities described in items (i) through (iv)

41-34

or the U.S. Department of Defense or the U.S. Department of Veteran Affairs;

42-1

     (vi) A qualified non-governmental research entity identified in the guidelines issued by

42-2

the federal National Institutes of Health for center support grants; or

42-3

     (vii) A study or investigation conducted by the U.S. Department of Veteran Affairs, the

42-4

U.S. Department of Defense, or the U.S. Department of Energy, if the study or investigation has

42-5

been reviewed and approved through a system of peer review that the Secretary of U.S.

42-6

Department of Health and Human Services determines:

42-7

     (I) Is comparable to the system of peer review of studies and investigations used by the

42-8

federal National Institutes of Health; and

42-9

     (II) Assures unbiased review of the highest scientific standards by qualified individuals

42-10

who have no interest in the outcome of the review.

42-11

     (B) The study or investigation is conducted under an investigational new drug application

42-12

reviewed by the U.S. Food and Drug Administration; or

42-13

     (C) The study or investigation is a drug trial that is exempt from having such an

42-14

investigational new drug application.

42-15

     (2) “Participant” has the meaning stated in section 3(7) of federal ERISA.

42-16

     (3) “Participating provider” means a health care provider that, under a contract with the

42-17

health carrier or with its contractor or subcontractor, has agreed to provide health care services to

42-18

covered persons with an expectation of receiving payment, other than coinsurance, copayments or

42-19

deductibles, directly or indirectly from the health carrier.

42-20

     (4) “Qualified individual” means a participant or beneficiary who meets the following

42-21

conditions:

42-22

     (A) The individual is eligible to participate in an approved clinical trial according to the

42-23

trial protocol with respect to the treatment of cancer or other life-threatening disease or condition;

42-24

and

42-25

     (B)(i) The referring health care professional is a participating provider and has concluded

42-26

that the individual’s participation in such trial would be appropriate based on the individual

42-27

meeting the conditions described in subdivision (A) of this subdivision (3); or

42-28

     (ii) The participant or beneficiary provides medical and scientific information

42-29

establishing the individual’s participation in such trial would be appropriate based on the

42-30

individual meeting the conditions described in subdivision (A) of this subdivision (3).

42-31

     (5) “Life-threatening condition” means any disease or condition from which the

42-32

likelihood of death is probable unless the course of the disease or condition is interrupted.

42-33

     (b)(1) If a health insurance carrier offering group or individual health insurance coverage

42-34

provides coverage to a qualified individual, the health carrier:

43-1

     (A) Shall not deny the individual participation in an approved clinical trial.

43-2

     (B) Subject to subdivision (3) of this subsection, shall not deny or limit or impose

43-3

additional conditions on the coverage of routine patient costs for items and services furnished in

43-4

connection with participation in the approved clinical trial; and

43-5

     (C) Shall not discriminate against the individual on the basis of the individual’s

43-6

participation in the approved clinical trial.

43-7

     (2)(A) Subject to subdivision (B) of this subdivision (2), routine patient costs include all

43-8

items and services consistent with the coverage typically covered for a qualified individual who is

43-9

not enrolled in an approved clinical trial.

43-10

     (B) For purposes of subdivision (B) of this subdivision (2), routine patient costs do not

43-11

include:

43-12

     (i) The investigational item, device or service itself;

43-13

     (ii) Items and services that are provided solely to satisfy data collection and analysis

43-14

needs and that are not used in the direct clinical management of the patient; or

43-15

     (iii) A service that is clearly inconsistent with widely accepted and established standards

43-16

of care for a particular diagnosis.

43-17

     (3) If one or more participating providers is participating in a clinical trial, nothing in

43-18

subdivision (1) of this subsection shall be construed as preventing a health carrier from requiring

43-19

that a qualified individual participate in the trial through such a participating provider if the

43-20

provider will accept the individual as a participant in the trial.

43-21

     (4) Notwithstanding subdivision (3) of this subsection, subdivision (1) of this subsection

43-22

shall apply to a qualified individual participating in an approved clinical trial that is conducted

43-23

outside this state.

43-24

     (5) This section shall not be construed to require a nonprofit medical service corporation

43-25

offering group or individual health insurance coverage to provide benefits for routine patient care

43-26

services provided outside of the coverage’s health care provider network unless out-of-network

43-27

benefits are otherwise provided under the coverage.

43-28

     (6) Nothing in this section shall be construed to limit a health insurance carrier’s

43-29

coverage with respect to clinical trials.

43-30

     (c) The requirements of this section shall be in addition to the requirements of Rhode

43-31

Island general laws sections 27-18-36 through 27-18-36.3.

43-32

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

43-33

to insurance coverage providing benefits for: (1) Hospital confinement indemnity; (2) Disability

43-34

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

44-1

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

44-2

both; and (9) Other limited benefit policies.

44-3

     (e) This section shall be effective for plan years beginning on or after January 1, 2014.

44-4

     27-20-61. Medical loss ratio reporting and rebates. – (a) A nonprofit medical service

44-5

corporation offering group or individual health insurance coverage of a health benefit plan,

44-6

including a grandfathered health plan, shall comply with the provisions of Section 2718 of the

44-7

Public Health Services Act as amended by the federal Affordable Care Act, in accordance with

44-8

regulations adopted thereunder.

44-9

     (b) Nonprofit medical service corporations required to report medical loss ratio and

44-10

rebate calculations and any other medical loss ratio and rebate information to the U.S.

44-11

Department of Health and Human Services shall concurrently file such information with the

44-12

commissioner.

44-13

     27-20-62. Emergency services -- (a) As used in this section:

44-14

     (1) “Emergency medical condition” means a medical condition manifesting itself by

44-15

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

44-16

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

44-17

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

44-18

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

44-19

impairment to bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or

44-20

part.

44-21

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

44-22

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

44-23

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

44-24

hospital, including ancillary services routinely available to the emergency department to evaluate

44-25

such emergency medical condition, and

44-26

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

44-27

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

44-28

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

44-29

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

44-30

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

44-31

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

44-32

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

44-33

emergency services consistent with the rules of this section.

45-34

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

45-35

services in the following manner:

45-36

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

45-37

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

45-38

     (2) Without regard to whether the health care provider furnishing the emergency services

45-39

is a participating network provider with respect to the services;

45-40

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

45-41

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

45-42

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

45-43

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

45-44

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

45-45

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

45-46

     (A) The exclusion of or coordination of benefits;

45-47

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

45-48

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

45-49

     (C) Applicable cost-sharing.

45-50

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

45-51

rate imposed with respect to a participant or beneficiary for out-of-network emergency services

45-52

cannot exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if

45-53

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

45-54

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

45-55

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

45-56

subdivision (1) of this subsection. A group health plan or health insurance carrier complies with

45-57

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

45-58

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

45-59

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

45-60

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

45-61

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

45-62

participant or beneficiary. If there is more than one amount negotiated with in-network providers

45-63

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

45-64

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

45-65

participant or beneficiary. In determining the median described in the preceding sentence, the

45-66

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

45-67

same amount is paid to more than one provider). If there is no per-service amount negotiated with

45-68

in-network providers (such as under a capitation or other similar payment arrangement), the

46-1

amount under this subdivision (A) is disregarded.

46-2

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

46-3

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

46-4

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

46-5

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

46-6

determined without reduction for out-of-network cost-sharing that generally applies under the

46-7

plan or health insurance coverage with respect to out-of-network services.

46-8

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

46-9

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

46-10

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

46-11

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

46-12

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

46-13

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

46-14

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

46-15

services only as part of a deductible that generally applies to out-of-network benefits. If an out-of-

46-16

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

46-17

apply to out-of-network emergency services.

46-18

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

46-19

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

46-20

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

46-21

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

46-22

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

46-23

     27-20-63. Internal and external appeal of adverse benefit determinations. -- (a) The

46-24

commissioner shall adopt regulations to implement standards and procedures with respect to

46-25

internal claims and appeals of adverse benefit determinations, and with respect to external appeals

46-26

of adverse benefit determinations.

46-27

     (b) The regulations adopted by the commissioner shall apply only to those adverse

46-28

benefit determinations which are not subject to the jurisdiction of the department of health

46-29

pursuant to R.I. Gen. Laws § 23-17.12 et seq. (Utilization Review Act).

46-30

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

46-31

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

46-32

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

46-33

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

46-34

shall not apply to grandfathered health plans.

47-1

     SECTION 9. Sections 27-41-2 and 27-41-61 of the General laws in Chapter 27-41

47-2

entitled "Health Maintenance Organizations” are hereby amended to read as follows:

47-3

     27-41-2. Definitions. – As used in this chapter:

47-4

     (a) “Adverse benefit determination" means any of the following: a denial, reduction, or

47-5

termination of, or a failure to provide or make payment (in whole or in part) for, a benefit,

47-6

including any such denial, reduction, termination, or failure to provide or make payment that is

47-7

based on a determination of a an individual’s eligibility to participate in a plan or to receive

47-8

coverage under a plan, and including, with respect to group health plans, a denial, reduction, or

47-9

termination of, or a failure to provide or make payment (in whole or in part) for, a benefit

47-10

resulting from the application of any utilization review, as well as a failure to cover an item or

47-11

service for which benefits are otherwise provided because it is determined to be experimental or

47-12

investigational or not medically necessary or appropriate. The term also includes a rescission of

47-13

coverage determination.

47-14

     (b) "Affordable Care Act" means the federal Patient Protection and Affordable Care act

47-15

of 2010, as amended by the federal Health Care and Education Reconciliation Act of 2010, and

47-16

federal regulations adopted thereunder;

47-17

     (c) “Commissioner” or “health insurance commissioner” means that individual appointed

47-18

pursuant to section 42-14.5-1 of the general laws.

47-19

     (d) "Covered health services" means the services that a health maintenance organization

47-20

contracts with enrollees and enrolled groups to provide or make available to an enrolled

47-21

participant.

47-22

     (e) "Director" means the director of the department of business regulation or his or her

47-23

duly appointed agents.

47-24

     (f) "Employee" means any person who has entered into the employment of or works

47-25

under a contract of service or apprenticeship with any employer. It shall not include a person who

47-26

has been employed for less than thirty (30) days by his or her employer, nor shall it include a

47-27

person who works less than an average of thirty (30) hours per week. For the purposes of this

47-28

chapter, the term "employee" means a person employed by an "employer" as defined in

47-29

subsection (d) of this section. Except as otherwise provided in this chapter the terms "employee"

47-30

and "employer" are to be defined according to the rules and regulations of the department of labor

47-31

and training.

47-32

     (g) "Employer" means any person, partnership, association, trust, estate, or corporation,

47-33

whether foreign or domestic, or the legal representative, trustee in bankruptcy, receiver, or trustee

47-34

of a receiver, or the legal representative of a deceased person, including the state of Rhode Island

48-1

and each city and town in the state, which has in its employ one or more individuals during any

48-2

calendar year. For the purposes of this section, the term "employer" refers only to an employer

48-3

with persons employed within the state of Rhode Island.

48-4

     (h) "Enrollee" means an individual who has been enrolled in a health maintenance

48-5

organization.

48-6

     (i) "Essential health benefits" shall have the meaning set forth in section 1302(b) of the

48-7

federal Affordable Care Act.

48-8

     (j) "Evidence of coverage" means any certificate, agreement, or contract issued to an

48-9

enrollee setting out the coverage to which the enrollee is entitled.

48-10

     (k) “Grandfathered health plan” means any group health plan or health insurance

48-11

coverage subject to 42 USC section 18011.

48-12

     (l) “Group health insurance coverage” means, in connection with a group health plan,

48-13

health insurance coverage offered in connection with such plan.

48-14

     (m) “Group health plan” means an employee welfare benefit plan as defined in 29 USC

48-15

section 1002(1), to the extent that the plan provides health benefits to employees or their

48-16

dependents directly or through insurance, reimbursement, or otherwise.

48-17

     (n) “Health benefits” or “covered benefits” means coverage or benefits for the diagnosis,

48-18

cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting

48-19

any structure or function of the body including coverage or benefits for transportation primarily

48-20

for and essential thereto, and including medical services as defined in R.I. Gen. Laws § 27-19-17;

48-21

     (o) “Health care facility” means an institution providing health care services or a health

48-22

care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory

48-23

surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic,

48-24

laboratory and imaging centers, and rehabilitation and other therapeutic health settings.

48-25

     (p) "Health care professional" means a physician or other health care practitioner

48-26

licensed, accredited or certified to perform specified health care services consistent with state

48-27

law.

48-28

     (q) "Health care provider" or "provider" means a health care professional or a health care

48-29

facility.

48-30

     (r) "Health care services" means any services included in the furnishing to any individual

48-31

of medical, podiatric, or dental care, or hospitalization, or incident to the furnishing of that care or

48-32

hospitalization, and the furnishing to any person of any and all other services for the purpose of

48-33

preventing, alleviating, curing, or healing human illness, injury, or physical disability.

