H7909A

	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

	____________


	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:

1-1	SECTION 1. Purpose and intent.
1-2	It is the purpose of this act to amend Rhode Island statutes so as to be consistent with
1-3	health insurance consumer protections enacted in federal law. This act is intended to establish
1-4	health insurance rules, standards, and policies pursuant to, and in furtherance of, the health
1-5	insurance standards established in the federal Patient Protection and Affordable Care Act of 2010,
1-6	as amended by the federal Health Care and Education Reconciliation Act of 2010.
1-7	SECTION 2. Chapter 27-18 of the General laws entitled "Accident and Sickness
1-8	Insurance Policies" is hereby amended by adding thereto the following sections:
1-9	27-18-1.1. Definitions. – As used in this chapter:
1-10	(1) “Adverse benefit determination” means any of the following: a denial, reduction, or
1-11	termination of, or a failure to provide or make payment (in whole or in part) for, a benefit,
1-12	including any such denial, reduction, termination, or failure to provide or make payment that is
1-13	based on a determination of an individual’s eligibility to participate in a plan or to receive
1-14	coverage under a plan, and including, with respect to group health plans, a denial, reduction, or
1-15	termination of, or a failure to provide or make payment (in whole or in part) for, a benefit
1-16	resulting from the application of any utilization review, as well as a failure to cover an item or
1-17	service for which benefits are otherwise provided because it is determined to be experimental or
1-18	investigational or not medically necessary or appropriate. The term also includes a rescission of
1-19	coverage determination.
2-20	(2) “Affordable Care Act” means the federal Patient Protection and Affordable Care Act
2-21	of 2010, as amended by the federal Health Care and Education Reconciliation Act of 2010, and
2-22	federal regulations adopted thereunder.
2-23	(3) “Commissioner” or “health insurance commissioner” means that individual appointed
2-24	pursuant to section 42-14.5-1 of the general laws.
2-25	(4) “Essential health benefits” shall have the meaning set forth in section 1302(b) of the
2-26	federal Affordable Care Act,
2-27	(5) “Grandfathered health plan” means any group health plan or health insurance
2-28	coverage subject to 42 USC section 18011.
2-29	(6) “Group health insurance coverage” means, in connection with a group health plan,
2-30	health insurance coverage offered in connection with such plan.
2-31	(7) “Group health plan” means an employee welfare benefit plan, as defined in 29 USC
2-32	section 1002(1), to the extent that the plan provides health benefits to employees or their
2-33	dependents directly or through insurance, reimbursement, or otherwise.
2-34	(8) “Health benefits” or “covered benefits” means coverage or benefits for the diagnosis,
2-35	cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting
2-36	any structure or function of the body including coverage or benefits for transportation primarily
2-37	for and essential thereto, and including medical services as defined in R.I. Gen. Laws § 27-19-17;
2-38	(9) “Health care facility” means an institution providing health care services or a health
2-39	care setting, including, but not limited to, hospitals and other licensed inpatient centers,
2-40	ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers,
2-41	diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health
2-42	settings.
2-43	(10) “Health care professional” means a physician or other health care practitioner
2-44	licensed, accredited or certified to perform specified health care services consistent with state
2-45	law.
2-46	(11) “Health care provider” or "provider" means a health care professional or a health
2-47	care facility.
2-48	(12) “Health care services” means services for the diagnosis, prevention, treatment, cure
2-49	or relief of a health condition, illness, injury or disease.
2-50	(13) “Health insurance carrier” means a person, firm, corporation or other entity subject
2-51	to the jurisdiction of the commissioner under this chapter. Such term does not include a group
2-52	health plan.
2-53	(14) “Health plan” or “health benefit plan” means health insurance coverage and a group
2-54	health plan, including coverage provided through an association plan if it covers Rhode Island
3-1	residents. Except to the extent specifically provided by the federal Affordable Care Act, the term
3-2	“health plan” shall not include a group health plan to the extent state regulation of the health plan
3-3	is pre-empted under section 514 of the federal Employee Retirement Income Security Act of
3-4	1974. The term also shall not include:
3-5	(A)(i) Coverage only for accident, or disability income insurance, or any combination
3-6	thereof.
