2014 -- H 7970

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LC005222

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2014

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A N   A C T

RELATING TO HEALTH AND SAFETY -- RHODE ISLAND BEHAVIORAL HEALTH

CARE REFORM ACT OF 2014

     Introduced By: Representatives Ferri, Naughton, McNamara, Bennett, and Cimini

     Date Introduced: March 20, 2014

     Referred To: House Corporations

     It is enacted by the General Assembly as follows:

     SECTION 1. Title 42 of the General Laws entitled "STATE AFFAIRS AND

GOVERNMENT" is hereby amended by adding thereto the following chapter:

CHAPTER 14.7

     RHODE ISLAND BEHAVIORAL HEALTH CARE REFORM ACT OF 2014

     42-14.7-1. Short title. -- This act shall be known and may be cited as the "Rhode Island

Behavioral Health Care Reform Act of 2014."

     42-14.7-2. Legislative findings. -- The general assembly finds and declares that:

     (1) Mental health and substance abuse problems affect one out of every four (4) Rhode

Islanders every year.

     (2) Health-related behaviors such as diet, exercise, tobacco use, and compliance with

medical treatment affect even more Rhode Islanders every year.

     (3) The resulting costs, both financial and in impairment, loss of productivity and

suffering, cause a significant burden on the state and its citizens.

     (4) Health care reform efforts can only succeed if a comprehensive approach is taken that

includes the role of behavior and behavioral health in health and health care.

     (5) Despite its significant potential impact on health care cost and effectiveness, spending

on behavioral health is a small percentage of all health care spending and is thus often neglected

in health care reform, improvement, or cost-containment efforts.

     (6) As is true for citizens of all states, half of Rhode Islanders with mental health,

substance abuse, or health-related behavioral problems receive no treatment at all, and of those

who do receive treatment, a large majority receives treatment that does not meet national

guidelines for effectiveness, resulting in significant avoidable personal suffering and waste of

health care funds.

     (7) "Stigma", as defined by the United States Surgeon General, includes a lack of

understanding and a lack of proportional attention to behavioral health, which impedes effective

management of behavioral health and other health care resources to address health-related

behaviors and behavioral health cost-effectively.

     (8) Tragedies such as the shootings in Newtown, Connecticut, have heightened attention

to the need for better regulation, management and delivery of behavioral health services.

     (9) Therefore, it is in the best interest of the state to ensure the most appropriate use of

health care resources to more effectively manage behavioral health services to protect the welfare

of its citizens.

     42-14.7-3. Purpose. -- The purpose of the behavioral health care reform act of 2014 is to

ensure appropriate use of health care resources to manage the contribution of behavioral health

and behavioral health services to the affordability and effectiveness of health care.

     42-14.7-4. Definitions. -- For the purposes of this chapter, the following terms shall have

the following meanings:

     (1) "Behavioral health" means mental health, substance abuse, and health-related

behavior.

     (2) "Health-related behavior" means behavior that creates risks for diseases, illnesses, or

conditions or that can be modified to reduce health risks, such as diet, exercise, tobacco use, and

compliance with medical treatment.

     (3) "Behavioral health provider" means mental health counselor, marriage and family

therapist, social worker, psychologist, advanced practice psychiatric nurse, and/or psychiatrist

licensed by the department of health under relevant law and regulation.

     (4) "Behavioral health services" means treatment and services offered by a behavioral

health provider for the purpose of affecting behavioral health.

     (5) "Services to treat health-related behaviors" means medically necessary treatment

offered by a behavioral health provider for the purpose of improving or preventing a specific,

diagnosable medical condition.

     (6) "Behavioral health functioning" means and is intended to refer to mental health

conditions, substance abuse disorders, and health-related behaviors and is not intended to expand

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the scope of covered services or benefits beyond those required in the federal parity law, also

known as the Mental Health Parity and Addiction Equity Act of 2008, Pub. L. 110-343.

     (7) Where behavioral health providers or behavioral health services are to be regulated

with reference to equivalent provisions addressing primary care providers or primary care

services, it is understood that behavioral health providers are not to be considered as primary care

providers themselves but as independent professional members of the primary care team, whether

practicing on-site or in coordination with primary care practices, in recognition of the fact that

behavioral health services are critical for achieving the best possible cost-effectiveness of primary

care services.

     SECTION 2. Sections 23-1-1, 23-1-2, 23-1-36, 23-1-43 and 23-1-44 of the General Laws

in Chapter 23-1 entitled "Department of Health" are hereby amended to read as follows:

     23-1-1. General functions of department. -- The department of health shall take

cognizance of the interests of life and health among the peoples of the state; shall make

investigations into the causes of disease, the prevalence of epidemics and endemics among the

people, the sources of mortality, the effect of localities, employments, and individual behaviors,

and all other conditions and circumstances on the public health, and do all in its power to

ascertain the causes and the best means for the prevention and control of diseases or conditions

detrimental to the public health, and adopt proper and expedient measures to prevent and control

diseases and conditions detrimental to the public health in the state. It shall publish and circulate,

from time to time, information that the director may deem to be important and useful for diffusion

among the people of the state, and shall investigate and give advice in relation to those subjects

relating to public health that may be referred to it by the general assembly or by the governor

when the general assembly is not in session, or when requested by any city or town. The

department shall adopt and promulgate rules and regulations that it deems necessary, not

inconsistent with law, to carry out the purposes of this section; provided, however, that the

department shall not require all nonprofit volunteer ambulance, rescue service, and volunteer fire

departments to have two (2) or more certified emergency medical technicians manning

ambulances or rescue vehicles.

     23-1-2. Inquiries to local authorities and physicians. -- The director of health shall

make inquiry, from time to time, of the city and town clerks and practicing physicians and

behavioral health providers, in relation to the prevalence of any disease, or knowledge of any

known or generally believed source of disease or causes of general ill health, and also in relation

to acts for the promotion and protection of the public health, and also in relation to diseases

among domestic animals in their several cities and towns; and those city and town clerks and

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practicing physicians shall give information, in reply to the inquiries, of those facts and

circumstances that have come to their knowledge.

     23-1-36. Director's duties regarding health education, alcohol, and substance abuse

programs Director's duties regarding health education, mental health, alcohol, and

substance abuse programs. -- The director shall establish health education, mental health,

alcohol, and substance abuse programs for students in grades kindergarten through twelve (12), in

accordance with section 35-4-18. The director shall make an annual report to the governor and the

general assembly on the administration of the program.

     23-1-43. Minority population health promotion. -- The director of health shall

establish a minority population health promotion program to provide health information,

education, health-related behavior change and risk reduction activities to reduce the risk of

premature death from preventable disease in minority populations.

     23-1-44. Routine childhood and adult immunization vaccines Routine childhood and

adult immunization vaccines and behavioral health prevention services. -- (a) The

department of health shall include in the department's immunization program those vaccines for

routine childhood immunization as recommended by the Advisory Committee for Immunization

Practices (ACIP) and the Academy of Pediatrics (AAP), and for adult influenza immunization as

recommended by the ACIP, to the extent permitted by available funds. The childhood

immunization program includes administrative and quality assurance services and KIDSNET, a

confidential, computerized child health information system that is used to manage statewide

immunizations, as well as other public health preventive services, for all children in Rhode Island

from birth through age 18. The department of health shall include in the department's behavioral

health prevention program those behavioral health screening or prevention services meeting the

United States Centers for Medicaid and Medicare Services definition of preventive services in the

Patient Protection and Affordable Care Act, Pub. L. 111-148, as amended by the Federal Health

Care and Education Reconciliation Act of 2010, Pub. L. 111-152, as both may be amended from

time to time, and regulations adopted thereunder.

      (b) The director of the department of health shall appoint an advisory committee that will

be convened after the ACIP or the United States Preventive Services Task Force (USPSTF)

makes a recommendation regarding adult immunization or adult behavioral health screening or

prevention. The committee will review the ACIP or USPSTF recommendations for the state,

assess the vaccine or service cost and feasibility, and advise the director of health and the office

of the health insurance commissioner regarding insurers and providers acting on the ACIP or

USPSTF adult immunization, behavioral health screening or prevention services

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recommendation. All recommendations will be posted on the department of health website. The

advisory committee membership shall include, but not be limited to, a primary care provider,

pharmacist, representatives of the nursing home industry, the home health care industry, a

licensed psychologist, a licensed social worker, a licensed mental health counselor, a licensed

marriage and family therapist, a licensed nurse or advanced practice nurse, a patient advocate, a

member of the general public and major insurers.

     SECTION 3. Chapter 23-13 of the General Laws entitled "Maternal and Child Health

Services for Children with Special Health Care Needs" is hereby amended by adding thereto the

following section:

     23-13-27. Routine childhood behavioral health screening. -- (a) The physician

attending any patient younger than twenty-one (21) years of age shall cause that child to be

subject to health screening services for psychiatric disorders, psychological, interpersonal, and

any other conditions for which there is a medical benefit to the early detection and treatment of

the disorder or condition, and an assessment for developmental risk. The department of health

shall promulgate regulations pertaining to behavioral health screenings, diagnostic and treatment

services as accepted medical practice shall indicate. The provisions of this section shall not apply

if the parents of the child up to the age of eighteen (18) years of age or the young adult between

the ages of eighteen (18) and twenty-one (21) years of age objects to the screening on the grounds

that those tests conflict with his or her religious tenets and practices.