49-34

     (s) “Health insurance carrier” means a person, firm, corporation or other entity subject to

49-35

the jurisdiction of the commissioner under this chapter, and includes a health maintenance

49-36

organization. Such term does not include a group health plan.

49-37

     (t) "Health maintenance organization" means a single public or private organization

49-38

which:

49-39

     (1) Provides or makes available to enrolled participants health care services, including at

49-40

least the following basic health care services: usual physician services, hospitalization, laboratory,

49-41

x-ray, emergency, and preventive services, and out of area coverage, and the services of licensed

49-42

midwives;

49-43

     (2) Is compensated, except for copayments, for the provision of the basic health care

49-44

services listed in subdivision (1) of this subsection to enrolled participants on a predetermined

49-45

periodic rate basis; and

49-46

     (3) Provides physicians' services primarily:

49-47

     (A) Directly through physicians who are either employees or partners of the organization;

49-48

or

49-49

     (B) Through arrangements with individual physicians or one or more groups of

49-50

physicians organized on a group practice or individual practice basis;

49-51

     (ii) "Health maintenance organization" does not include prepaid plans offered by entities

49-52

regulated under chapter 1, 2, 19, or 20 of this title that do not meet the criteria above and do not

49-53

purport to be health maintenance organizations;

49-54

     (4) Provides the services of licensed midwives primarily:

49-55

     (i) Directly through licensed midwives who are either employees or partners of the

49-56

organization; or

49-57

     (ii) Through arrangements with individual licensed midwives or one or more groups of

49-58

licensed midwives organized on a group practice or individual practice basis.

49-59

     (u) "Licensed midwife" means any midwife licensed pursuant to section 23-13-9.

49-60

     (v) "Material modification" means only systemic changes to the information filed under

49-61

section 27-41-3.

49-62

     (w) "Net worth", for the purposes of this chapter, means the excess of total admitted

49-63

assets over total liabilities.

49-64

     (x) "Office of the health insurance commissioner" means the agency established under

49-65

section 42-14.5-1 of the general laws.

49-66

     (y) "Physician" includes podiatrist as defined in chapter 29 of title 5.

49-67

     (z) "Private organization" means a legal corporation with a policy making and governing

49-68

body.

50-1

     (aa) "Provider" means any physician, hospital, licensed midwife, or other person who is

50-2

licensed or authorized in this state to furnish health care services.

50-3

     (bb) "Public organization" means an instrumentality of government.

50-4

     (cc) “Rescission" means a cancellation or discontinuance of coverage that has retroactive

50-5

effect for reasons unrelated to timely payment of required premiums or contribution to costs of

50-6

coverage.

50-7

     (dd) "Risk based capital ("RBC") instructions" means the risk based capital report

50-8

including risk based capital instructions adopted by the National Association of Insurance

50-9

Commissioners ("NAIC"), as these risk based capital instructions are amended by the NAIC in

50-10

accordance with the procedures adopted by the NAIC.

50-11

     (ee) "Total adjusted capital" means the sum of:

50-12

     (1) A health maintenance organization's statutory capital and surplus (i.e. net worth) as

50-13

determined in accordance with the statutory accounting applicable to the annual financial

50-14

statements required to be filed under section 27-41-9; and

50-15

     (2) Any other items, if any, that the RBC instructions provide.

50-16

     (ff) "Uncovered expenditures" means the costs of health care services that are covered by

50-17

a health maintenance organization, but that are not guaranteed, insured, or assumed by a person or

50-18

organization other than the health maintenance organization. Expenditures to a provider that

50-19

agrees not to bill enrollees under any circumstances are excluded from this definition.

50-20

     27-41-61. Termination of children's benefits Eligibility for children’s benefits --

50-21

(a)(1) Every individual health insurance contract, plan, or policy health benefit plan delivered,

50-22

issued for delivery, or renewed in this state which provides medical health benefits coverage for

50-23

dependent children that includes coverage for physician services in a physician’s office, and

50-24

every policy which provides major medical or similar comprehensive type coverage dependents,

50-25

except for supplemental policies which only provide coverage for specified diseases and other

50-26

supplemental policies, shall provide make coverage available of an unmarried child under the age

50-27

of nineteen (19) years, an unmarried child who is a student under the age of twenty-five (25)

50-28

years and who is financially dependent upon the parent and an unmarried child of any age who is

50-29

financially dependent upon the parent and medically determined to have a physical or mental

50-30

impairment which can be expected to result in death or which has lasted or can be expected to last

50-31

for a continuous period of not less than twelve (12) months for children until attainment of

50-32

twenty-six (26) years of age, and an unmarried child of any age who is financially dependent

50-33

upon the parent and medically determined to have a physical or mental impairment which can be

50-34

expected to result in death or which has lasted or can be expected to last for a continuous period

51-1

of not less than twelve (12) months. Such contract, plan or policy shall also include a provision

51-2

that policyholders shall receive no less than thirty (30) days notice from the accident and sickness

51-3

insurer that a child covered as a dependent by the policy holder is about to lose his or her

51-4

coverage as a result of reaching the maximum age for a dependent child, and that the child will

51-5

only continue to be covered upon documentation being provided of current full or part-time

51-6

enrollment in a post-secondary educational institution or that the child may purchase a conversion

51-7

policy if he or she is not an eligible student. Nothing in this section prohibits an accident and

51-8

sickness insurer from requiring a policy holder to annually provide proof of a child’s current full

51-9

or part-time enrollment in a post-secondary educational institution in order to maintain the child’s

51-10

coverage. Provided, nothing in this section requires coverage inconsistent with the membership

51-11

criteria in effect under the policyholder’s health benefits coverage.

51-12

     (2) With respect to a child who has not attained twenty-six (26) years of age, a health

51-13

maintenance organization shall not define “dependent” for purposes of eligibility for dependent

51-14

coverage of children other than the terms of a relationship between a child and the plan

51-15

participant, or subscriber.

51-16

     (3) A health maintenance organization shall not deny or restrict coverage for a child who

51-17

has not attained twenty-six (26) years of age based on the presence or absence of the child’s

51-18

financial dependency upon the participant, primary subscriber or any other person, residency with

51-19

the participant and in the individual market the primary subscriber, or with any other person,

51-20

marital status, student status, employment or any combination of those factors. A health carrier

51-21

shall not deny or restrict coverage of a child based on eligibility for other coverage, except as

51-22

provided in (b) (1) of this section.

51-23

     (4) Nothing in this section shall be construed to require a health maintenance

51-24

organization to make coverage available for the child of a child receiving dependent coverage,

51-25

unless the grandparent becomes the legal guardian or adoptive parent of that grandchild.

51-26

     (5) The terms of coverage in a health benefit plan offered by a health maintenance

51-27

organization providing dependent coverage of children cannot vary based on age except for

51-28

children who are twenty-six (26) years of age or older.

51-29

     (b)(1) For plan years beginning before January 1, 2014, a group health plan providing

51-30

group health insurance coverage that is a grandfathered health plan and makes available

51-31

dependent coverage of children may exclude an adult child who has not attained twenty-six (26)

51-32

years of age from coverage only if the adult child is eligible to enroll in an eligible employer-

51-33

sponsored health benefit plan, as defined in section 5000A(f)(2) of the federal Internal Revenue

51-34

Code, other than the group health plan of a parent.

52-1

     (2) For plan years, beginning on or after January 1, 2014, a group health plan providing

52-2

group health insurance coverage that is a grandfathered health plan shall comply with the

52-3

requirements of this section

52-4

     (e) This section does not apply to insurance coverage providing benefits for: (1) hospital

52-5

confinement indemnity; (2) disability income; (3) accident only; (4) long term care; (5) Medicare

52-6

supplement; (6) limited benefit health; (7) specified diseased indemnity; or (8) other limited

52-7

benefit policies.

52-8

     SECTION 10. Chapter 27-41 of the General laws entitled "Health Maintenance

52-9

Organizations" is hereby amended by adding thereto the following sections:

52-10

     27-41-29.1. Uniform explanation of benefits and coverage. -- (a) A health maintenance

52-11

organization shall provide a summary of benefits and coverage explanation and definitions to

52-12

policyholders and others required by, and at the times and in the format required, by the federal

52-13

regulations adopted under section 2715 of the Public Health Service Act, as amended by the

52-14

federal Affordable Care Act. The forms required by this section shall be made available to the

52-15

commissioner on request. Nothing in this section shall be construed to limit the authority of the

52-16

commissioner under existing state law.

52-17

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

52-18

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

52-19

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

52-20

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

52-21

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

52-22

     (c) If the commissioner of the office of the health insurance commissioner determines

52-23

that the corresponding provision of the federal Patient Protection and Affordable Care Act has

52-24

been declared invalid by a final judgment of the federal judicial branch or has been repealed by

52-25

an act of Congress, on the date of the commissioner’s determination this section shall have its

52-26

effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this

52-27

section. Nothing in this section shall be construed to limit the authority of the commissioner

52-28

under existing state law.

52-29

     27-41-29.2. Filing of policy forms. – (a) A health maintenance organization shall file all

52-30

policy forms and rates used by it in the state with the commissioner, including the forms of any

52-31

rider, endorsement, application blank, and other matter generally used or incorporated by

52-32

reference in its policies or contracts of insurance. No such form shall be used if disapproved by

52-33

the commissioner under this section, or if the commissioner’s approval has been withdrawn after

52-34

notice and an opportunity to be heard, or until the expiration of sixty (60) days following the

53-1

filing of the form. Such a company shall comply with its filed and approved forms.  If the

53-2

commissioner finds from an examination of any form that it is contrary to the public interest or

53-3

the requirements of this code or duly promulgated regulations, he or she shall forbid its use, and

53-4

shall notify the corporation in writing.

53-5

     (b) Each rate filing shall include a certification by a qualified actuary that to the best of

53-6

the actuary's knowledge and judgment, the entire rate filing is in compliance with applicable laws

53-7

and that the benefits offered or proposed to be offered are reasonable in relation to the premium

53-8

to be charged. A health insurance carrier shall comply with its filed and approved rates and

53-9

forms.

53-10

     27-41-75. Prohibition on rescission of coverage. -- (a)(1) Coverage under a health plan

53-11

subject to the jurisdiction of the commissioner under this chapter with respect to an individual,

53-12

including a group to which the individual belongs or family coverage in which the individual is

53-13

included, shall not be rescinded after the individual is covered under the plan, unless:

53-14

     (A) The individual or a person seeking coverage on behalf of the individual, performs an

53-15

act, practice or omission that constitutes fraud; or

53-16

     (B) The individual makes an intentional misrepresentation of material fact, as prohibited

53-17

by the terms of the plan or coverage.

53-18

     (2) For purposes of paragraph (1)(A), a person seeking coverage on behalf of an

53-19

individual does not include an insurance producer or employee or authorized representative of the

53-20

health maintenance organization.

53-21

     (b) At least thirty (30) days advance written notice shall be provided to each plan enrollee

53-22

or, for individual health insurance coverage, primary subscriber, who would be affected by the

53-23

proposed rescission of coverage before coverage under the plan may be rescinded in accordance

53-24

with subsection (a) regardless of, in the case of group health insurance coverage, whether the

53-25

rescission applies to the entire group or only to an individual within the group.

53-26

     (c) For purposes of this section, “to rescind” means to cancel or to discontinue coverage

53-27

with retroactive effect for reasons unrelated to timely payment of required premiums or

53-28

contribution to costs of coverage.

53-29

     (d) This section applies to grandfathered health plans.

53-30

     27-41-76. Prohibition on annual and lifetime limits. -- (a) Annual limits.

53-31

     (1) For plan or policy years beginning prior to January 1, 2014, for any individual, a

53-32

health maintenance organization subject to the jurisdiction of the commissioner under this chapter

53-33

may establish an annual limit on the dollar amount of benefits that are essential health benefits

53-34

provided the restricted annual limit is not less than the following:

54-1

     (A) For a plan or policy year beginning after September 22, 2011, but before September

54-2

23, 2012 – one million two hundred fifty thousand dollars ($1,250,000); and

54-3

     (B) For a plan or policy year beginning after September 22, 2012, but before January 1,

54-4

2014 – two million dollars ($2,000,000).

54-5

     (2 ) For plan or policy years beginning on or after January 1, 2014, a health maintenance

54-6

organization shall not establish any annual limit on the dollar amount of essential health benefits

54-7

for any individual, except:

54-8

     (A) A health flexible spending arrangement, as defined in section 106(c)(2)(i) of the

54-9

federal Internal Revenue Code, a medical savings account, as defined in section 220 of the federal

54-10

Internal Revenue Code, and a health savings account, as defined in section 223 of the federal

54-11

Internal Revenue Code are not subject to the requirements of subdivisions (1) and (2) of this

54-12

subsection .

54-13

     (B) The provisions of this subsection shall not prevent a health maintenance organization

54-14

from placing annual dollar limits for any individual on specific covered benefits that are not

54-15

essential health benefits to the extent that such limits are otherwise permitted under applicable

54-16

federal law or the laws and regulations of this state.