3-7	(ii) Coverage issued as a supplement to liability insurance.
3-8	(iii) Liability insurance, including general liability insurance and automobile liability
3-9	insurance.
3-10	(iv) Workers’ compensation or similar insurance.
3-11	(v) Automobile medical payment insurance.
3-12	(vi) Credit-only insurance.
3-13	(vii) Coverage for on-site medical clinics.
3-14	(viii) Other similar insurance coverage, specified in federal regulations issued pursuant to
3-15	Pub. L. No. 104-191, the federal health insurance portability and accountability act of 1996
3-16	(“HIPAA”), under which benefits for medical care are secondary or incidental to other insurance
3-17	benefits.
3-18	(B) The following benefits if they are provided under a separate policy, certificate or
3-19	contract of insurance or are otherwise not an integral part of the plan:
3-20	(i) Limited scope dental or vision benefits.
3-21	(ii) Benefits for long-term care, nursing home care, home health care, community-based
3-22	care, or any combination thereof.
3-23	(iii) Other excepted benefits specified in federal regulations issued pursuant to federal
3-24	Pub. L. No. 104-191 (“HIPAA”).
3-25	(C) The following benefits if the benefits are provided under a separate policy, certificate
3-26	or contract of insurance, there is no coordination between the provision of the benefits and any
3-27	exclusion of benefits under any group health plan maintained by the same plan sponsor, and the
3-28	benefits are paid with respect to an event without regard to whether benefits are provided with
3-29	respect to such an event under any group health plan maintained by the same plan sponsor:
3-30	(i) Coverage only for a specified disease or illness.
3-31	(ii) Hospital indemnity or other fixed indemnity insurance.
3-32	(D) The following if offered as a separate policy, certificate or contract of insurance:
3-33	(i) Medicare supplement health insurance as defined under section 1882(g)(1) of the
3-34	federal Social Security Act.
4-1	(ii) Coverage supplemental to the coverage provided under chapter 55 of title 10, United
4-2	States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)).
4-3	(iii) Similar supplemental coverage provided to coverage under a group health plan.
4-4	(15) "Office of the health insurance commissioner" means the agency established under
4-5	section 42-14.5-1 of the General laws.
4-6	(16) “Rescission" means a cancellation or discontinuance of coverage that has retroactive
4-7	effect for reasons unrelated to timely payment of required premiums or contribution to costs of
4-8	coverage.
4-9	27-18-2.1. Uniform explanation of benefits and coverage. – (a) A health insurance
4-10	carrier shall provide a summary of benefits and coverage explanation and definitions to
4-11	policyholders and others required by, and at the times and in the format required, by the federal
4-12	regulations adopted under section 2715 of the Public Health Service Act, as amended by the
4-13	federal Affordable Care Act. The forms required by this section shall be made available to the
4-14	commissioner on request. Nothing in this section shall be construed to limit the authority of the
4-15	commissioner under existing state law.
4-16	(b) The provisions of this section shall apply to grandfathered health plans. This section
4-17	shall not apply to insurance coverage providing benefits for: (1) hospital confinement indemnity;
4-18	(2) disability income; (3) accident only; (4) long term care; (5) Medicare supplement; (6) limited
4-19	benefit health; (7) specified disease indemnity; (8) sickness or bodily injury or death by accident
4-20	or both; and (9) other limited benefit policies.
4-21	(c) If the commissioner of the office of the health insurance commissioner determines
4-22	that the corresponding provision of the federal Patient Protection and Affordable Care Act has
4-23	been declared invalid by a final judgment of the federal judicial branch or has been repealed by
4-24	an act of Congress, on the date of the commissioner’s determination this section shall have its
4-25	effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this
4-26	section. Nothing in this section shall be construed to limit the authority of the commissioner
4-27	under existing state law.