     (b) In addition, the department of health is authorized to establish by regulation a

reasonable fee structure for the behavioral health screening and disease control program services,

which includes, but is not limited to, screening, diagnostic, and treatment services. The program

services shall be a covered benefit and be reimbursable by all health insurers, as defined in § 27-

38.2-2(1), providing health insurance coverage in Rhode Island except for supplemental policies

which only provide coverage for specific diseases, hospital indemnity, Medicare supplements, or

other supplemental policies. The department of human services shall pay for the program services

where the patient is eligible for medical assistance under the provisions of chapter 8 of title 40.

     SECTION 4. Sections 23-14.1-1 and 23-14.1-2 of the General Laws in Chapter 23-14.1

entitled "Health Professional Loan Repayment Program" are hereby amended to read as follows:

     23-14.1-1. Legislative findings. -- The general assembly finds that:

      (1) It is the right of every citizen of the state to have ready access to quality health care;

and

      (2) Health care facilities serving the poor, including community health centers

throughout the state, are experiencing increasing difficulty in attracting and retaining physicians

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and other health professionals to administer to the needy populations they serve. Therefore, it is

the general assembly's intent to provide incentives, in the form of loan repayment, to physicians,

dentists, dental hygienists, nurse practitioners, certified nurse midwives, physician assistants,

behavioral health providers, and any other eligible health care professional under section 338A of

the Public Health Service Act, 42 U.S.C. section 254l, who desire to serve the health care needs

of medically underserved individuals in Rhode Island.

     23-14.1-2. Definitions. -- For the purpose of this chapter, the following words and terms

have the following meanings unless the context clearly requires otherwise:

      (1) "Authority" means the higher education assistance authority.

      (2) "Board" means the health professional loan repayment board.

      (3) "Community health center" means a health care facility as defined and licensed under

chapter 17 of this title.

      (4) "Director" means the director of the higher education assistance authority.

      (5) "Eligible health professional" means a physician, dentist, dental hygienist, nurse

practitioner, certified nurse midwife, physician assistant, behavioral health providers, or any other

eligible health care professional under section 338A of the Public Health Service Act, 42 U.S.C.

section 254l, licensed in the state who has entered into a contract with the board to serve

medically underserved populations.

      (6) "Loan repayment" means an amount of money to be repaid to satisfy loan obligations

incurred to obtain a degree or certification in an eligible health profession as defined in

subdivision (5).

     SECTION 5. Section 23-17.12-9 of the General Laws in Chapter 23-17.12 entitled

"Health Care Services - Utilization Review Act" is hereby amended to read as follows:

     23-17.12-9. Review agency requirement for adverse determination and internal

appeals. -- (a) The adverse determination and appeals process of the review agent shall conform

to the following:

      (1) Notification of a prospective adverse determination by the review agent shall be

mailed or otherwise communicated to the provider of record and to the patient or other

appropriate individual as follows:

      (i) Within fifteen (15) business days of receipt of all the information necessary to

complete a review of non-urgent and/or non-emergent services;

      (ii) Within seventy-two (72) hours of receipt of all the information necessary to complete

a review of urgent and/or emergent services; and

      (iii) Prior to the expected date of service.

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      (2) Notification of a concurrent adverse determination shall be mailed or otherwise

communicated to the patient and to the provider of record period as follows:

      (i) To the provider(s) prior to the end of the current certified period; and

      (ii) To the patient within one business day of making the adverse determination.

      (3) Notification of a retrospective adverse determination shall be mailed or otherwise

communicated to the patient and to the provider of record within thirty (30) business days of

receipt of a request for payment with all supporting documentation for the covered benefit being

reviewed.

      (4) A utilization review agency shall not retrospectively deny authorization for health

care services provided to a covered person when an authorization has been obtained for that

service from the review agent unless the approval was based upon inaccurate information

material to the review or the health care services were not provided consistent with the provider's

submitted plan of care and/or any restrictions included in the prior approval granted by the review

agent.

      (5) Any notice of an adverse determination shall include:

      (i) The principal reasons for the adverse determination, to include explicit documentation

of the criteria not met and/or the clinical rationale utilized by the agency's clinical reviewer in

making the adverse determination. The criteria shall be in accordance with the agency criteria

noted in subsection 23-17.12-9(d) and shall be made available within the first level appeal

timeframe if requested unless otherwise provided as part of the adverse determination notification

process;

      (ii) The procedures to initiate an appeal of the adverse determination, including the name

and telephone number of the person to contract with regard to an appeal;

      (iii) The necessary contact information to complete the two-way direct communication

defined in subdivision 23-17.12-9(a)(7); and

      (iv) The information noted in subdivision 23-27.12-9(a)(5)(i)(ii)(iii) for all verbal

notifications followed by written notification to the patient and provider(s).

      (6) All initial retrospective adverse determinations of a health care service that had been

ordered by a physician, dentist or other practitioner shall be made, documented and signed

consistent with the regulatory requirements which shall be developed by the department with the

input of review agents, providers and other affected parties.

      (7) A level one appeal decision of an adverse determination shall not be made until an

appropriately qualified and licensed review physician, dentist or other practitioner has spoken to,

or otherwise provided for, an equivalent two-way direct communication with the patient's

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attending physician, dentist, other practitioner, other designated or qualified professional or

provider responsible for treatment of the patient concerning the medical care, with the exception

of the following:

      (i) When the attending provider is not reasonably available;

      (ii) When the attending provider chooses not to speak with agency staff;

      (iii) When the attending provider has negotiated an agreement with the review agent for

alternative care; and/or

      (iv) When the attending provider requests a peer to peer communication prior to the

adverse determination, the review agency shall then comply with subdivision 23-17.12-9(c)(1) in

responding to such a request. Such requests shall be on the case specific basis unless otherwise

arranged for in advance by the provider.

      (8) All initial, prospective and concurrent adverse determinations of a health care service

that had been ordered by a physician, dentist or other practitioner shall be made, documented and

signed by a licensed practitioner with the same licensure status as the ordering practitioner or a

licensed physician or dentist. This does not prohibit appropriately qualified review agency staff

from engaging in discussions with the attending provider, the attending provider's designee or

appropriate health care facility and office personnel regarding alternative service and treatment

options. Such a discussion shall not constitute an adverse determination provided though that any

change to the provider's original order and/or any decision for an alternative level of care must be

made and/or appropriately consented to by the attending provider or the provider's designee

responsible for treating the patient.

      (9) The requirement that, upon written request made by or on behalf of a patient, any

adverse determination and/or appeal shall include the written evaluation and findings of the

reviewing physician, dentist or other practitioner. The review agent is required to accept a verbal

request made by or on behalf of a patient for any information where a provider or patient can

demonstrate that a timely response is urgent.

      (b) The review agent shall conform to the following for the appeal of an adverse

determination:

      (1) The review agent shall maintain and make available a written description of the

appeal procedure by which either the patient or the provider of record may seek review of

determinations not to authorize a health care service. The process established by each review

agent may include a reasonable period within which an appeal must be filed to be considered and

that period shall not be less than sixty (60) days.

      (2) The review agent shall notify, in writing, the patient and provider of record of its

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decision on the appeal as soon as practical, but in no case later than fifteen (15) or twenty-one

(21) business days if verbal notice is given within fifteen (15) business days after receiving the

required documentation on the appeal.

      (3) The review agent shall also provide for an expedited appeals process for emergency

or life threatening situations. Each review agent shall complete the adjudication of expedited

appeals within two (2) business days of the date the appeal is filed and all information necessary

to complete the appeal is received by the review agent.

      (4) All first level appeals of determinations not to authorize a health care service that had

been ordered by a physician, dentist, or other practitioner shall be made, documented, and signed

by a licensed practitioner with the same licensure status as the ordering practitioner or a licensed

physician or a licensed dentist.

      (5) All second level appeal decisions shall be made, signed, and documented by a

licensed practitioner in the same or a similar general specialty as typically manages the medical

condition, procedure, or treatment under discussion.

      (6) The review agent shall maintain records of written appeals and their resolution, and

shall provide reports as requested by the department.

      (c) The review agency must conform to the following requirements when making its

adverse determination and appeal decisions:

      (1) The review agent must assure that the licensed practitioner or licensed physician is

reasonably available to review the case as required under subdivision 23-17.12-9(a)(7) and shall

conform to the following:

      (i) Each agency peer reviewer shall have access to and review all necessary information

as requested by the agency and/or submitted by the provider(s) and/or patients;

      (ii) Each agency shall provide accurate peer review contact information to the provider at

the time of service, if requested, and/or prior to such service, if requested. This contact

information must provide a mechanism for direct communication with the agency's peer

reviewer;

      (iii) Agency peer reviewers shall respond to the provider's request for a two-way direct

communication defined in subdivision 23-17.12-9(a)(7)(iv) as follows:

      (A) For a prospective review of non-urgent and non-emergent health care services, a

response within one business day of the request for a peer discussion;

      (B) For concurrent and prospective reviews of urgent and emergent health care services,

a response within a reasonable period of time of the request for a peer discussion; and

      (C) For retrospective reviews, prior to the first level appeal decision.