54-17

     (3) In determining whether an individual has received benefits that meet or exceed the

54-18

allowable limits, as provided in subdivision (1) of this subsection, a health maintenance

54-19

organization shall take into account only essential health benefits.

54-20

     (b) Lifetime limits.

54-21

     (1) A health insurance carrier and health benefit plan offering group or individual health

54-22

insurance coverage shall not establish a lifetime limit on the dollar value of essential health

54-23

benefits for any individual.

54-24

     (2) Notwithstanding subdivision (1) above, a health insurance carrier and health benefit

54-25

plan is not prohibited from placing lifetime dollar limits for any individual on specific covered

54-26

benefits that are not essential health benefits in accordance with federal laws and regulations.

54-27

     (c)(1) The provisions of this section relating to lifetime limits apply to any health

54-28

maintenance organization or health insurance carrier providing coverage under an individual or

54-29

group health plan, including grandfathered health plans.

54-30

     (2) The provisions of this section relating to annual limits apply to any health

54-31

maintenance organization or health insurance carrier providing coverage under a group health

54-32

plan, including grandfathered health plans, but the prohibition and limits on annual limits do not

54-33

apply to grandfathered health plans providing individual health insurance coverage.

55-34

     (d) This section shall not apply to a plan or to policy years prior to January 1, 2014 for

55-35

which the Secretary of the U.S. Department of Health and Human Services issued a waiver

55-36

pursuant to 45 C.F.R. § 147.126(d)(3). This section also shall not apply to insurance coverage

55-37

providing benefits for: (1) Hospital confinement indemnity; (2) Disability income; (3) Accident

55-38

only; (4) Long-term care; (5) Medicare supplement; (6) Limited benefit health; (7) Specified

55-39

disease indemnity; (8) Sickness or bodily injury or death by accident or both; and (9) Other

55-40

limited benefit policies.

55-41

     (e) If the commissioner of the office of the health insurance commissioner determines

55-42

that the corresponding provision of the federal Patient Protection and Affordable Care Act has

55-43

been declared invalid by a final judgment of the federal judicial branch or has been repealed by

55-44

an act of Congress, on the date of the commissioner’s determination this section shall have its

55-45

effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this

55-46

section. Nothing in this subsection shall be construed to limit the authority of the Commissioner

55-47

to regulate health insurance under existing state law.

55-48

     27-41-77. Coverage for individual participating in approved clinical trials. -- (a) As

55-49

used in this section.

55-50

     (1) “Approved clinical trial” means a phase I, phase II, phase III or phase IV clinical trial

55-51

that is conducted in relation to the prevention, detection or treatment of cancer or a life-

55-52

threatening disease or condition and is described in any of the following:

55-53

     (A) The study or investigation is approved or funded, which may include funding through

55-54

in-kind contributions, by one or more of the following:

55-55

     (i) The federal National Institutes of Health;

55-56

     (ii) The federal Centers for Disease Control and Prevention;

55-57

     (iii) The federal Agency for Health Care Research and Quality;

55-58

     (iv) The federal Centers for Medicare & Medicaid Services;

55-59

     (v) A cooperative group or center of any of the entities described in items (i) through (iv)

55-60

or the U.S. Department of Defense or the U.S. Department of Veteran Affairs;

55-61

     (vi) A qualified non-governmental research entity identified in the guidelines issued by

55-62

the federal National Institutes of Health for center support grants; or

55-63

     (vii) A study or investigation conducted by the U.S. Department of Veteran Affairs, the

55-64

U.S. Department of Defense, or the U.S. Department of Energy, if the study or investigation has

55-65

been reviewed and approved through a system of peer review that the Secretary of U.S.

55-66

Department of Health and Human Services determines:

55-67

     (I) Is comparable to the system of peer review of studies and investigations used by the

55-68

federal National Institutes of Health; and

56-1

     (II) Assures unbiased review of the highest scientific standards by qualified individuals

56-2

who have no interest in the outcome of the review.

56-3

     (B) The study or investigation is conducted under an investigational new drug application

56-4

reviewed by the U.S. Food and Drug Administration; or

56-5

     (C) The study or investigation is a drug trial that is exempt from having such an

56-6

investigational new drug application.

56-7

     (2) “Participant” has the meaning stated in section 3(7) of federal ERISA.

56-8

     (3) “Participating provider” means a health care provider that, under a contract with the

56-9

health carrier or with its contractor or subcontractor, has agreed to provide health care services to

56-10

covered persons with an expectation of receiving payment, other than coinsurance, copayments or

56-11

deductibles, directly or indirectly from the health carrier.

56-12

     (4) “Qualified individual” means a participant or beneficiary who meets the following

56-13

conditions:

56-14

     (A) The individual is eligible to participate in an approved clinical trial according to the

56-15

trial protocol with respect to the treatment of cancer or other life-threatening disease or condition;

56-16

and

56-17

     (B)(i) The referring health care professional is a participating provider and has concluded

56-18

that the individual’s participation in such trial would be appropriate based on the individual

56-19

meeting the conditions described in subdivision (A) of this subdivision (3); or

56-20

     (ii) The participant or beneficiary provides medical and scientific information

56-21

establishing the individual’s participation in such trial would be appropriate based on the

56-22

individual meeting the conditions described in subdivision (A) of this subdivision (3).

56-23

     (5) “Life-threatening condition” means any disease or condition from which the

56-24

likelihood of death is probable unless the course of the disease or condition is interrupted.

56-25

     (b)(1) If a health maintenance organization offering group or individual health insurance

56-26

coverage provides coverage to a qualified individual, it:

56-27

     (A) Shall not deny the individual participation in an approved clinical trial.

56-28

     (B) Subject to subdivision (3) of this subsection, shall not deny or limit or impose

56-29

additional conditions on the coverage of routine patient costs for items and services furnished in

56-30

connection with participation in the approved clinical trial; and

56-31

     (C) Shall not discriminate against the individual on the basis of the individual’s

56-32

participation in the approved clinical trial.

56-33

     (2)(A) Subject to subdivision (B) of this subdivision (2), routine patient costs include all

56-34

items and services consistent with the coverage typically covered for a qualified individual who is

57-1

not enrolled in an approved clinical trial.

57-2

     (B) For purposes of subdivision (B) of this subdivision (2), routine patient costs do not

57-3

include:

57-4

     (i) The investigational item, device or service itself;

57-5

     (ii) Items and services that are provided solely to satisfy data collection and analysis

57-6

needs and that are not used in the direct clinical management of the patient; or

57-7

     (iii) A service that is clearly inconsistent with widely accepted and established standards

57-8

of care for a particular diagnosis.

57-9

     (3) If one or more participating providers is participating in a clinical trial, nothing in

57-10

subdivision (1) of this subsection shall be construed as preventing a health maintenance

57-11

organization from requiring that a qualified individual participate in the trial through such a

57-12

participating provider if the provider will accept the individual as a participant in the trial.

57-13

     (4) Notwithstanding subdivision (3) of this subsection, subdivision (1) of this subsection

57-14

shall apply to a qualified individual participating in an approved clinical trial that is conducted

57-15

outside this state.

57-16

     (5) This section shall not be construed to require a health maintenance organization

57-17

offering group or individual health insurance coverage to provide benefits for routine patient care

57-18

services provided outside of the coverage’s health care provider network unless out-of-network

57-19

benefits are other provided under the coverage.

57-20

     (6) Nothing in this section shall be construed to limit a health maintenance organization’s

57-21

coverage with respect to clinical trials.

57-22

     (c) The requirements of this section shall be in addition to the requirements of Rhode

57-23

Island general laws sections 27-41-41 through 27-41-41.3.

57-24

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

57-25

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

57-26

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

57-27

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

57-28

     27-41-78. Medical loss ratio reporting and rebates. -- (a) A health maintenance

57-29

organization offering group or individual health insurance coverage of a health benefit plan,

57-30

including a grandfathered health plan, shall comply with the provisions of Section 2718 of the

57-31

Public Health Services Act as amended by the federal Affordable Care Act, in accordance with

57-32

regulations adopted thereunder.

57-33

     (b) Health maintenance organizations required to report medical loss ratio and rebate

57-34

calculations and any other medical loss ratio or rebate information to the U.S. Department of

58-1

Health and Human Services shall concurrently file such information with the commissioner.

58-2

     27-41-79. Emergency services. -- (a) As used in this section:

58-3

     (1) “Emergency medical condition” means a medical condition manifesting itself by

58-4

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

58-5

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

58-6

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

58-7

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

58-8

impairment to bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or

58-9

part.

58-10

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

58-11

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

58-12

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

58-13

hospital, including ancillary services routinely available to the emergency department to evaluate

58-14

such emergency medical condition, and

58-15

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

58-16

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

58-17

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

58-18

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

58-19

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

58-20

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

58-21

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

58-22

cover emergency services consistent with the rules of this section.

58-23

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

58-24

the following manner:

58-25

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

58-26

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

58-27

     (2) Without regard to whether the health care provider furnishing the emergency services

58-28

is a participating network provider with respect to the services;

58-29

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

58-30

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

58-31

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

58-32

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

58-33

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

59-34

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

59-35

     (A) The exclusion of or coordination of benefits;

59-36

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

59-37

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

59-38

     (C) Applicable cost sharing.

59-39

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

59-40

rate imposed with respect to a participant or beneficiary for out-of-network emergency services

59-41

cannot exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if

59-42

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

59-43

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

59-44

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

59-45

to pay under subdivision (1) of this subsection. A health maintenance organization complies with

59-46

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

59-47

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

59-48

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

59-49

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

59-50

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

59-51

participant or beneficiary. If there is more than one amount negotiated with in-network providers

59-52

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

59-53

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

59-54

participant or beneficiary. In determining the median described in the preceding sentence, the

59-55

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

59-56

same amount is paid to more than one provider). If there is no per-service amount negotiated with

59-57

in-network providers (such as under a capitation or other similar payment arrangement), the

59-58

amount under this subdivision (A) is disregarded.

59-59

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

59-60

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

59-61

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

59-62

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

59-63

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

59-64

coverage with respect to out-of-network services.

59-65

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

59-66

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

59-67

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

60-68

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

60-69

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

60-70

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

60-71

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

60-72

services only as part of a deductible that generally applies to out-of-network benefits. If an out-of-

60-73

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

60-74

apply to out-of-network emergency services.

60-75

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

60-76

23, 2010.

60-77

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

60-78

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

60-79

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

60-80

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

60-81

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

60-82

     27-41-80. Internal and external appeal of adverse benefit determinations. -- (a) The

60-83

commissioner shall adopt regulations to implement standards and procedures with respect to

60-84

internal claims and appeals of adverse benefit determinations, and with respect to external appeals

60-85

of adverse benefit determinations.

60-86

     (b) The regulations adopted by the commissioner shall apply only to those adverse

60-87

benefit determinations within the jurisdiction of the department of health pursuant to R.I. Gen.

60-88

Laws § 23-17.12 et seq. (Utilization Review Act).

60-89

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

60-90

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

60-91

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

60-92

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

60-93

shall not apply to grandfathered health plans.

60-94

     27-41-81. Prohibition on preexisting condition exclusions. -- (a) A health insurance

60-95

policy, subscriber contract, or health plan offered, issued, issued for delivery, or issued to cover a

60-96

resident of this state by a health insurance company licensed pursuant to this title and/or chapter:

60-97

     (1) Shall not limit or exclude coverage for an individual under the age of nineteen (19) by

60-98

imposing a preexisting condition exclusion on that individual.

60-99

     (2) For plan or policy years beginning on or after January 1, 2014, shall not limit or

60-100

exclude coverage for any individual by imposing a preexisting condition exclusion on that

60-101

individual.

61-102

     (b) As used in this section:

61-103

     (1) “Preexisting condition exclusion” means a limitation or exclusion of benefits,

61-104

including a denial of coverage, based on the fact that the condition (whether physical or mental)

61-105

was present before the effective date of coverage, or if the coverage is denied, the date of denial,

61-106

under a health benefit plan whether or not any medical advice, diagnosis, care or treatment was

61-107

recommended or received before the effective date of coverage.

61-108

     (2) “Preexisting condition exclusion” means any limitation or exclusion of benefits,

61-109

including a denial of coverage, applicable to an individual as a result of information relating to an

61-110

individual’s health status before the individual’s effective date of coverage, or if the coverage is

61-111

denied, the date of denial, under the health benefit plan, such as a condition (whether physical or

61-112

mental) identified as a result of a pre-enrollment questionnaire or physical examination given to

61-113

the individual, or review of medical records relating to the pre-enrollment period.

61-114

     (c) This section shall not apply to grandfathered health plans providing individual health

61-115

insurance coverage.