4-28	27-18-71. Prohibition on preexisting condition exclusions. – (a) A health insurance
4-29	policy, subscriber contract, or health plan offered, issued, issued for delivery, or issued to cover a
4-30	resident of this state by a health insurance company licensed pursuant to this title and/or chapter:
4-31	(1) Shall not limit or exclude coverage for an individual under the age of nineteen (19) by
4-32	imposing a preexisting condition exclusion on that individual.
4-33	(2) For plan or policy years beginning on or after January 1, 2014, shall not limit or
4-34	exclude coverage for any individual by imposing a preexisting condition exclusion on that
5-1	individual.
5-2	(b) As used in this section:
5-3	(1) “Preexisting condition exclusion” means a limitation or exclusion of benefits,
5-4	including a denial of coverage, based on the fact that the condition (whether physical or mental)
5-5	was present before the effective date of coverage, or if the coverage is denied, the date of denial,
5-6	under a health benefit plan whether or not any medical advice, diagnosis, care or treatment was
5-7	recommended or received before the effective date of coverage.
5-8	(2) “Preexisting condition exclusion” means any limitation or exclusion of benefits,
5-9	including a denial of coverage, applicable to an individual as a result of information relating to an
5-10	individual’s health status before the individual’s effective date of coverage, or if the coverage is
5-11	denied, the date of denial, under the health benefit plan, such as a condition (whether physical or
5-12	mental) identified as a result of a pre-enrollment questionnaire or physical examination given to
5-13	the individual, or review of medical records relating to the pre-enrollment period.
5-14	(c) This section shall not apply to grandfathered health plans providing individual health
5-15	insurance coverage.
5-16	(d) This section shall not apply to insurance coverage providing benefits for: (1) Hospital
5-17	confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5)
5-18	Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or
5-19	bodily injury or death by accident or both; and (9) Other limited benefit policies.
5-20	27-18-72. Prohibition on rescission of coverage. – (a)(1) Coverage under a health
5-21	benefit plan subject to the jurisdiction of the commissioner under this chapter with respect to an
5-22	individual, including a group to which the individual belongs or family coverage in which the
5-23	individual is included, shall not be rescinded after the individual is covered under the plan,
5-24	unless:
5-25	(A) The individual or a person seeking coverage on behalf of the individual, performs an
5-26	act, practice or omission that constitutes fraud; or
5-27	(B) The individual makes an intentional misrepresentation of material fact, as prohibited
5-28	by the terms of the plan or coverage.
5-29	(2) For purposes of paragraph (a)(1)(A), a person seeking coverage on behalf of an
5-30	individual does not include an insurance producer or employee or authorized representative of the
5-31	health carrier.
5-32	(b) At least thirty (30) days advance written notice shall be provided to each health
5-33	benefit plan enrollee or, for individual health insurance coverage, primary subscriber, who would
5-34	be affected by the proposed rescission of coverage before coverage under the plan may be
6-1	rescinded in accordance with subsection (a) regardless of, in the case of group health insurance
6-2	coverage, whether the rescission applies to the entire group or only to an individual within the
6-3	group.
6-4	(c) For purposes of this section, “to rescind” means to cancel or to discontinue coverage
6-5	with retroactive effect for reasons unrelated to timely payment of required premiums or
6-6	contribution to costs of coverage.
6-7	(d) This section applies to grandfathered health plans.
6-8	27-18-73. Prohibition on annual and lifetime limits. – (a) Annual limits.
6-9	(1) For plan or policy years beginning prior to January 1, 2014, for any individual, a
6-10	health insurance carrier and a health benefit plan subject to the jurisdiction of the commissioner
6-11	under this chapter may establish an annual limit on the dollar amount of benefits that are essential
6-12	health benefits provided the restricted annual limit is not less than the following:
6-13	(A) For a plan or policy year beginning after September 22, 2011, but before September
6-14	23, 2012 – one million two hundred fifty thousand dollars ($1,250,000); and
6-15	(B) For a plan or policy year beginning after September 22, 2012, but before January 1,
6-16	2014 – two million dollars ($2,000,000).