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      (iv) The review agency will have met the requirements of a two-way direct

communication, when requested and/or as required prior to the first level of appeal, when it has

made two (2) reasonable attempts to contact the attending provider directly.

      (v) Repeated violations of this section shall be deemed to be substantial violations

pursuant to section 23-17.12-14 and shall be cause for the imposition of penalties under that

section.

      (2) No reviewer at any level under this section shall be compensated or paid a bonus or

incentive based on making or upholding an adverse determination.

      (3) No reviewer under this section who has been involved in prior reviews of the case

under appeal or who has participated in the direct care of the patient may participate as the sole

reviewer in reviewing a case under appeal; provided, however, that when new information has

been made available at the first level of appeal, then the review may be conducted by the same

reviewer who made the initial adverse determination.

      (4) A review agent is only entitled to review information or data relevant to the

utilization review process. A review agent may not disclose or publish individual medical records

or any confidential medical information obtained in the performance of utilization review

activities. A review agent shall be considered a third party health insurer for the purposes of

section 5-37.3-6(b)(6) of this state and shall be required to maintain the security procedures

mandated in section 5-37.3-4(c).

      (5) Notwithstanding any other provision of law, the review agent, the department, and all

other parties privy to information which is the subject of this chapter shall comply with all state

and federal confidentiality laws, including, but not limited to, chapter 37.3 of title 5

(Confidentiality of Health Care Communications and Information Act) and specifically section 5-

37.3-4(c), which requires limitation on the distribution of information which is the subject of this

chapter on a "need to know" basis, and section 40.1-5-26.

      (6) The department may, in response to a complaint that is provided in written form to

the review agent, review an appeal regarding any adverse determination, and may request

information of the review agent, provider or patient regarding the status, outcome or rationale

regarding the decision.

      (d) The requirement that each review agent shall utilize and provide upon request, by

Rhode Island licensed hospitals and the Rhode Island Medical Society, the Rhode Island

Psychiatric Society, the Rhode Island Psychological Association, and the National Association of

Social Workers, Rhode Island chapter, in either electronic or paper format, written medically

acceptable screening criteria and review procedures which are established and periodically

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evaluated and updated with appropriate consultation with Rhode Island licensed physicians,

hospitals, including practicing physicians, and other health care providers in the same specialty as

would typically treat the services subject to the criteria as follows:

      (1) Utilization review agents shall consult with no fewer than five (5) Rhode Island

licensed physicians or other health care providers. Further, in instances where the screening

criteria and review procedures are applicable to inpatients and/or outpatients of hospitals, the

medical director of each licensed hospital in Rhode Island shall also be consulted. Utilization

review agents who utilize screening criteria and review procedures provided by another entity

may satisfy the requirements of this section if the utilization review agent demonstrates to the

satisfaction of the director that the entity furnishing the screening criteria and review procedures

has complied with the requirements of this section.

      (2) Utilization review agents seeking initial certification shall conduct the consultation

for all screening and review criteria to be utilized. Utilization review agents who have been

certified for one year or longer shall be required to conduct the consultation on a periodic basis

for the utilization review agent's highest volume services subject to utilization review during the

prior year; services subject to the highest volume of adverse determinations during the prior year;

and for any additional services identified by the director.

      (3) Utilization review agents shall not include in the consultations as required under

paragraph (1) of this subdivision, any physicians or other health services providers who have

financial relationships with the utilization review agent other than financial relationships for

provisions of direct patient care to utilization review agent enrollees and reasonable compensation

for consultation as required by paragraph (1) of this subdivision.

      (4) All documentation regarding required consultations, including comments and/or

recommendations provided by the health care providers involved in the review of the screening

criteria, as well as the utilization review agent's action plan or comments on any

recommendations, shall be in writing and shall be furnished to the department on request. The

documentation shall also be provided on request to any licensed health care provider at a nominal

cost that is sufficient to cover the utilization review agent's reasonable costs of copying and

mailing.

      (5) Utilization review agents may utilize non-Rhode Island licensed physicians or other

health care providers to provide the consultation as required under paragraph (1) of this

subdivision, when the utilization review agent can demonstrate to the satisfaction of the director

that the related services are not currently provided in Rhode Island or that another substantial

reason requires such approach.

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      (6) Utilization review agents whose annualized data reported to the department

demonstrate that the utilization review agent will review fewer than five hundred (500) such

requests for authorization may request a variance from the requirements of this section.

     (7) Medically acceptable screening criteria and review procedures for behavioral health

services by behavioral health providers shall be certified by the director of the department of

health as materially equivalent to criteria and procedures applied to primary care services and

providers as identified by the director.

     SECTION 6. Section 23-17.13-3 of the General Laws in Chapter 23-17.13 entitled

"Health Care Accessibility and Quality Assurance Act" is hereby amended to read as follows:

     23-17.13-3. Certification of health plans. -- (a) Certification process.

      (1) Certification.

      (i) The director shall establish a process for certification of health plans meeting the

requirements of certification in subsection (b).

      (ii) The director shall act upon the health plan's completed application for certification

within ninety (90) days of receipt of such application for certification.

      (2) Review and recertification. - To ensure compliance with subsection (b), the director

shall establish procedures for the periodic review and recertification of qualified health plans not

less than every five (5) years; provided, however, that the director may review the certification of

a qualified health plan at any time if there exists evidence that a qualified health plan may be in

violation of subsection (b).

      (3) Cost of certification. - The total cost of obtaining and maintaining certification under

this title and compliance with the requirements of the applicable rules and regulations are borne

by the entities so certified and shall be one hundred and fifty percent (150%) of the total salaries

paid to the certifying personnel of the department engaged in those certifications less any salary

reimbursements and shall be paid to the director to and for the use of the department. That

assessment shall be in addition to any taxes and fees otherwise payable to the state.

      (4) Standard definitions. - To help ensure a patient's ability to make informed decisions

regarding their health care, the director shall promulgate regulation(s) to provide for standardized

definitions (unless defined in existing statute) of the following terms in this subdivision,

provided, however, that no definition shall be construed to require a health care entity to add any

benefit, to increase the scope of any benefit, or to increase any benefit under any contract:

      (i) Allowable charge;

      (ii) Capitation;

      (iii) Co-payments;

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      (iv) Co-insurance;

      (v) Credentialing;

      (vi) Formulary;

      (vii) Grace period;

      (viii) Indemnity insurance;

      (ix) In-patient care;

      (x) Maximum lifetime cap;

      (xi) Medical necessity;

      (xii) Out-of-network;

      (xiii) Out-patient;

      (xiv) Pre-existing conditions;

      (xv) Point of service;

      (xvi) Risk sharing;

      (xvii) Second opinion;

      (xviii) Provider network;

      (xix) Urgent care.

      (b) Requirements for certification. - The director shall establish standards and procedures

for the certification of qualified health plans that conduct business in this state and who have

demonstrated the ability to ensure that health care services will be provided in a manner to assure

availability and accessibility, adequate personnel and facilities, and continuity of service, and has

demonstrated arrangements for ongoing quality assurance programs regarding care processes and

outcomes; other standards shall consist of, but are not limited to, the following:

      (1) Prospective and current enrollees in health plans must be provided information as to

the terms and conditions of the plan consistent with the rules and regulations promulgated under

chapter 12.3 of title 42 so that they can make informed decisions about accepting and utilizing the

health care services of the health plan. This must be standardized so that customers can compare

the attributes of the plans, and all information required by this paragraph shall be updated at

intervals determined by the director. Of those items required under this section, the director shall

also determine which items shall be routinely distributed to prospective and current enrollees as

listed in this subsection and which items may be made available upon request. The items to be

disclosed are:

      (i) Coverage provisions, benefits, and any restriction or limitations on health care

services, including but not limited to, any exclusions as follows: by category of service, and if

applicable, by specific service, by technology, procedure, medication, provider or treatment

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modality, diagnosis and condition, the latter three (3) of which shall be listed by name.

      (ii) Experimental treatment modalities that are subject to change with the advent of new

technology may be listed solely by the broad category "Experimental Treatments". The

information provided to consumers shall include the plan's telephone number and address where

enrollees may call or write for more information or to register a complaint regarding the plan or

coverage provision.

      (2) Written statement of the enrollee's right to seek a second opinion, and reimbursement

if applicable.

      (3) Written disclosure regarding the appeals process described in section 23-17.12-1 et

seq. and in the rules and regulations for the utilization review of care services, promulgated by the

department of health, the telephone numbers and addresses for the plan's office which handles

complaints as well as for the office which handles the appeals process under section 23-17.12-1 et

seq. and the rules and regulations for the utilization of health.

      (4) Written statement of prospective and current enrollees' right to confidentiality of all

health care record and information in the possession and/or control of the plan, its employees, its

agents and parties with whom a contractual agreement exists to provide utilization review or who

in any way have access to care information. A summary statement of the measures taken by the

plan to ensure confidentiality of an individual's health care records shall be disclosed.

      (5) Written disclosure of the enrollee's right to be free from discrimination by the health

plan and the right to refuse treatment without jeopardizing future treatment.

