2012 -- S 2887 SUBSTITUTE A AS AMENDED

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LC02074/SUB A/4

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STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2012

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A N A C T

RELATING TO INSURANCE -- HEALTH INSURANCE - CONSUMER PROTECTION

     Introduced By: Senator Rhoda E. Perry

     Date Introduced: April 12, 2012

     Referred To: Senate Health & Human Services

It is enacted by the General Assembly as follows:

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     SECTION 1. Purpose and intent.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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coverage determination.

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

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

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federal regulations adopted thereunder.

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

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

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

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federal Affordable Care Act,

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

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coverage subject to 42 USC section 18011.

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

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health insurance coverage offered in connection with such plan.

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

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

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dependents directly or through insurance, reimbursement, or otherwise.

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

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

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

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

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

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

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

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

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settings.

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

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

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law.

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

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care facility.

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

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

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

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

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health plan.

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

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

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

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

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

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1974. The term also shall not include:

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

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thereof.

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

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

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insurance.

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     (iv) Workers’ compensation or similar insurance.

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     (v) Automobile medical payment insurance.

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     (vi) Credit-only insurance.

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     (vii) Coverage for on-site medical clinics.

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

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

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

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benefits.

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

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

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     (i) Limited scope dental or vision benefits.

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

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care, or any combination thereof.

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

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Pub. L. No. 104-191 (“HIPAA”).

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

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

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

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

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

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

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     (ii) Hospital indemnity or other fixed indemnity insurance.

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

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

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federal Social Security Act.

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

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

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

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

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section 42-14.5-1 of the General laws.

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

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

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coverage.

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

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

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

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

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

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

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commissioner under existing state law.

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

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

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

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

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

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

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

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

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

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

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

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under existing state law.

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

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

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

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

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imposing a preexisting condition exclusion on that individual.

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

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

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individual.

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     (b) As used in this section:

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

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

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

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

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recommended or received before the effective date of coverage.

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

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

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

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

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

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

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

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insurance coverage.

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

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

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

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

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

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

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

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

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unless:

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

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act, practice or omission that constitutes fraud; or

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

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by the terms of the plan or coverage.

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

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

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health carrier.

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

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

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

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

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

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group.

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

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

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contribution to costs of coverage.

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     (d) This section applies to grandfathered health plans.

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

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

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

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

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

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

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

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

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

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

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

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essential health benefits for any individual, except:

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

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

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

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

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this subsection.

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

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

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

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

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

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

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

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     (b) Lifetime limits.

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

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

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benefits for any individual.

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

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

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

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

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

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grandfathered health plans.

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

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

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

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individual health insurance coverage.

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

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

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

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

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

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

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policies.

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

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

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

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

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

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

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to regulate health insurance under existing state law.

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

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used in this section,

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

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

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

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

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

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     (i) The federal National Institutes of Health;

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

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

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

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

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

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

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

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

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

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

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Department of Health and Human Services determines:

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

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federal National Institutes of Health; and

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

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who have no interest in the outcome of the review.

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

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

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

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investigational new drug application.

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

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

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

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

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deductibles, directly or indirectly from the health carrier.

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

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conditions:

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

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

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and

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

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

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

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

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

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

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

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

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

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

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

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

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

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connection with participation in the approved clinical trial; and

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

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participation in the approved clinical trial.

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

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

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not enrolled in an approved clinical trial.

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

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include:

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

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

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

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

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of care for a particular diagnosis.

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

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

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

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

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

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

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outside this state.

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

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

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

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are otherwise provided under the coverage.

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

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coverage with respect to clinical trials.

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

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

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

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

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

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

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and (9) other limited benefit policies.

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

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

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

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

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

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adopted thereunder.

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

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

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Services shall concurrently file such information with the commissioner.

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

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

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

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

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

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

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

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part.

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

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

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

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

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such emergency medical condition, and

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

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

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

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

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

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

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

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emergency services in compliance with this section.

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

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following manner:

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

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

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

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is a participating network provider with respect to the services;

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

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

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

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

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

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

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     (A) The exclusion of or coordination of benefits;

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

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

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     (C) Applicable cost-sharing.

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     (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