61-116

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

61-117

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

61-118

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

61-119

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

61-120

     SECTION 11. Sections 27-50-3 and 27-50-7 of the General Laws in Chapter 27-50

61-121

entitled "Small Employer Health Insurance Availability Act" are hereby amended to read as

61-122

follows:

61-123

     27-50-3. Definitions. [Effective December 31, 2010.] -- (a) "Actuarial certification"

61-124

means a written statement signed by a member of the American Academy of Actuaries or other

61-125

individual acceptable to the director that a small employer carrier is in compliance with the

61-126

provisions of section 27-50-5, based upon the person's examination and including a review of the

61-127

appropriate records and the actuarial assumptions and methods used by the small employer carrier

61-128

in establishing premium rates for applicable health benefit plans.

61-129

      (b) "Adjusted community rating" means a method used to develop a carrier's premium

61-130

which spreads financial risk across the carrier's entire small group population in accordance with

61-131

the requirements in section 27-50-5.

61-132

      (c) "Affiliate" or "affiliated" means any entity or person who directly or indirectly

61-133

through one or more intermediaries controls or is controlled by, or is under common control with,

61-134

a specified entity or person.

61-135

      (d) "Affiliation period" means a period of time that must expire before health insurance

61-136

coverage provided by a carrier becomes effective, and during which the carrier is not required to

62-1

provide benefits.

62-2

      (e) "Bona fide association" means, with respect to health benefit plans offered in this

62-3

state, an association which:

62-4

      (1) Has been actively in existence for at least five (5) years;

62-5

      (2) Has been formed and maintained in good faith for purposes other than obtaining

62-6

insurance;

62-7

      (3) Does not condition membership in the association on any health-status related factor

62-8

relating to an individual (including an employee of an employer or a dependent of an employee);

62-9

      (4) Makes health insurance coverage offered through the association available to all

62-10

members regardless of any health status-related factor relating to those members (or individuals

62-11

eligible for coverage through a member);

62-12

      (5) Does not make health insurance coverage offered through the association available

62-13

other than in connection with a member of the association;

62-14

      (6) Is composed of persons having a common interest or calling;

62-15

      (7) Has a constitution and bylaws; and

62-16

      (8) Meets any additional requirements that the director may prescribe by regulation.

62-17

      (f) "Carrier" or "small employer carrier" means all entities licensed, or required to be

62-18

licensed, in this state that offer health benefit plans covering eligible employees of one or more

62-19

small employers pursuant to this chapter. For the purposes of this chapter, carrier includes an

62-20

insurance company, a nonprofit hospital or medical service corporation, a fraternal benefit

62-21

society, a health maintenance organization as defined in chapter 41 of this title or as defined in

62-22

chapter 62 of title 42, or any other entity subject to state insurance regulation that provides

62-23

medical care as defined in subsection (y) that is paid or financed for a small employer by such

62-24

entity on the basis of a periodic premium, paid directly or through an association, trust, or other

62-25

intermediary, and issued, renewed, or delivered within or without Rhode Island to a small

62-26

employer pursuant to the laws of this or any other jurisdiction, including a certificate issued to an

62-27

eligible employee which evidences coverage under a policy or contract issued to a trust or

62-28

association.

62-29

      (g) "Church plan" has the meaning given this term under section 3(33) of the Employee

62-30

Retirement Income Security Act of 1974 [29 U.S.C. section 1002(33)_.

62-31

      (h) "Control" is defined in the same manner as in chapter 35 of this title.

62-32

      (i) (1) "Creditable coverage" means, with respect to an individual, health benefits or

62-33

coverage provided under any of the following:

63-34

      (i) A group health plan;

63-35

      (ii) A health benefit plan;

63-36

      (iii) Part A or part B of Title XVIII of the Social Security Act, 42 U.S.C. section 1395c

63-37

et seq., or 42 U.S.C. section 1395j et seq., (Medicare);

63-38

      (iv) Title XIX of the Social Security Act, 42 U.S.C. section 1396 et seq., (Medicaid),

63-39

other than coverage consisting solely of benefits under 42 U.S.C. section 1396s (the program for

63-40

distribution of pediatric vaccines);

63-41

      (v) 10 U.S.C. section 1071 et seq., (medical and dental care for members and certain

63-42

former members of the uniformed services, and for their dependents)(Civilian Health and

63-43

Medical Program of the Uniformed Services)(CHAMPUS). For purposes of 10 U.S.C. section

63-44

1071 et seq., "uniformed services" means the armed forces and the commissioned corps of the

63-45

National Oceanic and Atmospheric Administration and of the Public Health Service;

63-46

      (vi) A medical care program of the Indian Health Service or of a tribal organization;

63-47

      (vii) A state health benefits risk pool;

63-48

      (viii) A health plan offered under 5 U.S.C. section 8901 et seq., (Federal Employees

63-49

Health Benefits Program (FEHBP));

63-50

      (ix) A public health plan, which for purposes of this chapter, means a plan established or

63-51

maintained by a state, county, or other political subdivision of a state that provides health

63-52

insurance coverage to individuals enrolled in the plan; or

63-53

      (x) A health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C. section

63-54

2504(e)).

63-55

      (2) A period of creditable coverage shall not be counted, with respect to enrollment of an

63-56

individual under a group health plan, if, after the period and before the enrollment date, the

63-57

individual experiences a significant break in coverage.

63-58

      (j) "Dependent" means a spouse, an unmarried child under the age of nineteen (19)

63-59

twenty-six (26) years, an unmarried child who is a student under the age of twenty-five (25)

63-60

years, and an unmarried child of any age who is financially dependent upon, the parent and is

63-61

medically determined to have a physical or mental impairment which can be expected to result in

63-62

death or which has lasted or can be expected to last for a continuous period of not less than

63-63

twelve (12) months.

63-64

      (k) "Director" means the director of the department of business regulation.

63-65

      (l) [Deleted by P.L. 2006, ch. 258, section 2, and P.L. 2006, ch. 296, section 2.]

63-66

      (m) "Eligible employee" means an employee who works on a full-time basis with a

63-67

normal work week of thirty (30) or more hours, except that at the employer's sole discretion, the

63-68

term shall also include an employee who works on a full-time basis with a normal work week of

64-1

anywhere between at least seventeen and one-half (17.5) and thirty (30) hours, so long as this

64-2

eligibility criterion is applied uniformly among all of the employer's employees and without

64-3

regard to any health status-related factor. The term includes a self-employed individual, a sole

64-4

proprietor, a partner of a partnership, and may include an independent contractor, if the self-

64-5

employed individual, sole proprietor, partner, or independent contractor is included as an

64-6

employee under a health benefit plan of a small employer, but does not include an employee who

64-7

works on a temporary or substitute basis or who works less than seventeen and one-half (17.5)

64-8

hours per week. Any retiree under contract with any independently incorporated fire district is

64-9

also included in the definition of eligible employee, as well as any former employee of an

64-10

employer who retired before normal retirement age, as defined by 42 U.S.C. 18002(a)(2)(c) while

64-11

the employer participates in the early retiree reinsurance program defined by that chapter. Persons

64-12

covered under a health benefit plan pursuant to the Consolidated Omnibus Budget Reconciliation

64-13

Act of 1986 shall not be considered "eligible employees" for purposes of minimum participation

64-14

requirements pursuant to section 27-50-7(d)(9).

64-15

      (n) "Enrollment date" means the first day of coverage or, if there is a waiting period, the

64-16

first day of the waiting period, whichever is earlier.

64-17

      (o) "Established geographic service area" means a geographic area, as approved by the

64-18

director and based on the carrier's certificate of authority to transact insurance in this state, within

64-19

which the carrier is authorized to provide coverage.

64-20

      (p) "Family composition" means:

64-21

      (1) Enrollee;

64-22

      (2) Enrollee, spouse and children;

64-23

      (3) Enrollee and spouse; or

64-24

      (4) Enrollee and children.

64-25

      (q) "Genetic information" means information about genes, gene products, and inherited

64-26

characteristics that may derive from the individual or a family member. This includes information

64-27

regarding carrier status and information derived from laboratory tests that identify mutations in

64-28

specific genes or chromosomes, physical medical examinations, family histories, and direct

64-29

analysis of genes or chromosomes.

64-30

      (r) "Governmental plan" has the meaning given the term under section 3(32) of the

64-31

Employee Retirement Income Security Act of 1974, 29 U.S.C. section 1002(32), and any federal

64-32

governmental plan.

64-33

      (s) (1) "Group health plan" means an employee welfare benefit plan as defined in section

64-34

3(1) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. section 1002(1), to the

65-1

extent that the plan provides medical care, as defined in subsection (y) of this section, and

65-2

including items and services paid for as medical care to employees or their dependents as defined

65-3

under the terms of the plan directly or through insurance, reimbursement, or otherwise.

65-4

      (2) For purposes of this chapter:

65-5

      (i) Any plan, fund, or program that would not be, but for PHSA Section 2721(e), 42

65-6

U.S.C. section 300gg(e), as added by P.L. 104-191, an employee welfare benefit plan and that is

65-7

established or maintained by a partnership, to the extent that the plan, fund or program provides

65-8

medical care, including items and services paid for as medical care, to present or former partners

65-9

in the partnership, or to their dependents, as defined under the terms of the plan, fund or program,

65-10

directly or through insurance, reimbursement or otherwise, shall be treated, subject to paragraph

65-11

(ii) of this subdivision, as an employee welfare benefit plan that is a group health plan;

65-12

      (ii) In the case of a group health plan, the term "employer" also includes the partnership

65-13

in relation to any partner; and

65-14

      (iii) In the case of a group health plan, the term "participant" also includes an individual

65-15

who is, or may become, eligible to receive a benefit under the plan, or the individual's beneficiary

65-16

who is, or may become, eligible to receive a benefit under the plan, if:

65-17

      (A) In connection with a group health plan maintained by a partnership, the individual is

65-18

a partner in relation to the partnership; or

65-19

      (B) In connection with a group health plan maintained by a self-employed individual,

65-20

under which one or more employees are participants, the individual is the self-employed

65-21

individual.

65-22

      (t) (1) "Health benefit plan" means any hospital or medical policy or certificate, major

65-23

medical expense insurance, hospital or medical service corporation subscriber contract, or health

65-24

maintenance organization subscriber contract. Health benefit plan includes short-term and

65-25

catastrophic health insurance policies, and a policy that pays on a cost-incurred basis, except as

65-26

otherwise specifically exempted in this definition.

65-27

      (2) "Health benefit plan" does not include one or more, or any combination of, the

65-28

following:

65-29

      (i) Coverage only for accident or disability income insurance, or any combination of

65-30

those;

65-31

      (ii) Coverage issued as a supplement to liability insurance;

65-32

      (iii) Liability insurance, including general liability insurance and automobile liability

65-33

insurance;

66-34

      (iv) Workers' compensation or similar insurance;

66-35

      (v) Automobile medical payment insurance;

66-36

      (vi) Credit-only insurance;

66-37

      (vii) Coverage for on-site medical clinics; and

66-38

      (viii) Other similar insurance coverage, specified in federal regulations issued pursuant

66-39

to Pub. L. No. 104-191, under which benefits for medical care are secondary or incidental to other

66-40

insurance benefits.

66-41

      (3) "Health benefit plan" does not include the following benefits if they are provided

66-42

under a separate policy, certificate, or contract of insurance or are otherwise not an integral part

66-43

of the plan:

66-44

      (i) Limited scope dental or vision benefits;

66-45

      (ii) Benefits for long-term care, nursing home care, home health care, community-based

66-46

care, or any combination of those; or

66-47

      (iii) Other similar, limited benefits specified in federal regulations issued pursuant to

66-48

Pub. L. No. 104-191.

66-49

      (4) "Health benefit plan" does not include the following benefits if the benefits are

66-50

provided under a separate policy, certificate or contract of insurance, there is no coordination

66-51

between the provision of the benefits and any exclusion of benefits under any group health plan

66-52

maintained by the same plan sponsor, and the benefits are paid with respect to an event without

66-53

regard to whether benefits are provided with respect to such an event under any group health plan

66-54

maintained by the same plan sponsor:

66-55

      (i) Coverage only for a specified disease or illness; or

66-56

      (ii) Hospital indemnity or other fixed indemnity insurance.

66-57

      (5) "Health benefit plan" does not include the following if offered as a separate policy,

66-58

certificate, or contract of insurance:

66-59

      (i) Medicare supplemental health insurance as defined under section 1882(g)(1) of the

66-60

Social Security Act, 42 U.S.C. section 1395ss(g)(1);

66-61

      (ii) Coverage supplemental to the coverage provided under 10 U.S.C. section 1071 et

66-62

seq.; or

66-63

      (iii) Similar supplemental coverage provided to coverage under a group health plan.