      (6) Written disclosure of a plan's policy to direct enrollees to particular providers. Any

limitations on reimbursement should the enrollee refuse the referral must be disclosed.

      (7) A summary of prior authorization or other review requirements including

preauthorization review, concurrent review, post-service review, post-payment review and any

procedure that may lead the patient to be denied coverage for or not be provided a particular

service.

      (8) Any health plan that operates a provider incentive plan shall not enter into any

compensation agreement with any provider of covered services or pharmaceutical manufacturer

pursuant to which specific payment is made directly or indirectly to the provider as an

inducement or incentive to reduce or limit services, to reduce the length of stay or the use of

alternative treatment settings or the use of a particular medication with respect to an individual

patient, provided however, that capitation agreements and similar risk sharing arrangements are

not prohibited.

      (9) Health plans must disclose to prospective and current enrollees the existence of

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financial arrangements for capitated or other risk sharing arrangements that exist with providers

in a manner described in paragraphs (i), (ii), and (iii):

      (i) "This health plan utilizes capitated arrangements, with its participating providers, or

contains other similar risk sharing arrangements;

      (ii) This health plan may include a capitated reimbursement arrangement or other similar

risk sharing arrangement, and other financial arrangements with your provider;

      (iii) This health plan is not capitated and does not contain other risk sharing

arrangements."

      (10) Written disclosure of criteria for accessing emergency health care services as well

as a statement of the plan's policies regarding payment for examinations to determine if

emergency health care services are necessary, the emergency care itself, and the necessary

services following emergency treatment or stabilization. The health plan must respond to the

request of the treating provider for post-stabilization treatment by approving or denying it as soon

as possible.

      (11) Explanation of how health plan limitations impact enrollees, including information

on enrollee financial responsibility for payment for co-insurance, co-payment, or other non-

covered, out-of-pocket, or out-of-plan services. This shall include information on deductibles and

benefits limitations including, but not limited to, annual limits and maximum lifetime benefits.

      (12) The terms under which the health plan may be renewed by the plan enrollee,

including any reservation by the plan of any right to increase premiums.

      (13) Summary of criteria used to authorize treatment.

      (14) A schedule of revenues and expenses, including direct service ratios and other

statistical information which meets the requirements set forth below on a form prescribed by the

director.

      (15) Plan costs of health care services, including but not limited to all of the following:

      (i) Physician services;

      (ii) Hospital services, including both inpatients and outpatient services;

      (iii) Other professional services;

      (iv) Pharmacy services, excluding pharmaceutical products dispensed in a physician's

office;

      (v) Health education;

      (vi) Substance abuse services and mental health services.

      (16) Plan complaint, adverse decision, and prior authorization statistics. This statistical

data shall be updated annually:

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      (i) The ratio of the number of complaints received to the total number of covered

persons, reported by category, listed in paragraphs (b)(15)(i) -- (vi);

      (ii) The ratio of the number of adverse decisions issued to the number of complaints

received, reported by category;

      (iii) The ratio of the number of prior authorizations denied to the number of prior

authorizations requested, reported by category;

      (iv) The ratio of the number of successful enrollee appeals to the total number of appeals

filed.

      (17) Plans must demonstrate that:

      (i) They have reasonable access to providers, so that all covered health care services will

be provided. This requirement cannot be waived and must be met in all areas where the health

plan has enrollees;

      (ii) Urgent health care services, if covered, shall be available within a time frame that

meets standards set by the director.

      (18) A comprehensive list of participating providers listed by office location, specialty if

applicable, and other information as determined by the director, updated annually.

      (19) Plans must provide to the director, at intervals determined by the director, enrollee

satisfaction measures. The director is authorized to specify reasonable requirements for these

measures consistent with industry standards to assure an acceptable degree of statistical validity

and comparability of satisfaction measures over time and among plans. The director shall publish

periodic reports for the public providing information on health plan enrollee satisfaction.

      (c) Issuance of certification.

      (1) Upon receipt of an application for certification, the director shall notify and afford

the public an opportunity to comment upon the application.

      (2) A health care plan will meet the requirements of certification, subsection (b) by

providing information required in subsection (b) to any state or federal agency in conformance

with any other applicable state or federal law, or in conformity with standards adopted by an

accrediting organization provided that the director determines that the information is substantially

similar to the previously mentioned requirements and is presented in a format that provides a

meaningful comparison between health plans.

      (3) All health plans shall be required to establish a mechanism, under which providers,

including local providers participating in the plan, provide input into the plan's health care policy,

including technology, medications and procedures, utilization review criteria and procedures,

quality and credentialing criteria, and medical management procedures.

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      (4) All health plans shall be required to establish a mechanism under which local

individual subscribers to the plan provide input into the plan's procedures and processes regarding

the delivery of health care services.

      (5) A health plan shall not refuse to contract with or compensate for covered services an

otherwise eligible provider or non-participating provider solely because that provider has in good

faith communicated with one or more of his or her patients regarding the provisions, terms or

requirements of the insurer's products as they relate to the needs of that provider's patients.

      (6) (i) All health plans shall be required to publicly notify providers within the health

plans' geographic service area of the opportunity to apply for credentials. This notification

process shall be required only when the plan contemplates adding additional providers and may

be specific as to geographic area and provider specialty. Any provider not selected by the health

plan may be placed on a waiting list.

      (ii) This credentialing process shall begin upon acceptance of an application from a

provider to the plan for inclusion.

      (iii) Each application shall be reviewed by the plan's credentialing body.

      (iv) All health plans shall develop and maintain credentialing criteria to be utilized in

adding providers from the plans' network. Credentialing criteria shall be based on input from

providers credentialed in the plan and these standards shall be available to applicants. When

economic considerations are part of the decisions, the criteria must be available to applicants.

Any economic profiling must factor the specialty utilization and practice patterns and general

information comparing the applicant to his or her peers in the same specialty will be made

available. Any economic profiling of providers must be adjusted to recognize case mix, severity

of illness, age of patients and other features of a provider's practice that may account for higher

than or lower than expected costs. Profiles must be made available to those so profiled.

      (7) A health plan shall not exclude a provider of covered services from participation in

its provider network based solely on:

      (i) The provider's degree or license as applicable under state law; or

      (ii) The provider of covered services lack of affiliation with, or admitting privileges at a

hospital, if that lack of affiliation is due solely to the provider's type of license.

      (8) Health plans shall not discriminate against providers solely because the provider

treats a substantial number of patients who require expensive or uncompensated medical care.

      (9) The applicant shall be provided with all reasons used if the application is denied.

      (10) Plans shall not be allowed to include clauses in physician or other provider contracts

that allow for the plan to terminate the contract "without cause"; provided, however, cause shall

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include lack of need due to economic considerations.

      (11) (i) There shall be due process for non-institutional providers for all adverse

decisions resulting in a change of privileges of a credentialed non-institutional provider. The

details of the health plan's due process shall be included in the plan's provider contracts.

      (ii) A health plan is deemed to have met the adequate notice and hearing requirement of

this section with respect to a non-institutional provider if the following conditions are met (or are

waived voluntarily by the non-institutional provider):

      (A) The provider shall be notified of the proposed actions and the reasons for the

proposed action.

      (B) The provider shall be given the opportunity to contest the proposed action.

      (C) The health plan has developed an internal appeals process that has reasonable time

limits for the resolution of an internal appeal.

      (12) If the plan places a provider or provider group at financial risk for services not

provided by the provider or provider group, the plan must require that a provider or group has met

all appropriate standards of the department of business regulation.

      (13) A health plan shall not include a most favored rate clause in a provider contract.

     (d) Network adequacy standards shall include and be governed by the following, in

consideration of the requirements of the Patient Protection and Affordable Care Act, Pub. L. 111-

148, as amended by the Federal Health Care and Education Reconciliation Act of 2010, Pub. L.

111-152, as both may be amended from time to time, including, but not limited to, federal

regulations regarding establishment of exchanges and qualified health plans, and exchange

standards for employers as it relates to qualified health plans:

     (1) Health plans offered by issuers shall provide timely access, based on referral from the

enrollee's attending or primary care physician, to at least one hospital in-network for each of the

following services: child outpatient services treating health-related behaviors, and adult outpatient

services treating health-related behaviors.

     (2) Of the primary care practices that health plans contract within each county of Rhode

Island, at least ten percent (10%) shall offer integrated behavioral health, mental health and

substance abuse services for their patients. Incentives included in health plans' contracts with

primary care practices, or alternative incentives certified by the health insurance commissioner to

be equivalent, shall be offered to behavioral health providers offering services on-site in primary

care practices. Health plans shall include sufficient incentives for behavioral health providers to

offer services on-site in primary care practices to enable at least ten percent (10%) of primary

care practices, geographically distributed throughout the state of Rhode Island, to hire or contract

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with behavioral health providers who meet standards for training, qualification, and preparation to

practice in integrated primary care settings that have been determined by the department of

health;

     (3) Health plans offered by issuers shall include providers of step-down and diversion

behavioral health services from hospital levels of care.