6-17	(2) For plan or policy years beginning on or after January 1, 2014, a health insurance
6-18	carrier and a health benefit plan shall not establish any annual limit on the dollar amount of
6-19	essential health benefits for any individual, except:
6-20	(A) A health flexible spending arrangement, as defined in Section 106(c)(2)(i) of the
6-21	Federal Internal Revenue Code, a medical savings account, as defined in section 220 of the
6-22	federal Internal Revenue Code, and a health savings account, as defined in Section 223 of the
6-23	federal Internal Revenue Code are not subject to the requirements of subdivisions (1) and (2) of
6-24	this subsection.
6-25	(B) The provisions of this subsection shall not prevent a health insurance carrier and a
6-26	health benefit plan from placing annual dollar limits for any individual on specific covered
6-27	benefits that are not essential health benefits to the extent that such limits are otherwise permitted
6-28	under applicable federal law or the laws and regulations of this state.
6-29	(3) In determining whether an individual has received benefits that meet or exceed the
6-30	allowable limits, as provided in subdivision (1) of this subsection, a health insurance carrier and a
6-31	health benefit plan shall take into account only essential health benefits.
6-32	(b) Lifetime limits.
6-33	(1) A health insurance carrier and health benefit plan offering group or individual health
6-34	insurance coverage shall not establish a lifetime limit on the dollar value of essential health
7-1	benefits for any individual.
7-2	(2) Notwithstanding subdivision (1) above, a health insurance carrier and health benefit
7-3	plan is not prohibited from placing lifetime dollar limits for any individual on specific covered
7-4	benefits that are not essential health benefits, in accordance with federal laws and regulations.
7-5	(c)(1) The provisions of this section relating to lifetime limits apply to any health
7-6	insurance carrier providing coverage under an individual or group health plan, including
7-7	grandfathered health plans.
7-8	(2) The provisions of this section relating to annual limits apply to any health insurance
7-9	carrier providing coverage under a group health plan, including grandfathered health plans, but
7-10	the prohibition and limits on annual limits do not apply to grandfathered health plans providing
7-11	individual health insurance coverage.
7-12	(d) This section shall not apply to a plan or to policy years prior to January 1, 2014 for
7-13	which the Secretary of the U.S. Department of Health and Human Services issued a waiver
7-14	pursuant to 45 C.F.R. § 147.126(d)(3). This section also shall not apply to insurance coverage
7-15	providing benefits for: (1) hospital confinement indemnity; (2) disability income; (3) accident
7-16	only; (4) long term care; (5) Medicare supplement; (6) limited benefit health; (7) specified disease
7-17	indemnity; (8) sickness or bodily injury or death by accident or both; and (9) other limited benefit
7-18	policies.
7-19	(e) If the commissioner of the office of the health insurance commissioner determines
7-20	that the corresponding provision of the federal Patient Protection and Affordable Care Act has
7-21	been declared invalid by a final judgment of the federal judicial branch or has been repealed by
7-22	an act of Congress, on the date of the commissioner’s determination this section shall have its
7-23	effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this
7-24	section. Nothing in this subsection shall be construed to limit the authority of the Commissioner
7-25	to regulate health insurance under existing state law.
7-26	27-18-74. Coverage for individuals participating in approved clinical trials. – (a) As
7-27	used in this section,
7-28	(1) “Approved clinical trial” means a phase I, phase II, phase III or phase IV clinical trial
7-29	that is conducted in relation to the prevention, detection or treatment of cancer or a life-
7-30	threatening disease or condition and is described in any of the following:
7-31	(A) The study or investigation is approved or funded, which may include funding through
7-32	in-kind contributions, by one or more of the following:
7-33	(i) The federal National Institutes of Health;
8-34	(ii) The federal Centers for Disease Control and Prevention;
8-35	(iii) The federal Agency for Health Care Research and Quality;
8-36	(iv) The federal Centers for Medicare & Medicaid Services;
8-37	(v) A cooperative group or center of any of the entities described in items (i) through (iv)
8-38	or the U.S. Department of Defense or the U.S. Department of Veteran Affairs;
8-39	(vi) A qualified non-governmental research entity identified in the guidelines issued by
8-40	the federal National Institutes of Health for center support grants; or
8-41	(vii) A study or investigation conducted by the U.S. Department of Veteran Affairs, the
8-42	U.S. Department of Defense, or the U.S. Department of Energy, if the study or investigation has
8-43	been reviewed and approved through a system of peer review that the Secretary of U.S.