66-64

      (6) A carrier offering policies or certificates of specified disease, hospital confinement

66-65

indemnity, or limited benefit health insurance shall comply with the following:

66-66

      (i) The carrier files on or before March 1 of each year a certification with the director

66-67

that contains the statement and information described in paragraph (ii) of this subdivision;

67-68

      (ii) The certification required in paragraph (i) of this subdivision shall contain the

67-69

following:

67-70

      (A) A statement from the carrier certifying that policies or certificates described in this

67-71

paragraph are being offered and marketed as supplemental health insurance and not as a substitute

67-72

for hospital or medical expense insurance or major medical expense insurance; and

67-73

      (B) A summary description of each policy or certificate described in this paragraph,

67-74

including the average annual premium rates (or range of premium rates in cases where premiums

67-75

vary by age or other factors) charged for those policies and certificates in this state; and

67-76

      (iii) In the case of a policy or certificate that is described in this paragraph and that is

67-77

offered for the first time in this state on or after July 13, 2000, the carrier shall file with the

67-78

director the information and statement required in paragraph (ii) of this subdivision at least thirty

67-79

(30) days prior to the date the policy or certificate is issued or delivered in this state.

67-80

      (u) "Health maintenance organization" or "HMO" means a health maintenance

67-81

organization licensed under chapter 41 of this title.

67-82

      (v) "Health status-related factor" means any of the following factors:

67-83

      (1) Health status;

67-84

      (2) Medical condition, including both physical and mental illnesses;

67-85

      (3) Claims experience;

67-86

      (4) Receipt of health care;

67-87

      (5) Medical history;

67-88

      (6) Genetic information;

67-89

      (7) Evidence of insurability, including conditions arising out of acts of domestic

67-90

violence; or

67-91

      (8) Disability.

67-92

      (w) (1) "Late enrollee" means an eligible employee or dependent who requests

67-93

enrollment in a health benefit plan of a small employer following the initial enrollment period

67-94

during which the individual is entitled to enroll under the terms of the health benefit plan,

67-95

provided that the initial enrollment period is a period of at least thirty (30) days.

67-96

      (2) "Late enrollee" does not mean an eligible employee or dependent:

67-97

      (i) Who meets each of the following provisions:

67-98

      (A) The individual was covered under creditable coverage at the time of the initial

67-99

enrollment;

67-100

      (B) The individual lost creditable coverage as a result of cessation of employer

67-101

contribution, termination of employment or eligibility, reduction in the number of hours of

67-102

employment, involuntary termination of creditable coverage, or death of a spouse, divorce or

68-1

legal separation, or the individual and/or dependents are determined to be eligible for RIteCare

68-2

under chapter 5.1 of title 40 or chapter 12.3 of title 42 or for RIteShare under chapter 8.4 of title

68-3

40; and

68-4

      (C) The individual requests enrollment within thirty (30) days after termination of the

68-5

creditable coverage or the change in conditions that gave rise to the termination of coverage;

68-6

      (ii) If, where provided for in contract or where otherwise provided in state law, the

68-7

individual enrolls during the specified bona fide open enrollment period;

68-8

      (iii) If the individual is employed by an employer which offers multiple health benefit

68-9

plans and the individual elects a different plan during an open enrollment period;

68-10

      (iv) If a court has ordered coverage be provided for a spouse or minor or dependent child

68-11

under a covered employee's health benefit plan and a request for enrollment is made within thirty

68-12

(30) days after issuance of the court order;

68-13

      (v) If the individual changes status from not being an eligible employee to becoming an

68-14

eligible employee and requests enrollment within thirty (30) days after the change in status;

68-15

      (vi) If the individual had coverage under a COBRA continuation provision and the

68-16

coverage under that provision has been exhausted; or

68-17

      (vii) Who meets the requirements for special enrollment pursuant to section 27-50-7 or

68-18

27-50-8.

68-19

      (x) "Limited benefit health insurance" means that form of coverage that pays stated

68-20

predetermined amounts for specific services or treatments or pays a stated predetermined amount

68-21

per day or confinement for one or more named conditions, named diseases or accidental injury.

68-22

      (y) "Medical care" means amounts paid for:

68-23

      (1) The diagnosis, care, mitigation, treatment, or prevention of disease, or amounts paid

68-24

for the purpose of affecting any structure or function of the body;

68-25

      (2) Transportation primarily for and essential to medical care referred to in subdivision

68-26

(1); and

68-27

      (3) Insurance covering medical care referred to in subdivisions (1) and (2) of this

68-28

subsection.

68-29

      (z) "Network plan" means a health benefit plan issued by a carrier under which the

68-30

financing and delivery of medical care, including items and services paid for as medical care, are

68-31

provided, in whole or in part, through a defined set of providers under contract with the carrier.

68-32

      (aa) "Person" means an individual, a corporation, a partnership, an association, a joint

68-33

venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any

68-34

combination of the foregoing.

69-1

      (bb) "Plan sponsor" has the meaning given this term under section 3(16)(B) of the

69-2

Employee Retirement Income Security Act of 1974, 29 U.S.C. section 1002(16)(B).

69-3

      (cc) (1) "Preexisting condition" means a condition, regardless of the cause of the

69-4

condition, for which medical advice, diagnosis, care, or treatment was recommended or received

69-5

during the six (6) months immediately preceding the enrollment date of the coverage.

69-6

      (2) "Preexisting condition" does not mean a condition for which medical advice,

69-7

diagnosis, care, or treatment was recommended or received for the first time while the covered

69-8

person held creditable coverage and that was a covered benefit under the health benefit plan,

69-9

provided that the prior creditable coverage was continuous to a date not more than ninety (90)

69-10

days prior to the enrollment date of the new coverage.

69-11

      (3) Genetic information shall not be treated as a condition under subdivision (1) of this

69-12

subsection for which a preexisting condition exclusion may be imposed in the absence of a

69-13

diagnosis of the condition related to the information.

69-14

      (dd) "Premium" means all moneys paid by a small employer and eligible employees as a

69-15

condition of receiving coverage from a small employer carrier, including any fees or other

69-16

contributions associated with the health benefit plan.

69-17

      (ee) "Producer" means any insurance producer licensed under chapter 2.4 of this title.

69-18

      (ff) "Rating period" means the calendar period for which premium rates established by a

69-19

small employer carrier are assumed to be in effect.

69-20

      (gg) "Restricted network provision" means any provision of a health benefit plan that

69-21

conditions the payment of benefits, in whole or in part, on the use of health care providers that

69-22

have entered into a contractual arrangement with the carrier pursuant to provide health care

69-23

services to covered individuals.

69-24

      (hh) "Risk adjustment mechanism" means the mechanism established pursuant to section

69-25

27-50-16.

69-26

      (ii) "Self-employed individual" means an individual or sole proprietor who derives a

69-27

substantial portion of his or her income from a trade or business through which the individual or

69-28

sole proprietor has attempted to earn taxable income and for which he or she has filed the

69-29

appropriate Internal Revenue Service Form 1040, Schedule C or F, for the previous taxable year.

69-30

      (jj) "Significant break in coverage" means a period of ninety (90) consecutive days

69-31

during all of which the individual does not have any creditable coverage, except that neither a

69-32

waiting period nor an affiliation period is taken into account in determining a significant break in

69-33

coverage.

70-34

      (kk) "Small employer" means, except for its use in section 27-50-7, any person, firm,

70-35

corporation, partnership, association, political subdivision, or self-employed individual that is

70-36

actively engaged in business including, but not limited to, a business or a corporation organized

70-37

under the Rhode Island Non-Profit Corporation Act, chapter 6 of title 7, or a similar act of

70-38

another state that, on at least fifty percent (50%) of its working days during the preceding

70-39

calendar quarter, employed no more than fifty (50) eligible employees, with a normal work week

70-40

of thirty (30) or more hours, the majority of whom were employed within this state, and is not

70-41

formed primarily for purposes of buying health insurance and in which a bona fide employer-

70-42

employee relationship exists. In determining the number of eligible employees, companies that

70-43

are affiliated companies, or that are eligible to file a combined tax return for purposes of taxation

70-44

by this state, shall be considered one employer. Subsequent to the issuance of a health benefit

70-45

plan to a small employer and for the purpose of determining continued eligibility, the size of a

70-46

small employer shall be determined annually. Except as otherwise specifically provided,

70-47

provisions of this chapter that apply to a small employer shall continue to apply at least until the

70-48

plan anniversary following the date the small employer no longer meets the requirements of this

70-49

definition. The term small employer includes a self-employed individual.

70-50

      (ll ) "Waiting period" means, with respect to a group health plan and an individual who

70-51

is a potential enrollee in the plan, the period that must pass with respect to the individual before

70-52

the individual is eligible to be covered for benefits under the terms of the plan. For purposes of

70-53

calculating periods of creditable coverage pursuant to subsection (j)(2) of this section, a waiting

70-54

period shall not be considered a gap in coverage.

70-55

      (mm) "Wellness health benefit plan" means a plan developed pursuant to section 27-50-

70-56

10.

70-57

      (nn) "Health insurance commissioner" or "commissioner" means that individual

70-58

appointed pursuant to section 42-14.5-1 of the general laws and afforded those powers and duties

70-59

as set forth in sections 42-14.5-2 and 42-14.5-3 of title 42.

70-60

      (oo) "Low-wage firm" means those with average wages that fall within the bottom

70-61

quartile of all Rhode Island employers.

70-62

      (pp) "Wellness health benefit plan" means the health benefit plan offered by each small

70-63

employer carrier pursuant to section 27-50-7.

70-64

      (qq) "Commissioner" means the health insurance commissioner.

70-65

     27-50-7. Availability of coverage. -- (a) Until October 1, 2004, for purposes of this

70-66

section, "small employer" includes any person, firm, corporation, partnership, association, or

70-67

political subdivision that is actively engaged in business that on at least fifty percent (50%) of its

70-68

working days during the preceding calendar quarter, employed a combination of no more than

71-1

fifty (50) and no less than two (2) eligible employees and part-time employees, the majority of

71-2

whom were employed within this state, and is not formed primarily for purposes of buying health

71-3

insurance and in which a bona fide employer-employee relationship exists. After October 1, 2004,

71-4

for the purposes of this section, "small employer" has the meaning used in section 27-50-3(kk).

71-5

      (b) (1) Every small employer carrier shall, as a condition of transacting business in this

71-6

state with small employers, actively offer to small employers all health benefit plans it actively

71-7

markets to small employers in this state including a wellness health benefit plan. A small

71-8

employer carrier shall be considered to be actively marketing a health benefit plan if it offers that

71-9

plan to any small employer not currently receiving a health benefit plan from the small employer

71-10

carrier.

71-11

      (2) Subject to subdivision (1) of this subsection, a small employer carrier shall issue any

71-12

health benefit plan to any eligible small employer that applies for that plan and agrees to make the

71-13

required premium payments and to satisfy the other reasonable provisions of the health benefit

71-14

plan not inconsistent with this chapter. However, no carrier is required to issue a health benefit

71-15

plan to any self-employed individual who is covered by, or is eligible for coverage under, a health

71-16

benefit plan offered by an employer.

71-17

      (c) (1) A small employer carrier shall file with the director, in a format and manner

71-18

prescribed by the director, the health benefit plans to be used by the carrier. A health benefit plan

71-19

filed pursuant to this subdivision may be used by a small employer carrier beginning thirty (30)

71-20

days after it is filed unless the director disapproves its use.

71-21

      (2) The director may at any time may, after providing notice and an opportunity for a

71-22

hearing to the small employer carrier, disapprove the continued use by a small employer carrier of

71-23

a health benefit plan on the grounds that the plan does not meet the requirements of this chapter.

71-24

      (d) Health benefit plans covering small employers shall comply with the following

71-25

provisions:

71-26

      (1) A health benefit plan shall not deny, exclude, or limit benefits for a covered

71-27

individual for losses incurred more than six (6) months following the enrollment date of the

71-28

individual's coverage due to a preexisting condition, or the first date of the waiting period for

71-29

enrollment if that date is earlier than the enrollment date. A health benefit plan shall not define a

71-30

preexisting condition more restrictively than as defined in section 27-50-3.

71-31

      (2) (i) Except as provided in subdivision (3) of this subsection, a small employer carrier

71-32

shall reduce the period of any preexisting condition exclusion by the aggregate of the periods of

71-33

creditable coverage without regard to the specific benefits covered during the period of creditable

71-34

coverage, provided that the last period of creditable coverage ended on a date not more than

72-1

ninety (90) days prior to the enrollment date of new coverage.

72-2

      (ii) The aggregate period of creditable coverage does not include any waiting period or

72-3

affiliation period for the effective date of the new coverage applied by the employer or the carrier,

72-4

or for the normal application and enrollment process following employment or other triggering

72-5

event for eligibility.

72-6

      (iii) A carrier that does not use preexisting condition limitations in any of its health

72-7

benefit plans may impose an affiliation period that:

72-8

      (A) Does not exceed sixty (60) days for new entrants and not to exceed ninety (90) days

72-9

for late enrollees;

72-10

      (B) During which the carrier charges no premiums and the coverage issued is not

72-11

effective; and

72-12

      (C) Is applied uniformly, without regard to any health status-related factor.

72-13

      (iv) This section does not preclude application of any waiting period applicable to all

72-14

new enrollees under the health benefit plan, provided that any carrier-imposed waiting period is

72-15

no longer than sixty (60) days.