     SECTION 7. Sections 23-17.17-3, 23-17.17-9 and 23-17.17-10 of the General Laws in

Chapter 23-17.17 entitled "Health Care Quality Program" are hereby amended to read as follows:

     23-17.17-3. Establishment of health care quality performance measurement and

reporting program. -- The director of health is authorized and directed to develop a state health

care quality performance measurement and reporting program. The health care quality

performance measurement and reporting program shall include quality performance measures and

reporting for health care facilities licensed in Rhode Island. The program shall be phased in over

a multi-year period and shall begin with the establishment of a program of quality performance

measurement and reporting for hospitals. In subsequent years, quality performance measurement

and reporting requirements will be established for other types of health care facilities such as

nursing facilities, home nursing care providers, other licensed facilities, and licensed health care

providers, including behavioral health providers, as determined by the director of health. Prior to

developing and implementing a quality performance measurement and reporting program for

hospitals or any other health care facility or health care provider, the director shall seek public

comment regarding the type of performance measures to be used and the methods and format for

collecting the data.

     23-17.17-9. Health care quality and value database. -- (a) The director shall establish

and maintain a unified health care quality and value database, including information about

behavioral health services, to:

      (1) Determine the capacity and distribution of existing resources;

      (2) Identify health care needs and inform health care policy;

      (3) Evaluate the effectiveness of intervention programs on improving patient outcomes;

      (4) Compare costs between various treatment settings and approaches;

      (5) Provide information to consumers and purchasers of health care;

      (6) Improve the quality and affordability of patient health care and health care coverage;

      (7) Strengthen primary care and behavioral health infrastructure;

      (8) Strengthen chronic disease management, including management of health-related

behaviors;

      (9) Encourage evidence-based practices in health care, including behavioral health.

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      (b) The program authorized by this section shall include a consumer health care quality

and value information system designed to make available to consumers transparent health care

price information, quality information and such other information as the director determines is

necessary to empower individuals, including uninsured individuals, to make economically sound

and medically appropriate decisions.

      (c) The health care quality steering committee shall serve as the working group to advise

the director on the development and implementation of the consumer health care quality and

value information system.

      (d) The director, in collaboration with the health insurance commissioner, may require

an insurer covering at least five percent (5%) of the lives covered in the insured market in this

state to file with the director a consumer health care price and quality information plan in

accordance with regulations adopted by the director pursuant to this section.

      (e) The director shall adopt such regulations as are necessary to carry out the purposes of

this section and this chapter. The regulations may permit the gradual implementation of the

consumer health care quality and value information system over time, beginning with health care

price and quality information that the director determines is most needed by consumers or that

can be most practically provided to the consumer in an understandable manner. The regulations

shall permit insurers to use security measures designed to allow subscribers access to price and

other information without disclosing trade secrets to individuals and entities who are not

subscribers. The regulations shall avoid unnecessary duplication of efforts relating to price and

quality reporting by insurers, health care providers, health care facilities, and others, including

activities undertaken by hospitals pursuant to their reporting obligations under this chapter and

other chapters of the general laws.

      (f) Requirements for reporting to the health care quality database enumerated in this

section and subsequent sections of this chapter shall not apply to insurance coverage providing

benefits for:

      (1) Hospital confinement indemnity;

      (2) Disability income;

      (3) Accident only;

      (4) Long-term care;

      (5) Medicare supplement;

      (6) Limited benefit health;

      (7) Specified disease indemnity;

      (8) Sickness or bodily injury or death by accident or both; or

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      (9) Other limited benefit policies.

     23-17.17-10. Reporting requirements for the health care database. -- (a) Insurers,

health care providers, health care facilities and governmental agencies shall file reports, data,

schedules, statistics or other information determined by the director to be necessary to carry out

the purposes of this chapter. The reports required by this chapter shall be accepted by the director

in any certification commission for health care information technology ("CCHIT") certified form.

Such information may include:

      (1) health insurance claims and enrollment information used by health insurers;

      (2) information relating to hospital finance; and

     (3) information relating to behavioral health conditions and treatments based on valid and

reliable standardized measures of specific behavioral health disorders, conditions, symptoms,

risks, or health-related behaviors and services; and

     (3)(4) any other information relating to health care costs, prices, quality, utilization, or

resources required to be filed by the director.

      (b) The comprehensive health care information system shall not collect any data that

contains direct personal identifiers. For the purposes of this section "direct personal identifiers"

includes information relating to an individual that contains primary or obvious identifiers, such as

the individual's name, street address, e-mail address, telephone number and social security

number. All data submitted to the director pursuant to this chapter shall be protected by the

removal of all personal identifiers and the assignment by the insurer to each subscriber record of a

unique identifier not linked to any personally identifiable information.

     SECTION 8. Section 23-17.18-1 of the General Laws in Chapter 23-17.18 entitled

"Health Plan Modification Act" is hereby amended to read as follows:

     23-17.18-1. Modification of health plans. -- (a) A health plan may materially modify the

terms of a participating agreement it maintains with a physician or behavioral health provider

only if the plan disseminates in writing by mail to the physician or behavioral health provider the

contents of the proposed modification and an explanation, in nontechnical terms, of the

modification's impact.

      (b) The health plan shall provide the physician or behavioral health provider an

opportunity to amend or terminate the physician or provider contract with the health plan within

sixty (60) days of receipt of the notice of modification. Any termination of a physician or

provider contract made pursuant to this section shall be effective fifteen (15) calendar days from

the mailing of the notice of termination in writing by mail to the health plan. The termination

shall not affect the method of payment or reduce the amount of reimbursement to the physician or

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behavioral health provider by the health plan for any patient in active treatment for an acute

medical or behavioral health condition at the time the patient's physician or behavioral health

provider terminates his, her, or its physician or provider contract with the health plan until the

active treatment is concluded or, if earlier, one year after the termination; and, with respect to the

patient, during the active treatment period the physician or behavioral health provider shall be

subject to all the terms and conditions of the terminated physician or provider contract, including

but not limited to, all reimbursement provisions which limit the patient's liability.

      (c) Nothing in this section shall apply to accident-only, specified disease, hospital

indemnity, Medicare supplement, long-term care, disability income, or other limited benefit

health insurance policies.

     SECTION 9. Sections 23-17.22-2 and 23-17.22-3 of the General Laws in Chapter 23-

17.22 entitled "Healthy Rhode Island Reform Act of 2008" are hereby amended to read as

follows:

     23-17.22-2. Establishment of the healthy Rhode Island strategic plan. -- (a) The

director of health in consultation with the health care planning and accountability advisory

council established pursuant to chapter 81 of title 23, shall be responsible for the development

and implementation of a five (5) year strategic plan that charts the course for a healthy Rhode

Island.

      (b) The director and the health care planning and accountability advisory council shall

engage a broad range of health care providers, health insurance plans, professional organizations,

community and nonprofit groups, consumers, businesses, school districts, and state and local

government in developing and implementing the healthy Rhode Island five (5) year strategic plan.

      (c) (1) The healthy Rhode Island strategic plan shall include:

      (i) A description of the course charted to a healthy Rhode Island (the healthy Rhode

Island model), which includes patient self-management, emphasis on primary care and behavioral

health, particularly health-related behaviors, community initiatives, and health system and

information technology reform, to be used uniformly statewide by private insurers, third party

administrators, and public programs;

      (ii) A description of prevention programs and how these programs are integrated into

communities, with chronic care management, health-related behavior changes, and the healthy

Rhode Island model;

      (iii) A plan to develop and implement reimbursement systems aligned with the goal of

managing the care for individuals with or at risk for conditions in order to improve outcomes and

the quality of care;

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      (iv) The involvement of public and private groups, health care professionals, insurers,

third party administrators, associations, and firms to facilitate and assure the sustainability of a

new system of care;

      (v) The involvement of community and consumer groups to facilitate and assure the

sustainability of health services supporting healthy behaviors and good patient self-management

for the prevention and management of chronic conditions;

      (vi) Alignment of any information technology needs with other health care information

technology initiatives;

      (vii) The use and development of outcome measures and reporting requirements, aligned

with outcome measures established by the director under this section, to assess and evaluate the

healthy Rhode Island model system of chronic care management;

      (viii) Target timelines for inclusion of specific chronic conditions to be included in the

chronic care infrastructure and for statewide implementation of the healthy Rhode Island model;

      (ix) Identification of resource needs for implementation and sustaining the healthy

Rhode Island model and strategies to meet the identified needs; and

      (x) A strategy for ensuring statewide participation no later than January 1, 2010 by all

health insurers, third-party administrators, health care professionals, health care facilities as

defined in section 23-17-2 of the Rhode Island general laws, and consumers in the healthy Rhode

Island chronic care management plan, including common outcome measures, best practices and

protocols, data reporting requirements, payment methodologies, and other standards.

      (2) The strategic plan shall be reviewed biennially and amended as necessary to reflect

changes in priorities. Amendments to the plan shall be reported to the general assembly in the

report established under subsection (d) of this section.

      (d) (1) The director shall report to the general assembly annually on the status of

implementation of the Rhode Island blueprint for health. The report shall include the number of

participating insurers, health care facilities, health care professionals and patients; the progress for

achieving statewide participation in the chronic care management plan, including the measures

established under subsection (c) of this section; the expenditures and savings for the period; the

results of health care professional and patient satisfaction surveys; the progress toward creation

and implementation of privacy and security protocols; and other information as requested by the

committees. The surveys shall be developed in collaboration with the health care planning and

accountability advisory council.