8-44	Department of Health and Human Services determines:
8-45	(I) Is comparable to the system of peer review of studies and investigations used by the
8-46	federal National Institutes of Health; and
8-47	(II) Assures unbiased review of the highest scientific standards by qualified individuals
8-48	who have no interest in the outcome of the review.
8-49	(B) The study or investigation is conducted under an investigational new drug application
8-50	reviewed by the U.S. Food and Drug Administration; or
8-51	(C) The study or investigation is a drug trial that is exempt from having such an
8-52	investigational new drug application.
8-53	(2) “Participant” has the meaning stated in section 3(7) of federal ERISA.
8-54	(3) “Participating provider” means a health care provider that, under a contract with the
8-55	health carrier or with its contractor or subcontractor, has agreed to provide health care services to
8-56	covered persons with an expectation of receiving payment, other than coinsurance, copayments or
8-57	deductibles, directly or indirectly from the health carrier.
8-58	(4) “Qualified individual” means a participant or beneficiary who meets the following
8-59	conditions:
8-60	(A) The individual is eligible to participate in an approved clinical trial according to the
8-61	trial protocol with respect to the treatment of cancer or other life-threatening disease or condition;
8-62	and
8-63	(B)(i) The referring health care professional is a participating provider and has concluded
8-64	that the individual’s participation in such trial would be appropriate based on the individual
8-65	meeting the conditions described in subdivision (A) of this subdivision (3); or
8-66	(ii) The participant or beneficiary provides medical and scientific information
8-67	establishing the individual’s participation in such trial would be appropriate based on the
8-68	individual meeting the conditions described in subdivision (A) of this subdivision (3).
9-1	(5) “Life-threatening condition” means any disease or condition from which the
9-2	likelihood of death is probable unless the course of the disease or condition is interrupted.
9-3	(b)(1) If a health insurance carrier offering group or individual health insurance coverage
9-4	provides coverage to a qualified individual, the health insurance carrier:
9-5	(A) Shall not deny the individual participation in an approved clinical trial.
9-6	(B) Subject to subdivision (3) of this subsection, shall not deny or limit or impose
9-7	additional conditions on the coverage of routine patient costs for items and services furnished in
9-8	connection with participation in the approved clinical trial; and
9-9	(C) Shall not discriminate against the individual on the basis of the individual’s
9-10	participation in the approved clinical trial.
9-11	(2)(A) Subject to subdivision (B) of this subdivision (2), routine patient costs include all
9-12	items and services consistent with the coverage typically covered for a qualified individual who is
9-13	not enrolled in an approved clinical trial.
9-14	(B) For purposes of subdivision (B) of this subdivision (2), routine patient costs do not
9-15	include:
9-16	(i) The investigational item, device or service itself;
9-17	(ii) Items and services that are provided solely to satisfy data collection and analysis
9-18	needs and that are not used in the direct clinical management of the patient; or
9-19	(iii) A service that is clearly inconsistent with widely accepted and established standards
9-20	of care for a particular diagnosis.
9-21	(3) If one or more participating providers are participating in a clinical trial, nothing in
9-22	subdivision (1) of this subsection shall be construed as preventing a health carrier from requiring
9-23	that a qualified individual participate in the trial through such a participating provider if the
9-24	provider will accept the individual as a participant in the trial.
9-25	(4) Notwithstanding subdivision (3) of this subsection, subdivision (1) of this subsection
9-26	shall apply to a qualified individual participating in an approved clinical trial that is conducted
9-27	outside this state.
9-28	(5) This section shall not be construed to require a health insurance carrier offering group
9-29	or individual health insurance coverage to provide benefits for routine patient care services
9-30	provided outside of the coverage’s health care provider network unless out-of-network benefits
9-31	are otherwise provided under the coverage.