72-16

      (3) (i) Instead of as provided in paragraph (2)(i) of this subsection, a small employer

72-17

carrier may elect to reduce the period of any preexisting condition exclusion based on coverage of

72-18

benefits within each of several classes or categories of benefits specified in federal regulations.

72-19

      (ii) A small employer electing to reduce the period of any preexisting condition

72-20

exclusion using the alternative method described in paragraph (i) of this subdivision shall:

72-21

      (A) Make the election on a uniform basis for all enrollees; and

72-22

      (B) Count a period of creditable coverage with respect to any class or category of

72-23

benefits if any level of benefits is covered within the class or category.

72-24

      (iii) A small employer carrier electing to reduce the period of any preexisting condition

72-25

exclusion using the alternative method described under paragraph (i) of this subdivision shall:

72-26

      (A) Prominently state that the election has been made in any disclosure statements

72-27

concerning coverage under the health benefit plan to each enrollee at the time of enrollment under

72-28

the plan and to each small employer at the time of the offer or sale of the coverage; and

72-29

      (B) Include in the disclosure statements the effect of the election.

72-30

      (4) (i) A health benefit plan shall accept late enrollees, but may exclude coverage for late

72-31

enrollees for preexisting conditions for a period not to exceed twelve (12) months.

72-32

      (ii) A small employer carrier shall reduce the period of any preexisting condition

72-33

exclusion pursuant to subdivision (2) or (3) of this subsection.

73-34

      (5) A small employer carrier shall not impose a preexisting condition exclusion:

73-35

      (i) Relating to pregnancy as a preexisting condition; or

73-36

      (ii) With regard to a child who is covered under any creditable coverage within thirty

73-37

(30) days of birth, adoption, or placement for adoption, provided that the child does not

73-38

experience a significant break in coverage, and provided that the child was adopted or placed for

73-39

adoption before attaining eighteen (18) years of age.

73-40

      (6) A small employer carrier shall not impose a preexisting condition exclusion in the

73-41

case of a condition for which medical advice, diagnosis, care or treatment was recommended or

73-42

received for the first time while the covered person held creditable coverage, and the medical

73-43

advice, diagnosis, care or treatment was a covered benefit under the plan, provided that the

73-44

creditable coverage was continuous to a date not more than ninety (90) days prior to the

73-45

enrollment date of the new coverage.

73-46

      (7) (i) A small employer carrier shall permit an employee or a dependent of the

73-47

employee, who is eligible, but not enrolled, to enroll for coverage under the terms of the group

73-48

health plan of the small employer during a special enrollment period if:

73-49

      (A) The employee or dependent was covered under a group health plan or had coverage

73-50

under a health benefit plan at the time coverage was previously offered to the employee or

73-51

dependent;

73-52

      (B) The employee stated in writing at the time coverage was previously offered that

73-53

coverage under a group health plan or other health benefit plan was the reason for declining

73-54

enrollment, but only if the plan sponsor or carrier, if applicable, required that statement at the

73-55

time coverage was previously offered and provided notice to the employee of the requirement and

73-56

the consequences of the requirement at that time;

73-57

      (C) The employee's or dependent's coverage described under subparagraph (A) of this

73-58

paragraph:

73-59

      (I) Was under a COBRA continuation provision and the coverage under this provision

73-60

has been exhausted; or

73-61

      (II) Was not under a COBRA continuation provision and that other coverage has been

73-62

terminated as a result of loss of eligibility for coverage, including as a result of a legal separation,

73-63

divorce, death, termination of employment, or reduction in the number of hours of employment or

73-64

employer contributions towards that other coverage have been terminated; and

73-65

      (D) Under terms of the group health plan, the employee requests enrollment not later

73-66

than thirty (30) days after the date of exhaustion of coverage described in item (C)(I) of this

73-67

paragraph or termination of coverage or employer contribution described in item (C)(II) of this

73-68

paragraph.

74-1

      (ii) If an employee requests enrollment pursuant to subparagraph (i)(D) of this

74-2

subdivision, the enrollment is effective not later than the first day of the first calendar month

74-3

beginning after the date the completed request for enrollment is received.

74-4

      (8) (i) A small employer carrier that makes coverage available under a group health plan

74-5

with respect to a dependent of an individual shall provide for a dependent special enrollment

74-6

period described in paragraph (ii) of this subdivision during which the person or, if not enrolled,

74-7

the individual may be enrolled under the group health plan as a dependent of the individual and,

74-8

in the case of the birth or adoption of a child, the spouse of the individual may be enrolled as a

74-9

dependent of the individual if the spouse is eligible for coverage if:

74-10

      (A) The individual is a participant under the health benefit plan or has met any waiting

74-11

period applicable to becoming a participant under the plan and is eligible to be enrolled under the

74-12

plan, but for a failure to enroll during a previous enrollment period; and

74-13

      (B) A person becomes a dependent of the individual through marriage, birth, or adoption

74-14

or placement for adoption.

74-15

      (ii) The special enrollment period for individuals that meet the provisions of paragraph

74-16

(i) of this subdivision is a period of not less than thirty (30) days and begins on the later of:

74-17

      (A) The date dependent coverage is made available; or

74-18

      (B) The date of the marriage, birth, or adoption or placement for adoption described in

74-19

subparagraph (i)(B) of this subdivision.

74-20

      (iii) If an individual seeks to enroll a dependent during the first thirty (30) days of the

74-21

dependent special enrollment period described under paragraph (ii) of this subdivision, the

74-22

coverage of the dependent is effective:

74-23

      (A) In the case of marriage, not later than the first day of the first month beginning after

74-24

the date the completed request for enrollment is received;

74-25

      (B) In the case of a dependent's birth, as of the date of birth; and

74-26

      (C) In the case of a dependent's adoption or placement for adoption, the date of the

74-27

adoption or placement for adoption.

74-28

      (9) (i) Except as provided in this subdivision, requirements used by a small employer

74-29

carrier in determining whether to provide coverage to a small employer, including requirements

74-30

for minimum participation of eligible employees and minimum employer contributions, shall be

74-31

applied uniformly among all small employers applying for coverage or receiving coverage from

74-32

the small employer carrier.

74-33

      (ii) For health benefit plans issued or renewed on or after October 1, 2000, a small

74-34

employer carrier shall not require a minimum participation level greater than seventy-five percent

75-1

(75%) of eligible employees.

75-2

      (iii) In applying minimum participation requirements with respect to a small employer, a

75-3

small employer carrier shall not consider employees or dependents who have creditable coverage

75-4

in determining whether the applicable percentage of participation is met.

75-5

      (iv) A small employer carrier shall not increase any requirement for minimum employee

75-6

participation or modify any requirement for minimum employer contribution applicable to a small

75-7

employer at any time after the small employer has been accepted for coverage.

75-8

      (10) (i) If a small employer carrier offers coverage to a small employer, the small

75-9

employer carrier shall offer coverage to all of the eligible employees of a small employer and

75-10

their dependents who apply for enrollment during the period in which the employee first becomes

75-11

eligible to enroll under the terms of the plan. A small employer carrier shall not offer coverage to

75-12

only certain individuals or dependents in a small employer group or to only part of the group.

75-13

      (ii) A small employer carrier shall not place any restriction in regard to any health status-

75-14

related factor on an eligible employee or dependent with respect to enrollment or plan

75-15

participation.

75-16

      (iii) Except as permitted under subdivisions (1) and (4) of this subsection, a small

75-17

employer carrier shall not modify a health benefit plan with respect to a small employer or any

75-18

eligible employee or dependent, through riders, endorsements, or otherwise, to restrict or exclude

75-19

coverage or benefits for specific diseases, medical conditions, or services covered by the plan.

75-20

      (e) (1) Subject to subdivision (3) of this subsection, a small employer carrier is not

75-21

required to offer coverage or accept applications pursuant to subsection (b) of this section in the

75-22

case of the following:

75-23

      (i) To a small employer, where the small employer does not have eligible individuals

75-24

who live, work, or reside in the established geographic service area for the network plan;

75-25

      (ii) To an employee, when the employee does not live, work, or reside within the

75-26

carrier's established geographic service area; or

75-27

      (iii) Within an area where the small employer carrier reasonably anticipates, and

75-28

demonstrates to the satisfaction of the director, that it will not have the capacity within its

75-29

established geographic service area to deliver services adequately to enrollees of any additional

75-30

groups because of its obligations to existing group policyholders and enrollees.

75-31

      (2) A small employer carrier that cannot offer coverage pursuant to paragraph (1)(iii) of

75-32

this subsection may not offer coverage in the applicable area to new cases of employer groups

75-33

until the later of one hundred and eighty (180) days following each refusal or the date on which

75-34

the carrier notifies the director that it has regained capacity to deliver services to new employer

76-1

groups.

76-2

      (3) A small employer carrier shall apply the provisions of this subsection uniformly to all

76-3

small employers without regard to the claims experience of a small employer and its employees

76-4

and their dependents or any health status-related factor relating to the employees and their

76-5

dependents.

76-6

      (f) (1) A small employer carrier is not required to provide coverage to small employers

76-7

pursuant to subsection (b) of this section if:

76-8

      (i) For any period of time the director determines the small employer carrier does not

76-9

have the financial reserves necessary to underwrite additional coverage; and

76-10

      (ii) The small employer carrier is applying this subsection uniformly to all small

76-11

employers in the small group market in this state consistent with applicable state law and without

76-12

regard to the claims experience of a small employer and its employees and their dependents or

76-13

any health status-related factor relating to the employees and their dependents.

76-14

      (2) A small employer carrier that denies coverage in accordance with subdivision (1) of

76-15

this subsection may not offer coverage in the small group market for the later of:

76-16

      (i) A period of one hundred and eighty (180) days after the date the coverage is denied;

76-17

or

76-18

      (ii) Until the small employer has demonstrated to the director that it has sufficient

76-19

financial reserves to underwrite additional coverage.

76-20

      (g) (1) A small employer carrier is not required to provide coverage to small employers

76-21

pursuant to subsection (b) of this section if the small employer carrier elects not to offer new

76-22

coverage to small employers in this state.

76-23

      (2) A small employer carrier that elects not to offer new coverage to small employers

76-24

under this subsection may be allowed, as determined by the director, to maintain its existing

76-25

policies in this state.

76-26

      (3) A small employer carrier that elects not to offer new coverage to small employers

76-27

under subdivision (g)(1) shall provide at least one hundred and twenty (120) days notice of its

76-28

election to the director and is prohibited from writing new business in the small employer market

76-29

in this state for a period of five (5) years beginning on the date the carrier ceased offering new

76-30

coverage in this state.

76-31

     (h) No small group carrier may impose a pre-existing condition exclusion pursuant to the

76-32

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-

76-33

7(d)(5) and 27-50-7(d)(6) with regard to an individual that is less than nineteen (19) years of age.

76-34

With respect to health benefit plans issued on and after January 1, 2014 a small employer carrier

77-1

shall offer and issue coverage to small employers and eligible individuals notwithstanding any

77-2

pre-existing condition of an employee, member, or individual, or their dependents.

77-3

     SECTION 12. Section 27-18.6-3 of the General laws in Chapter 27-18.6 entitled "Large

77-4

Group Health Insurance Coverage" is hereby amended to read as follows:

77-5

     27-18.6-3. Limitation on preexisting condition exclusion. -- (a) (1) Notwithstanding

77-6

any of the provisions of this title to the contrary, a group health plan and a health insurance

77-7

carrier offering group health insurance coverage shall not deny, exclude, or limit benefits with

77-8

respect to a participant or beneficiary because of a preexisting condition exclusion except if:

77-9

     (i) The exclusion relates to a condition (whether physical or mental), regardless of the

77-10

cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended

77-11

or received within the six (6) month period ending on the enrollment date;

77-12

     (ii) The exclusion extends for a period of not more than twelve (12) months (or eighteen

77-13

(18) months in the case of a late enrollee) after the enrollment date; and

77-14

     (iii) The period of the preexisting condition exclusion is reduced by the aggregate of the

77-15

periods of creditable coverage, if any, applicable to the participant or the beneficiary as of the

77-16

enrollment date.

77-17

     (2) For purposes of this section, genetic information shall not be treated as a preexisting

77-18

condition in the absence of a diagnosis of the condition related to that information.

77-19

     (b) With respect to paragraph (a)(1)(iii) of this section, a period of creditable coverage

77-20

shall not be counted, with respect to enrollment of an individual under a group health plan, if,

77-21

after that period and before the enrollment date, there was a sixty-three (63) day period during

77-22

which the individual was not covered under any creditable coverage.

77-23

     (c) Any period that an individual is in a waiting period for any coverage under a group

77-24

health plan or for group health insurance or is in an affiliation period shall not be taken into

77-25

account in determining the continuous period under subsection (b) of this section.