      (2) If statewide participation in the healthy Rhode Island model for health is not

achieved by January 1, 2010, the director shall evaluate the healthy Rhode Island model for

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health and recommend to the general assembly changes necessary to create alternative measures

to ensure statewide participation by all health insurers, third-party administrators, health care

facilities, and health care professionals.

     23-17.22-3. Healthy Rhode Island chronic care management program. -- (a) The

director shall create criteria for the healthy Rhode Island chronic care management program as

provided for in this section.

      (b) The director shall include a broad range of chronic conditions in the healthy Rhode

Island chronic care management program.

      (c) The healthy Rhode Island chronic care management program shall be designed to

include:

      (1) A method involving the health care or behavioral health care professional in

identifying eligible patients, including the use of a chronic care information system established

pursuant to this section, an enrollment process which provides incentives and strategies for

maximum patient participation, and a standard statewide health and behavioral health risk

assessment for each individual;

      (2) The process for coordinating care among health care professionals, including a

process for ensuring that each patient has a designated primary care physician;

      (3) The methods of increasing communications among health care professionals and

patients, including patient education, self-management, health-related behavior change, and

follow-up plans;

      (4) The educational, wellness, and clinical management protocols and tools used by the

care management organization, including management guideline materials for health care

professionals to assist in patient-specific recommendations;

      (5) Process and outcome measures to provide performance feedback for health and

behavioral health care professionals and information on the quality of care, including patient

satisfaction and health status outcomes;

      (6) Payment methodologies to align reimbursements and create financial incentives and

rewards for health and behavioral health care professionals to establish management systems for

chronic conditions, to improve health outcomes, and to improve the quality of care, including

case management fees, pay for performance, payment for technical support and data entry

associated with patient registries, the cost of staff coordination within a medical or behavioral

health practice, and any reduction in a health or behavioral health care professional's productivity;

      (7) Payment methodologies to any care management organization implementing a

chronic care management program which would put the care management organization's fee at

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risk if the management is not successful in reducing costs; and

      (8) A requirement that the data on enrollees in any chronic care management program

implemented pursuant to this section be shared, to the extent allowable under federal law, and in a

format that does not provide any patient-identifiable information, with the director in order to

inform the health care reform initiatives.

      (d) No later than January 1, 2009 the secretary of health and human services shall ensure

access to a healthy Rhode Island chronic care management program consistent with the program

criteria developed by the director under this section for appropriate persons receiving any type of

medical assistance benefits through the department of human services, the department of mental

health, retardation and hospitals, the department of children, youth and families, or the

department of elderly affairs with such chronic care management program to be available to all

such persons by July 1, 2009. Any contract to provide medical assistance benefits may allow the

entity to subcontract some chronic care management services to other entities if it is cost-

effective, efficient, or in the best interests of the individuals enrolled in the program.

      (e) No later than January 1, 2009 the director of administration shall ensure access to a

healthy Rhode Island chronic care management program, consistent with program criteria

developed by the director under this section, for appropriate state employees and their dependents

who receive medical coverage through the health benefit plan for state employees.

      (f) No later than January 1, 2010 the director, in collaboration with the health insurance

commissioner, shall require statewide participation by all health insurers, third-party

administrators, health care professionals, health care facilities and other professionals, in the

healthy Rhode Island chronic care management plan, including common outcome measures, best

practices and protocols, data reporting requirements, payment methodologies, and other

standards.

      (g) The director shall ensure that the healthy Rhode Island chronic care management

program is modified over time to comply with the healthy Rhode Island strategic plan established

under this chapter.

     SECTION 10. Section 27-18-1.1 of the General Laws in Chapter 27-18 entitled

"Accident and Sickness Insurance Policies" is hereby amended to read as follows:

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

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

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

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

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

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

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

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

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

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

coverage determination.

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

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

federal regulations adopted thereunder.

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

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

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

federal Affordable Care Act,

      (5) "Grandfathered health plan" means any group health plan or health insurance

coverage subject to 42 USC section 18011.

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

health insurance coverage offered in connection with such plan.

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

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

dependents directly or through insurance, reimbursement, or otherwise.

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

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

any structure or function of the body or behavioral health functioning including coverage or

benefits for transportation primarily for and essential thereto, and including medical services as

defined in R.I. Gen. Laws section 27-19-17;

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

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

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

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

settings.

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

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

law.

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

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care facility.

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

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

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

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

health plan.

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

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

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

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

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

1974. The term also shall not include:

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

thereof.

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

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

insurance.

      (iv) Workers' compensation or similar insurance.

      (v) Automobile medical payment insurance.

      (vi) Credit-only insurance.

      (vii) Coverage for on-site medical clinics.

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

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

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

benefits.

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

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

      (i) Limited scope dental or vision benefits.

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

care, or any combination thereof.

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

Pub. L. No. 104-191 ("HIPAA").

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

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

LC005222 - Page 27 of 72

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

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

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

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

      (ii) Hospital indemnity or other fixed indemnity insurance.

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

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

federal Social Security Act.

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

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

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

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

section 42-14.5-1 of the General laws.

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

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

coverage.

     SECTION 11. Section 27-18.5-8 of the General Laws in Chapter 27-18.5 entitled

"Individual Health Insurance Coverage" is hereby amended to read as follows:

     27-18.5-8. Wellness health benefit plan. -- All carriers that offer health insurance in the

individual market shall actively market and offer the wellness health direct benefit plan to eligible

individuals. The wellness health direct benefit plan shall be determined by regulation

promulgated by the office of the health insurance commissioner (OHIC). The OHIC shall develop

the criteria for the direct wellness health benefit plan, including, but not limited to, benefit levels,

cost sharing levels, exclusions and limitations in accordance with the following:

      (1) Form and utilize an advisory committee in accordance with subsection 27-50-10(5).

      (2) Set a target for the average annualized individual premium rate for the direct

wellness health benefit plan to be less than ten percent (10%) of the average annual statewide

wage, dependent upon the availability of reinsurance funds, as reported by the Rhode Island

department of labor and training, in their report entitled "Quarterly Census of Rhode Island

Employment and Wages." In the event that this report is no longer available, or the OHIC

determines that it is no longer appropriate for the determination of maximum annualized

premium, an alternative method shall be adopted in regulation by the OHIC. The maximum

annualized individual premium rate shall be determined no later than August 1st of each year, to

be applied to the subsequent calendar year premiums rates.

LC005222 - Page 28 of 72

      (3) Ensure that the direct wellness health benefit plan creates appropriate incentives for

employers, providers, health plans and consumers to, among other things:

      (i) Focus on primary care, behavioral health care, prevention and wellness;

      (ii) Actively manage the chronically ill population, including health-related behavior;

      (iii) Use the least cost, most appropriate setting; and

      (iv) Use evidence based, quality care.

      (4) The plan shall be made available in accordance with title 27, chapter 18.5 as required

by regulation on or before May 1, 2007.

     SECTION 12. Section 27-18.6-2 of the General Laws in Chapter 27-18.6 entitled "Large

Group Health Insurance Coverage" is hereby amended to read as follows:

     27-18.6-2. Definitions. -- The following words and phrases as used in this chapter have

the following meanings unless a different meaning is required by the context:

      (1) "Affiliation period" means a period which, under the terms of the health insurance

coverage offered by a health maintenance organization, must expire before the health insurance

coverage becomes effective. The health maintenance organization is not required to provide

health care services or benefits during the period and no premium shall be charged to the

participant or beneficiary for any coverage during the period;

      (2) "Beneficiary" has the meaning given that term under section 3(8) of the Employee

Retirement Security Act of 1974, 29 U.S.C. section 1002(8);

      (3) "Bona fide association" means, with respect to health insurance coverage in this state,

an association which:

      (i) Has been actively in existence for at least five (5) years;

      (ii) Has been formed and maintained in good faith for purposes other than obtaining

insurance;

      (iii) Does not condition membership in the association on any health status-relating

factor relating to an individual (including an employee of an employer or a dependent of an

employee);

      (iv) Makes health insurance coverage offered through the association available to all

members regardless of any health status-related factor relating to the members (or individuals

eligible for coverage through a member);

      (v) Does not make health insurance coverage offered through the association available

other than in connection with a member of the association;

      (vi) Is composed of persons having a common interest or calling;

      (vii) Has a constitution and bylaws; and

LC005222 - Page 29 of 72

      (viii) Meets any additional requirements that the director may prescribe by regulation;

      (4) "COBRA continuation provision" means any of the following:

      (i) Section 4980(B) of the Internal Revenue Code of 1986, 26 U.S.C. section 4980B,

other than the subsection (f)(1) of that section insofar as it relates to pediatric vaccines;

      (ii) Part 6 of subtitle B of title 1 of the Employee Retirement Income Security Act of

1974, 29 U.S.C. section 1161 et seq., other than section 609 of that act, 29 U.S.C. section 1169;

or

      (iii) Title XXII of the United States Public Health Service Act, 42 U.S.C. section 300bb-

1 et seq.;

      (5) "Creditable coverage" has the same meaning as defined in the United States Public

Health Service Act, section 2701(c), 42 U.S.C. section 300gg(c), as added by P.L. 104-191;

      (6) "Church plan" has the meaning given that term under section 3(33) of the Employee