9-32	(6) Nothing in this section shall be construed to limit a health insurance carrier’s
9-33	coverage with respect to clinical trials.
10-34	(c) The requirements of this section shall be in addition to the requirements of Rhode
10-35	Island general laws sections 27-18-36 through 27-18-36.3.
10-36	(d) This section shall not apply to grandfathered health plans. This section shall not apply
10-37	to insurance coverage providing benefits for: (1) hospital confinement indemnity; (2) disability
10-38	income; (3) accident only; (4) long term care; (5) Medicare supplement; (6) limited benefit
10-39	health; (7) specified disease indemnity; (8) sickness or bodily injury or death by accident or both;
10-40	and (9) other limited benefit policies.
10-41	(e) This section shall be effective for plan years beginning on or after January 1, 2014.
10-42	27-18-75. Medical loss ratio reporting and rebates. – (a) A health insurance carrier
10-43	offering group or individual health insurance coverage of a health benefit plan, including a
10-44	grandfathered health plan, shall comply with the provisions of Section 2718 of the Public Health
10-45	Services Act as amended by the federal Affordable Care Act, in accordance with regulations
10-46	adopted thereunder.
10-47	(b) Health insurance carriers required to report medical loss ratio and rebate calculations
10-48	and other medical loss ratio and rebate information to the U.S. Department of Health and Human
10-49	Services shall concurrently file such information with the commissioner.
10-50	27-18-76. Emergency services. – (a) As used in this section:
10-51	(1) “Emergency medical condition” means a medical condition manifesting itself by
10-52	acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who
10-53	possesses an average knowledge of health and medicine, could reasonably expect the absence of
10-54	immediate medical attention to result in a condition: (i) Placing the health of the individual, or
10-55	with respect to a pregnant woman her unborn child, in serious jeopardy; (ii) Constituting a serious
10-56	impairment to bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or
10-57	part.
10-58	(2) “Emergency services” means, with respect to an emergency medical condition:
10-59	(A) A medical screening examination (as required under section 1867 of the Social
10-60	Security Act, 42 U.S.C. 1395dd) that is within the capability of the emergency department of a
10-61	hospital, including ancillary services routinely available to the emergency department to evaluate
10-62	such emergency medical condition, and
10-63	(B) Such further medical examination and treatment, to the extent they are within the
10-64	capabilities of the staff and facilities available at the hospital, as are required under section 1867
10-65	of the Social Security Act (42 U.S.C. 1395dd) to stabilize the patient.
10-66	(3) “Stabilize”, with respect to an emergency medical condition has the meaning given in
10-67	section 1867(e)(3) of the Social Security Act (42 U.S.C. 1395dd(e)(3)).
11-68	(b) If a health insurance carrier offering health insurance coverage provides any benefits
11-69	with respect to services in an emergency department of a hospital, the carrier must cover
11-70	emergency services in compliance with this section.
11-71	(c) A health insurance carrier shall provide coverage for emergency services in the
11-72	following manner:
11-73	(1) Without the need for any prior authorization determination, even if the emergency
11-74	services are provided on an out-of-network basis;
11-75	(2) Without regard to whether the health care provider furnishing the emergency services
11-76	is a participating network provider with respect to the services;
11-77	(3) If the emergency services are provided out of network, without imposing any
11-78	administrative requirement or limitation on coverage that is more restrictive than the requirements
11-79	or limitations that apply to emergency services received from in-network providers;
11-80	(4) If the emergency services are provided out of network, by complying with the cost-
11-81	sharing requirements of subsection (d) of this section; and
11-82	(5) Without regard to any other term or condition of the coverage, other than:
11-83	(A) The exclusion of or coordination of benefits;
11-84	(B) An affiliation or waiting period permitted under part 7 of federal ERISA, part A of
11-85	title XXVII of the federal PHS Act, or chapter 100 of the federal Internal Revenue Code; or
11-86	(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.

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	LC02084/SUB A/2
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	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.

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	LC02084/SUB A/2
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H7909A