77-26

     (d) Except as otherwise provided in subsection (e) of this section, for purposes of

77-27

applying paragraph (a)(1)(iii) of this section, a group health plan and a health insurance carrier

77-28

offering group health insurance coverage shall count a period of creditable coverage without

77-29

regard to the specific benefits covered during the period.

77-30

     (e) (1) A group health plan or a health insurance carrier offering group health insurance

77-31

may elect to apply paragraph (a)(1)(iii) of this section based on coverage of benefits within each

77-32

of several classes or categories of benefits. Those classes or categories of benefits are to be

77-33

determined by the secretary of the United States Department of Health and Human Services

77-34

pursuant to regulation. The election shall be made on a uniform basis for all participants and

78-1

beneficiaries. Under the election, a group health plan or carrier shall count a period of creditable

78-2

coverage with respect to any class or category of benefits if any level of benefits is covered

78-3

within the class or category.

78-4

     (2) In the case of an election under this subsection with respect to a group health plan

78-5

(whether or not health insurance coverage is provided in connection with that plan), the plan

78-6

shall:

78-7

     (i) Prominently state in any disclosure statements concerning the plan, and state to each

78-8

enrollee under the plan, that the plan has made the election; and

78-9

     (ii) Include in the statements a description of the effect of this election.

78-10

     (3) In the case of an election under this subsection with respect to health insurance

78-11

coverage offered by a carrier in the large group market, the carrier shall:

78-12

     (i) Prominently state in any disclosure statements concerning the coverage, and to each

78-13

employer at the time of the offer or sale of the coverage, that the carrier has made the election;

78-14

and

78-15

     (ii) Include in the statements a description of the effect of the election.

78-16

     (f) (1) A group health plan and a health insurance carrier offering group health insurance

78-17

coverage may not impose any preexisting condition exclusion in the case of an individual who, as

78-18

of the last day of the thirty (30) day period beginning with the date of birth, is covered under

78-19

creditable coverage.

78-20

     (2) Subdivision (1) of this subsection shall no longer apply to an individual after the end

78-21

of the first sixty-three (63) day period during all of which the individual was not covered under

78-22

any creditable coverage. Moreover, any period that an individual is in a waiting period for any

78-23

coverage under a group health plan (or for group health insurance coverage) or is in an affiliation

78-24

period shall not be taken into account in determining the continuous period for purposes of

78-25

determining creditable coverage.

78-26

     (g) (1) A group health plan and a health insurance carrier offering group health insurance

78-27

coverage may not impose any preexisting condition exclusion in the case of a child who is

78-28

adopted or placed for adoption before attaining eighteen (18) years of age and who, as of the last

78-29

day of the thirty (30) day period beginning on the date of the adoption or placement for adoption,

78-30

is covered under creditable coverage. The previous sentence does not apply to coverage before

78-31

the date of the adoption or placement for adoption.

78-32

     (2) Subdivision (1) of this subsection shall no longer apply to an individual after the end

78-33

of the first sixty-three (63) day period during all of which the individual was not covered under

78-34

any creditable coverage. Any period that an individual is in a waiting period for any coverage

79-1

under a group health plan (or for group health insurance coverage) or is in an affiliation period

79-2

shall not be taken into account in determining the continuous period for purposes of determining

79-3

creditable coverage.

79-4

     (h) A group health plan and a health insurance carrier offering group health insurance

79-5

coverage may not impose any preexisting condition exclusion relating to pregnancy as a

79-6

preexisting condition or with regard to an individual who is under nineteen (19) years of age.

79-7

     (i) (1) Periods of creditable coverage with respect to an individual shall be established

79-8

through presentation of certifications. A group health plan and a health insurance carrier offering

79-9

group health insurance coverage shall provide certifications:

79-10

     (i) At the time an individual ceases to be covered under the plan or becomes covered

79-11

under a COBRA continuation provision;

79-12

     (ii) In the case of an individual becoming covered under a continuation provision, at the

79-13

time the individual ceases to be covered under that provision; and

79-14

     (iii) On the request of an individual made not later than twenty-four (24) months after the

79-15

date of cessation of the coverage described in paragraph (i) or (ii) of this subdivision, whichever

79-16

is later.

79-17

     (2) The certification under this subsection may be provided, to the extent practicable, at a

79-18

time consistent with notices required under any applicable COBRA continuation provision.

79-19

     (3) The certification described in this subsection is a written certification of:

79-20

     (i) The period of creditable coverage of the individual under the plan and the coverage (if

79-21

any) under the COBRA continuation provision; and

79-22

     (ii) The waiting period (if any) (and affiliation period, if applicable) imposed with respect

79-23

to the individual for any coverage under the plan.

79-24

     (4) To the extent that medical care under a group health plan consists of group health

79-25

insurance coverage, the plan is deemed to have satisfied the certification requirement under this

79-26

subsection if the health insurance carrier offering the coverage provides for the certification in

79-27

accordance with this subsection.

79-28

     (5) In the case of an election taken pursuant to subsection (e) of this section by a group

79-29

health plan or a health insurance carrier, if the plan or carrier enrolls an individual for coverage

79-30

under the plan and the individual provides a certification of creditable coverage, upon request of

79-31

the plan or carrier, the entity which issued the certification shall promptly disclose to the

79-32

requisition plan or carrier information on coverage of classes and categories of health benefits

79-33

available under that entity's plan or coverage, and the entity may charge the requesting plan or

79-34

carrier for the reasonable cost of disclosing the information.

80-1

     (6) Failure of an entity to provide information under this subsection with respect to

80-2

previous coverage of an individual so as to adversely affect any subsequent coverage of the

80-3

individual under another group health plan or health insurance coverage, as determined in

80-4

accordance with rules and regulations established by the secretary of the United States

80-5

Department of Health and Human Services, is a violation of this chapter.

80-6

     (j) A group health plan and a health insurance carrier offering group health insurance

80-7

coverage in connection with a group health plan shall permit an employee who is eligible, but not

80-8

enrolled, for coverage under the terms of the plan (or a dependent of an employee if the

80-9

dependent is eligible, but not enrolled, for coverage under the terms) to enroll for coverage under

80-10

the terms of the plan if each of the following conditions are met:

80-11

     (1) The employee or dependent was covered under a group health plan or had health

80-12

insurance coverage at the time coverage was previously offered to the employee or dependent;

80-13

     (2) The employee stated in writing at the time that coverage under a group health plan or

80-14

health insurance coverage was the reason for declining enrollment, but only if the plan sponsor or

80-15

carrier (if applicable) required a statement at the time and provided the employee with notice of

80-16

that requirement (and the consequences of the requirement) at the time;

80-17

     (3) The employee's or dependent's coverage described in subsection (j)(1):

80-18

     (i) Was under a COBRA continuation provision and the coverage under that provision

80-19

was exhausted; or

80-20

     (ii) Was not under a continuation provision and either the coverage was terminated as a

80-21

result of loss of eligibility for the coverage (including as a result of legal separation, divorce,

80-22

death, termination of employment, or reduction in the number of hours of employment) or

80-23

employer contributions towards the coverage were terminated; and

80-24

     (4) Under the terms of the plan, the employee requests enrollment not later than thirty

80-25

(30) days after the date of exhaustion of coverage described in paragraph (3)(i) of this subsection

80-26

or termination of coverage or employer contribution described in paragraph (3)(ii) of this

80-27

subsection.

80-28

     (k) (1) If a group health plan makes coverage available with respect to a dependent of an

80-29

individual, the individual is a participant under the plan (or has met any waiting period applicable

80-30

to becoming a participant under the plan and is eligible to be enrolled under the plan but for a

80-31

failure to enroll during a previous enrollment period), and a person becomes a dependent of the

80-32

individual through marriage, birth, or adoption or placement through adoption, the group health

80-33

plan shall provide for a dependent special enrollment period during which the person (or, if not

80-34

enrolled, the individual) may be enrolled under the plan as a dependent of the individual, and in

81-1

the case of the birth or adoption of a child, the spouse of the individual may be enrolled as a

81-2

dependent of the individual if the spouse is eligible for coverage.

81-3

     (2) A dependent special enrollment period shall be a period of not less than thirty (30)

81-4

days and shall begin on the later of:

81-5

     (i) The date dependent coverage is made available; or

81-6

     (ii) The date of the marriage, birth, or adoption or placement for adoption (as the case

81-7

may be).

81-8

     (3) If an individual seeks to enroll a dependent during the first thirty (30) days of a

81-9

dependent special enrollment period, the coverage of the dependent shall become effective:

81-10

     (i) In the case of marriage, not later than the first day of the first month beginning after

81-11

the date the completed request for enrollment is received;

81-12

     (ii) In the case of a dependent's birth, as of the date of the birth; or

81-13

     (iii) In the case of a dependent's adoption or placement for adoption, the date of the

81-14

adoption or placement for adoption.

81-15

     (l) (1) A health maintenance organization which offers health insurance coverage in

81-16

connection with a group health plan and which does not impose any preexisting condition

81-17

exclusion allowed under subsection (a) of this section with respect to any particular coverage

81-18

option may impose an affiliation period for the coverage option, but only if that period is applied

81-19

uniformly without regard to any health status-related factors, and the period does not exceed two

81-20

(2) months (or three (3) months in the case of a late enrollee).

81-21

     (2) For the purposes of this subsection, an affiliation shall begin on the enrollment date.

81-22

     (3) An affiliation period under a plan shall run concurrently with any waiting period

81-23

under the plan.

81-24

     (4) The director may approve alternative methods from those described under this

81-25

subsection to address adverse selection.

81-26

     (m) For the purpose of determining creditable coverage pursuant to this chapter, no

81-27

period before July 1, 1996, shall be taken into account. Individuals who need to establish

81-28

creditable coverage for periods before July 1, 1996, and who would have the coverage credited

81-29

but for the prohibition in the preceding sentence may be given credit for creditable coverage for

81-30

those periods through the presentation of documents or other means in accordance with any rule

81-31

or regulation that may be established by the secretary of the United States Department of Health

81-32

and Human Services.

81-33

     (n) In the case of an individual who seeks to establish creditable coverage for any period

81-34

for which certification is not required because it relates to an event occurring before June 30,

82-1

1996, the individual may present other credible evidence of coverage in order to establish the

82-2

period of creditable coverage. The group health plan and a health insurance carrier shall not be

82-3

subject to any penalty or enforcement action with respect to the plan's or carrier's crediting (or not

82-4

crediting) the coverage if the plan or carrier has sought to comply in good faith with the

82-5

applicable requirements of this section.

82-6

     (o) Notwithstanding the provisions of any general or public law to the contrary, for plan

82-7

or policy years beginning on and after January 1, 2014, a group health plan and a health insurance

82-8

carrier offering group health insurance coverage shall not deny, exclude, or limit benefits with

82-9

respect to a participant or beneficiary because of a preexisting condition exclusion.

82-10

     SECTION. 13 Applicability and Construction.

82-11

     (a) This act shall apply only to health insurance policies, subscriber contracts, and any

82-12

other health benefit contract issued on and after July 1, 2012 notwithstanding any other provision

82-13

of this act.

82-14

     (b) In its construction and enforcement of the provisions of this act, and in the interests of

82-15

promoting uniform national rules for health insurance carriers, the office of the health insurance

82-16

commissioner shall give due deference to the construction, enforcement policies, and guidance of

82-17

the federal government with respect to federal law substantially similar to the provisions of this

82-18

act.

82-19

     SECTION 14. Sections 27-18-36, 27-18-36.1, 27-18-36.2 and 27-18-36.3 of the General

82-20

Laws in Chapter 27-18 entitled "Accident and Sickness Insurance Policies" are hereby repealed

82-21

on the effective date of RI General Law 27-18-80.

82-22

     27-18-36. New cancer therapies -- Under investigation. -- Every individual or group

82-23

hospital or medical expense insurance policy or individual or group hospital or medical service

82-24

plan contract delivered, issued for delivery or renewed in this state, except policies which only

82-25

provide coverage for specified diseases other than cancer, fixed indemnity, disability income,

82-26

accident only, long-term care Medicare supplement limited benefit health, sickness or bodily

82-27

injury or death by accident or both, or other limited benefit policies, shall provide coverage for

82-28

new cancer therapies still under investigation as outlined in this chapter.

82-29

     27-18-36.1. "Reliable evidence" defined. -- "Reliable evidence" means:

82-30

      (1) Evidence including published reports and articles in authoritative, peer reviewed

82-31

medical and scientific literature;

82-32

      (2) A written informed consent used by the treating facility or by another facility

82-33

studying substantially the same service; or

83-34

      (3) A written protocol or protocols used by the treating facility or protocols of another

83-35

facility studying substantially the same service.