Retirement Income Security Act of 1974, 29 U.S.C. section 1002(33);

      (7) "Director" means the director of the department of business regulation;

      (8) "Employee" has the meaning given that term under section 3(6) of the Employee

Retirement Income Security Act of 1974, 29 U.S.C. section 1002(6);

      (9) "Employer" has the meaning given that term under section 3(5) of the Employee

Retirement Income Security Act of 1974, 29 U.S.C. section 1002(5), except that the term includes

only employers of two (2) or more employees;

      (10) "Enrollment date" means, with respect to an individual covered under a group health

plan or health insurance coverage, the date of enrollment of the individual in the plan or coverage

or, if earlier, the first day of the waiting period for the enrollment;

      (11) "Governmental plan" has the meaning given that term under section 3(32) of the

Employee Retirement Income Security Act of 1974, 29 U.S.C. section 1002(32), and includes any

governmental plan established or maintained for its employees by the government of the United

States, the government of any state or political subdivision of the state, or by any agency or

instrumentality of government;

      (12) "Group health insurance coverage" means, in connection with a group health plan,

health insurance coverage offered in connection with that plan;

      (13) "Group health plan" means an employee welfare benefits plan as defined in section

3(1) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. section 1002(1), to the

extent that the plan provides medical care and including items and services paid for as medical

care to employees or their dependents as defined under the terms of the plan directly or through

insurance, reimbursement or otherwise;

LC005222 - Page 30 of 72

      (14) "Health insurance carrier" or "carrier" means any entity subject to the insurance

laws and regulations of this state, or subject to the jurisdiction of the director, that contracts or

offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health

care services, including, without limitation, an insurance company offering accident and sickness

insurance, a health maintenance organization, a nonprofit hospital, medical or dental service

corporation, or any other entity providing a plan of health insurance, health benefits, or health

services;

      (15) (i) "Health insurance coverage" means a policy, contract, certificate, or agreement

offered by a health insurance carrier to provide, deliver, arrange for, pay for, or reimburse any of

the costs of health care services. Health insurance coverage does include short-term and

catastrophic health insurance policies, and a policy that pays on a cost-incurred basis, except as

otherwise specifically exempted in this definition;

      (ii) "Health insurance coverage" does not include one or more, or any combination of,

the following "excepted benefits":

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

those;

      (B) Coverage issued as a supplement to liability insurance;

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

insurance;

      (D) Workers' compensation or similar insurance;

      (E) Automobile medical payment insurance;

      (F) Credit-only insurance;

      (G) Coverage for on-site medical clinics; and

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

P.L. 104-191, under which benefits for medical care are secondary or incidental to other

insurance benefits;

      (iii) "Health insurance coverage" does not include the following "limited, excepted

benefits" if they are provided under a separate policy, certificate of insurance, or are not an

integral part of the plan:

      (A) Limited scope dental or vision benefits;

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

care, or any combination of those; and

      (C) Any other similar, limited benefits that are specified in federal regulations issued

pursuant to P.L. 104-191;

LC005222 - Page 31 of 72

      (iv) "Health insurance coverage" does not include the following "noncoordinated,

excepted benefits" if the benefits are provided under a separate policy, certificate, or contract of

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

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

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

event under any group health plan maintained by the same plan sponsor:

      (A) Coverage only for a specified disease or illness; and

      (B) Hospital indemnity or other fixed indemnity insurance;

      (v) "Health insurance coverage" does not include the following "supplemental, excepted

benefits" if offered as a separate policy, certificate, or contract of insurance:

      (A) Medicare supplemental health insurance as defined under section 1882(g)(1) of the

Social Security Act, 42 U.S.C. section 1395ss(g)(1);

      (B) Coverage supplemental to the coverage provided under 10 U.S.C. section 1071 et

seq.; and

      (C) Similar supplemental coverage provided to coverage under a group health plan;

      (16) "Health maintenance organization" ("HMO") means a health maintenance

organization licensed under chapter 41 of this title;

      (17) "Health status-related factor" means any of the following factors:

      (i) Health status;

      (ii) Medical condition, including both physical and mental illnesses, and behaviors

related to health status;

      (iii) Claims experience;

      (iv) Receipt of health or behavioral health care;

      (v) Medical history;

      (vi) Genetic information;

      (vii) Evidence of insurability, including contributions arising out of acts of domestic

violence; and

      (viii) Disability;

      (18) "Large employer" means, in connection with a group health plan with respect to a

calendar year and a plan year, an employer who employed an average of at least fifty-one (51)

employees on business days during the preceding calendar year and who employs at least two (2)

employees on the first day of the plan year. In the case of an employer which was not in existence

throughout the preceding calendar year, the determination of whether the employer is a large

employer shall be based on the average number of employees that is reasonably expected the

LC005222 - Page 32 of 72

employer will employ on business days in the current calendar year;

      (19) "Large group market" means the health insurance market under which individuals

obtain health insurance coverage (directly or through any arrangement) on behalf of themselves

(and their dependents) through a group health plan maintained by a large employer;

      (20) "Late enrollee" means, with respect to coverage under a group health plan, a

participant or beneficiary who enrolls under the plan other than during:

      (i) The first period in which the individual is eligible to enroll under the plan; or

      (ii) A special enrollment period;

      (21) "Medical care" means amounts paid for:

      (i) The diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid

for the purpose of affecting any structure or function of the body, or behavioral health

functioning;

      (ii) Amounts paid for transportation primarily for and essential to medical care referred

to in paragraph (i) of this subdivision; and

      (iii) Amounts paid for insurance covering medical care referred to in paragraphs (i) and

(ii) of this subdivision;

      (22) "Network plan" means health insurance coverage offered by a health insurance

carrier under which the financing and delivery of medical care including items and services paid

for as medical care are provided, in whole or in part, through a defined set of providers under

contract with the carrier;

      (23) "Participant" has the meaning given such term under section 3(7) of the Employee

Retirement Income Security Act of 1974, 29 U.S.C. section 1002(7);

      (24) "Placed for adoption" means, in connection with any placement for adoption of a

child with any person, the assumption and retention by that person of a legal obligation for total

or partial support of the child in anticipation of adoption of the child. The child's placement with

the person terminates upon the termination of the legal obligation;

      (25) "Plan sponsor" has the meaning given that term under section 3(16)(B) of the

Employee Retirement Income Security Act of 1974, 29 U.S.C. section 1002(16)(B). "Plan

sponsor" also includes any bona fide association, as defined in this section;

      (26) "Preexisting condition exclusion" means, with respect to health insurance coverage,

a limitation or exclusion of benefits relating to a condition based on the fact that the condition

was present before the date of enrollment for the coverage, whether or not any medical advice,

diagnosis, care or treatment was recommended or received before the date; and

      (27) "Waiting period" means, with respect to a group health plan and an individual who

LC005222 - Page 33 of 72

is a potential participant or beneficiary in the plan, the period that must pass with respect to the

individual before the individual is eligible to be covered for benefits under the terms of the plan.

     SECTION 13. Sections 27-19-1 and 27-19-5.2 of the General Laws in Chapter 27-19

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

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

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

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

hospital service plan operated by the corporation;

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

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

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

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

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

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

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

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

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

coverage determination.

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

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

federal regulations adopted thereunder;

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

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

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

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

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

majority of the directors of the nonprofit hospital service corporation;

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

federal Affordable Care Act.

      (7) "Grandfathered health plan" means any group health plan or health insurance

coverage subject to 42 USC section 18011;

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

health insurance coverage offered in connection with such plan;

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

LC005222 - Page 34 of 72

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

dependents directly or through insurance, reimbursement, or otherwise;

      (10) "Health benefits" or "covered benefits" means coverage or benefits for the

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

of affecting any structure or function of the body, or behavioral health functioning including

coverage or benefits for transportation primarily for and essential thereto, and including medical

services as defined in R.I. Gen. Laws section 27-19-17;

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

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

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

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

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

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

law;

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

care facility;

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

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

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

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

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

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

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

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

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

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

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

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

1974. The term also shall not include:

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

thereof.

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

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

insurance.

LC005222 - Page 35 of 72

      (iv) Workers' compensation or similar insurance.

      (v) Automobile medical payment insurance.

      (vi) Credit-only insurance.

      (vii) Coverage for on-site medical clinics.

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

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

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

insurance benefits.

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

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

      (i) Limited scope dental or vision benefits.

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

care, or any combination thereof.

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

Pub. L. No. 104-191 ("HIPAA").

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

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

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

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

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

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

      (ii) Hospital indemnity or other fixed indemnity insurance.

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

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

federal Social Security Act.

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

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

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

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

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

service plan;

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

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

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

LC005222 - Page 36 of 72

section 42-14.5-1 of the General Law;

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

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

coverage; and

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

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

hospital service plan operated by the corporation.

     27-19-5.2. Patient responsibility -- Administrative requirements. -- For health benefit

contracts issued, renewed, or delivered on or after April 1, 2002, the following shall apply:

      (1) The amount of copayments for physician office visits and hospital emergency room

visits shall be printed on the subscriber identification cards issued to insureds. The amount of

copayments of behavioral health office visits shall be equal to those for non-preventive primary

care office visits.