83-36

     27-18-36.2. Conditions of coverage. -- As provided in section 27-18-36, coverage shall

83-37

be extended to new cancer therapies still under investigation when the following circumstances

83-38

are present:

83-39

      (1) Treatment is being provided pursuant to a phase II, III or IV clinical trial which has

83-40

been approved by the National Institutes of Health (NIH) in cooperation with the National Cancer

83-41

Institute (NCI), Community clinical oncology programs; the Food and Drug Administration in the

83-42

form of an Investigational New Drug (IND) exemption; the Department of Veterans' Affairs; or a

83-43

qualified nongovernmental research entity as identified in the guidelines for NCI cancer center

83-44

support grants;

83-45

      (2) The proposed therapy has been reviewed and approved by a qualified institutional

83-46

review board (IRB);

83-47

      (3) The facility and personnel providing the treatment are capable of doing so by virtue

83-48

of their experience, training, and volume of patients treated to maintain expertise;

83-49

      (4) The patients receiving the investigational treatment meet all protocol requirements;

83-50

      (5) There is no clearly superior, noninvestigational alternative to the protocol treatment;

83-51

      (6) The available clinical or preclinical data provide a reasonable expectation that the

83-52

protocol treatment will be at least as efficacious as the noninvestigational alternative; and

83-53

      (7) The coverage of new cancer therapy treatment provided pursuant to a Phase II

83-54

clinical trial shall not be required for only that portion of that treatment provided as part of the

83-55

phase II clinical trial and is otherwise funded by a national agency, such as the National Cancer

83-56

Institute, the Veteran's Administration, the Department of Defense, or funded by commercial

83-57

organizations such as the biotechnical and/or pharmaceutical industry or manufacturers of

83-58

medical devices. Any portions of a Phase II trial which are customarily funded by government,

83-59

biotechnical and/or pharmaceutical and/or medical device industry sources in Rhode Island or in

83-60

other states shall continue to be so funded in Rhode Island and coverage pursuant to this section

83-61

shall supplement, not supplant, customary funding.

83-62

     27-18-36.3. Managed care. -- Nothing in this chapter shall preclude the conducting of

83-63

managed care reviews and medical necessity reviews by an insurer, hospital or medical service

83-64

corporation, or health maintenance organization.

83-65

     SECTION 15. Sections 27-19-32, 27-19-32.1, 27-19-32.2 and 27-19-32.3 of the General

83-66

Laws in Chapter 27-19 entitled "Nonprofit Hospital Service Corporations" are hereby repealed on

83-67

the effective date of RI General Law 27-19-64.

84-68

     27-19-32. New cancer therapies -- Under investigation. -- Every individual or group

84-69

hospital or medical expense insurance policy or individual or group hospital or medical service

84-70

plan contract delivered, issued for delivery or renewed in this state shall provide coverage for new

84-71

cancer therapies still under investigation as outlined in this chapter.

84-72

     27-19-32.1. "Reliable evidence" defined. -- "Reliable evidence" means:

84-73

      (1) Evidence including published reports and articles in authoritative, peer reviewed

84-74

medical and scientific literature;

84-75

      (2) A written informed consent used by the treating facility or by another facility

84-76

studying substantially the same service; or

84-77

      (3) A written protocol or protocols used by the treating facility or protocols of another

84-78

facility studying substantially the same service.

84-79

     27-19-32.2. Conditions of coverage. -- As provided in section 27-19-32, coverage shall

84-80

be extended to new cancer therapies still under investigation when the following circumstances

84-81

are present:

84-82

      (1) Treatment is being provided pursuant to a phase II, III or IV clinical trial which has

84-83

been approved by the National Institutes of Health (NIH) in cooperation with the National Cancer

84-84

Institute (NCI), community clinical oncology programs; the Food and Drug Administration in the

84-85

form of an investigation new drug (IND) exemption; the Department of Veterans' Affairs; or a

84-86

qualified nongovernmental research entity as identified in the guidelines for NCI cancer center

84-87

support grants;

84-88

      (2) The proposed therapy has been reviewed and approved by a qualified institutional

84-89

review board (IRB);

84-90

      (3) The facility and personnel providing the treatment are capable of doing so by virtue

84-91

of their experience, training, and volume of patients treated to maintain expertise;

84-92

      (4) The patients receiving the investigational treatment meet all protocol requirements;

84-93

      (5) There is no clearly superior, noninvestigational alternative to the protocol treatment;

84-94

      (6) The available clinical or preclinical data provide a reasonable expectation that the

84-95

protocol treatment will be at least as efficacious as the noninvestigational alternative; and

84-96

      (7) The coverage of new cancer therapy treatment provided pursuant to a phase II

84-97

clinical trial shall not be required for that portion of that treatment that is provided as part of the

84-98

phase II clinical trial and is funded by a national agency, such as the National Cancer Institute,

84-99

the Veteran's Administration, the Department of Defense, or funded by commercial organizations

84-100

such as the biotechnical and/or pharmaceutical industry or manufacturers of medical devices. Any

84-101

portions of a phase II trial which are customarily funded by government, biotechnical and/or

84-102

pharmaceutical and/or medical device industry sources in Rhode Island or in other states shall

85-1

continue to be funded in Rhode Island and coverage pursuant to this section shall supplement, not

85-2

supplant, customary funding.

85-3

     27-19-32.3. Managed care. -- Nothing in this chapter shall preclude the conducting of

85-4

managed care reviews and medical necessity reviews by an insurer, hospital or medical service

85-5

corporation, or health maintenance corporation.

85-6

     SECTION 16. Sections 27-20-27, 27-20-27.1, 27-20-27.2 and 27-20-27.3 of the General

85-7

Laws in Chapter 27-20 entitled "Nonprofit Medical Service Corporations" are hereby repealed on

85-8

the effective date of RI General Law 27-20-64.

85-9

     27-20-27. New cancer therapies -- Under investigation. -- Every individual or group

85-10

hospital or medical expense insurance policy or individual or group hospital or medical service

85-11

plan contract delivered, issued for delivery or renewed in this state shall provide coverage for new

85-12

cancer therapies still under investigation as outlined in this chapter.

85-13

     27-20-27.1. "Reliable evidence" defined. -- "Reliable evidence" means:

85-14

      (1) Evidence including published reports and articles in authoritative, peer reviewed

85-15

medical and scientific literature;

85-16

      (2) A written informed consent used by the treating facility or by another facility

85-17

studying substantially the same service; or

85-18

      (3) A written protocol or protocols used by the treating facility or protocols of another

85-19

facility studying substantially the same service.

85-20

     27-20-27.2. Conditions of coverage. -- As provided in section 27-20-27, coverage shall

85-21

be extended to new cancer therapies still under investigation when the following circumstances

85-22

are present:

85-23

      (1) Treatment is being provided pursuant to a phase II, III or IV clinical trial which has

85-24

been approved by the National Institutes of Health (NIH) in cooperation with the National Cancer

85-25

Institute (NCI), community clinical oncology programs; the Food and Drug Administration in the

85-26

form of an investigational new drug (IND) exemption; the Department of Veterans' Affairs; or a

85-27

qualified nongovernmental research entity as identified in the guidelines for NCI cancer center

85-28

support grants;

85-29

      (2) The proposed therapy has been reviewed and approved by a qualified institutional

85-30

review board (IRB);

85-31

      (3) The facility and personnel providing the treatment are capable of doing so by virtue

85-32

of their experience, training, and volume of patients treated to maintain expertise;

85-33

      (4) The patients receiving the investigational treatment meet all protocol requirements;

86-34

      (5) There is no clearly superior, noninvestigational alternative to the protocol treatment;

86-35

      (6) The available clinical or preclinical data provide a reasonable expectation that the

86-36

protocol treatment will be at least as efficacious as the noninvestigational alternative; and

86-37

      (7) The coverage of new cancer therapy treatment provided pursuant to a phase II

86-38

clinical trial is not required for only that portion of that treatment that is provided as part of the

86-39

phase II clinical trial and is funded by a national agency, such as the National Cancer Institute,

86-40

the Veteran's Administration, the Department of Defense, or funded by commercial organizations

86-41

such as the biotechnical and/or pharmaceutical industry or manufacturers of medical devices. Any

86-42

portions of a phase II trial which are customarily funded by government, biotechnical and/or

86-43

pharmaceutical and/or medical device industry sources in Rhode Island or in other states shall

86-44

continue to be funded in Rhode Island and coverage pursuant to this section supplements, does

86-45

not supplant customary funding.

86-46

     27-20-27.3. Managed care. -- Nothing in this chapter shall preclude the conducting of

86-47

managed care reviews and medical necessity reviews by an insurer, hospital or medical service

86-48

corporation, or health maintenance organization. A nonprofit medical service corporation may, as

86-49

a condition of coverage, require its members to obtain new cancer therapies still under

86-50

investigation as outlined in this chapter from providers and facilities designated by the nonprofit

86-51

medical service corporation to render these new cancer therapies.

86-52

     SECTION 17. Sections 27-41-41, 27-41-41.1, 27-41-41.2 and 27-41-41.3 of the General

86-53

Laws in Chapter 27-41 entitled "Health Maintenance Organizations" are hereby repealed on the

86-54

effective date of RI General Law 27-41-77.

86-55

     27-41-41. New cancer therapies -- Under investigation. -- Every individual or group

86-56

hospital or medical expense insurance policy or individual or group hospital or medical service

86-57

plan contract delivered, issued for delivery or renewed in this state shall provide coverage for new

86-58

cancer therapies still under investigation as outlined in this chapter.

86-59

     27-41-41.1. "Reliable evidence" defined. -- "Reliable evidence" means:

86-60

      (1) Evidence including published reports and articles in authoritative, peer reviewed

86-61

medical and scientific literature;

86-62

      (2) A written informed consent used by the treating facility or by another facility

86-63

studying substantially the same service; or

86-64

      (3) A written protocol or protocols used by the treating facility or protocols of another

86-65

facility studying substantially the same service.

86-66

     27-41-41.2. Conditions of coverage. -- As provided in section 27-41-41, coverage shall

86-67

be extended to new cancer therapies still under investigation when the following circumstances

86-68

are present:

87-1

      (1) Treatment is being provided pursuant to a phase II, III or IV clinical trial which has

87-2

been approved by the National Institutes of Health (NIH) in cooperation with the National Cancer

87-3

Institute (NCI), community clinical oncology programs; the food and drug administration in the

87-4

form of an investigational new drug (IND) exemption; the Department of Veterans' Affairs; or a

87-5

qualified nongovernmental research entity as identified in the guidelines for NCI cancer center

87-6

support grants;

87-7

      (2) The proposed therapy has been reviewed and approved by a qualified institutional

87-8

review board (IRB);

87-9

      (3) The facility and personnel providing the treatment are capable of doing so by virtue

87-10

of their experience, training, and volume of patients treated to maintain expertise;

87-11

      (4) The patients receiving the investigational treatment meet all protocol requirements;

87-12

      (5) There are no clearly superior, noninvestigational alternatives to the protocol

87-13

treatment;

87-14

      (6) The available clinical or preclinical data provide a reasonable expectation that the

87-15

protocol treatment will be at least as efficacious as the noninvestigational alternative; and

87-16

      (7) The coverage of new cancer therapy treatment provided pursuant to a phase II

87-17

clinical trial is not required for only the portion of that treatment that is provided as part of the

87-18

phase II clinical trial and is funded by a national agency, such as the National Cancer Institute,

87-19

the Veteran's Administration, the Department of Defense, or funded by commercial organizations

87-20

such as the biotechnical and/or pharmaceutical industry or manufacturers of medical devices. Any

87-21

portions of a phase II trial which are customarily funded by government, biotechnical and/or

87-22

pharmaceutical and/or medical device industry sources in Rhode Island or in other states shall

87-23

continue to be funded in Rhode Island and coverage pursuant to this section supplements, but

87-24

does not supplant, that customary funding.

87-25

     27-41-41.3. Managed care. -- Nothing in this chapter shall preclude the conducting of

87-26

managed care reviews and medical necessity reviews by an insurer, hospital or medical service

87-27

corporation, or health maintenance organization. A health maintenance organization may as a

87-28

condition of coverage require its members to obtain these new cancer therapies still under

87-29

investigation from providers and facilities designated by the health maintenance organization to

87-30

render these new cancer therapies.

87-31

     SECTION18. This act shall take effect upon passage.

     

=======

LC02084/SUB A/2

========

EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N A C T

RELATING TO INSURANCE -- HEALTH INSURANCE - CONSUMER PROTECTION

***

88-1

     This act would establish health insurance standards consistent with the health insurance

88-2

standards established in the Patient Protection and Affordable Care Act of 2010, as amended by

88-3

the Health Care and Education Reconciliation Act of 2010. These rules and standards would

88-4

include, but are not limited to, prohibitions on rescission of coverage, discrimination in coverage,

88-5

and prohibitions on annual and lifetime limits of coverage unless such limits meet set minimum

88-6

amounts, as well as adding definitions to the chapters covering health insurance. Specific

88-7

provisions of this act shall not be enforced by the commissioner of the RI Office of the Health

88-8

Insurance Commissioner in the event that corresponding sections of the Patient Protection and

88-9

Affordable Care Act are repealed or found invalid.

88-10

     This act would take effect upon passage.

     

=======

LC02084/SUB A/2

=======

H7909A