      (2) A schedule of all applicable copayments, by product or by group, in paper or

electronic format, or both, shall be published, updated, and distributed to participating providers.

      (3) Notification shall be provided to subscribers on an annual basis regarding their

responsibility for copayments and deductibles.

     SECTION 14. Sections 27-20-1, 27-20-3 and 27-20-5.3 of the General Laws in Chapter

27-20 entitled "Nonprofit Medical Service Corporations" are hereby amended to read as follows:

     27-20-1. Definitions. -- As used in this chapter:

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

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

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

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

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

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

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

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

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

coverage determination.

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

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

federal regulations adopted thereunder;

      (3) "Certified registered nurse practitioners" is an expanded role utilizing independent

LC005222 - Page 37 of 72

knowledge of physical assessment and management of health care and illnesses. The practice

includes collaboration with other licensed health care professionals including, but not limited to,

physicians, pharmacists, podiatrists, dentists, and nurses;

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

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

      (5) "Counselor in mental health" means a person who has been licensed pursuant to

section 5-63.2-9.

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

federal Affordable Care Act.

      (7) "Grandfathered health plan" means any group health plan or health insurance

coverage subject to 42 USC section 18011.

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

health insurance coverage offered in connection with such plan.

      (9) "Group health plan" means an employee welfare benefit plan as defined in 29 USC

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

dependents directly or through insurance, reimbursement, or otherwise.

      (10) "Health benefits" or "covered benefits" means coverage or benefits for the

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

of affecting any structure or function of the body or behavioral health functioning including

coverage or benefits for transportation primarily for and essential thereto, and including medical

services as defined in R.I. Gen. Laws section 27-19-17;

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

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

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

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

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

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

law.

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

care facility.

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

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

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

to the jurisdiction of the commissioner under this chapter, and includes a nonprofit medical

LC005222 - Page 38 of 72

service corporation. Such term does not include a group health plan.

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

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

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

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

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

1974. The term also shall not include:

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

thereof.

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

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

insurance.

      (iv) Workers' compensation or similar insurance.

      (v) Automobile medical payment insurance.

      (vi) Credit-only insurance.

      (vii) Coverage for on-site medical clinics.

      (viii) Other similar insurance coverage,

      specified in federal regulations issued pursuant to Federal Pub. L. No. 104-191, the

federal health insurance portability and accountability act of 1996 ("HIPAA"), under which

benefits for medical care are secondary or incidental to other insurance benefits.

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

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

      (i) Limited scope dental or vision benefits.

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

care, or any combination thereof.

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

Pub. L. No. 104-191 ("HIPAA").

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

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

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

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

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

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

      (ii) Hospital indemnity or other fixed indemnity insurance.

LC005222 - Page 39 of 72

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

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

federal Social Security Act.

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

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

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

      (17) "Licensed midwife" means any midwife licensed under section 23-13-9;

      (18) "Medical services" means those professional services rendered by persons duly

licensed under the laws of this state to practice medicine, surgery, chiropractic, podiatry, and

other professional services rendered by a licensed midwife, certified registered nurse

practitioners, and psychiatric and mental health nurse clinical specialists, and appliances, drugs,

medicines, supplies, and nursing care necessary in connection with the services, or the expense

indemnity for the services, appliances, drugs, medicines, supplies, and care, as may be specified

in any nonprofit medical service plan. Medical service shall not be construed to include hospital

services;

      (19) "Nonprofit medical service corporation" means any corporation organized pursuant

hereto for the purpose of establishing, maintaining, and operating a nonprofit medical service

plan;

      (20) "Nonprofit medical service plan" means a plan by which specified medical service

is provided to subscribers to the plan by a nonprofit medical service corporation;

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

section 42-14.5-1 of the General laws.

      (22) "Psychiatric and mental health nurse clinical specialist" is an expanded role utilizing

independent knowledge and management of mental health and illnesses. The practice includes

collaboration with other licensed health care professionals, including, but not limited to,

psychiatrists, psychologists, physicians, pharmacists, and nurses;

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

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

coverage.

      (24) "Subscribers" means those persons or groups of persons who contract with a

nonprofit medical service corporation for medical service pursuant to a nonprofit medical service

plan; and

      (25) "Therapist in marriage and family practice" means a person who has been licensed

pursuant to section 5-63.2-10.

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     27-20-3. Qualifications of directors. -- A majority of the directors of a nonprofit

medical service corporation, other than a corporation organized pursuant to the provisions of

chapter 19 of this title, must at all times be doctors of medicine or behavioral health providers

duly licensed to practice under the laws of this state. The directors of any nonprofit medical

service corporation formed after January 1, 1964 shall consist of an equal number of

representatives of the public, doctors of medicine or behavioral health providers duly licensed to

practice under the laws of this state, and subscribers.

     27-20-5.3. Patient responsibility -- Administrative requirements. -- For health benefit

contracts issued, renewed, or delivered on or after April 1, 2002, the following shall apply:

      (1) The amount of copayments for physician office visits and hospital emergency room

visits shall be printed on the subscriber identification cards issued to insureds. The amount of

copayments for behavioral health office visits shall be equal to those for non-preventive primary

care office visits.

      (2) A schedule of all applicable copayments, by product or by group, in paper or

electronic format, or both, shall be published, updated, and distributed to participating providers.

      (3) On an annual basis, notification shall be provided to subscribers regarding their

responsibility for copayments and deductibles.

     SECTION 15. Section 27-20.9-3 of the General Laws in Chapter 27-20.9 entitled

"Contract With Health Care Providers" is hereby amended to read as follows:

     27-20.9-3. Pay-for-performance guidelines. -- A health insurer shall not require a

physician or behavioral health provider, as a condition of contracting, to participate in any

financial or reimbursement incentive program, commonly referred to as pay-for-performance

programs unless such program meets the principles and guidelines for pay-for-performance

programs endorsed by the national quality forum and adopted by the AQA Alliance or the

hospital quality alliance, or similar principles and guidelines for pay-for-performance programs

approved by the office of the health insurance commissioner. Any pay-for-performance program

offered to a primary care physician, or a program certified by the health insurance commissioner

to be equivalent, shall be made available for behavioral health providers.

     SECTION 16. Sections 27-38.2-1, 27-38.2-2, 27-38.2-3 and 27-38.2-4 of the General

Laws in Chapter 27-38.2 entitled "Insurance Coverage for Mental Illness and Substance Abuse"

are hereby amended to read as follows:

     27-38.2-1. Mental illness coverage. -- Every health care insurer that delivers or issues

for delivery or renews in this state a contract, plan, or policy except contracts providing

supplemental coverage to Medicare or other governmental programs, shall provide coverage for

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the medical treatment of mental illness, and substance abuse, and health-related behaviors under

the same terms and conditions as that coverage is provided for other illnesses and diseases and in

particular, for illnesses and diseases commonly treated by primary care providers. Insurance

coverage offered pursuant to this statute must include the same durational limits, amount limits,

deductibles, and co-insurance factors for mental illness as for other illnesses and diseases and in

particular, for illnesses and diseases commonly treated by primary care providers.

     27-38.2-2. Definitions. -- For the purposes of this chapter, the following words and terms

have the following meanings:

      (1) "Health insurers" means all persons, firms, corporations, or other organizations

offering and assuring health services on a prepaid or primarily expense-incurred basis, including

but not limited to policies of accident or sickness insurance, as defined by chapter 18 of this title,

nonprofit hospital or medical service plans, whether organized under chapter 19 or 20 of this title

or under any public law or by special act of the general assembly, health maintenance

organizations, or any other entity which insures or reimburses for diagnostic, therapeutic, or

preventive services to a determined population on the basis of a periodic premium. Provided, this

chapter does not apply to insurance coverage providing benefits for:

      (i) Hospital confinement indemnity;

      (ii) Disability income;

      (iii) Accident only;

      (iv) Long-term care;

      (v) Medicare supplement;

      (vi) Limited benefit health;

      (vii) Specific disease indemnity;

      (viii) Sickness or bodily injury or death by accident or both; and

      (ix) Other limited benefit policies.

      (2) "Mental illness" means any mental disorder and substance abuse disorder that is

listed in the most recent revised publication or the most updated volume of either the Diagnostic

and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric

Association or the International Classification of Disease Manual (ICO) published by the World

Health Organization or any health-related behavior identified by the director of health as having a

significant effect on health, illness, disease, or functioning and that substantially limits the life

activities of the person with the illness; provided, that tobacco and caffeine are excluded from the

definition of "substance" for the purposes of this chapter. "Mental illness" shall not include: (i)

mental retardation, (ii) learning disorders, (iii) motor skills disorders, (iv) communication

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disorders, and (v) mental disorders classified as "V" codes. Nothing shall preclude persons with

these conditions from receiving benefits provided under this chapter for any other diagnoses

covered by this chapter.

      (3) "Mental illness coverage" means inpatient hospitalization, partial hospitalization

provided in a hospital or any other licensed facility, intensive out patient services, outpatient

services, services provided by a behavioral health provider in a medical facility or practice, and

community residential care services for substance abuse treatment. It shall not include methadone

maintenance services or community residential care services for mental illnesses other than

substance abuse disorders.

      (4) "Outpatient services" means office visits that provide for the treatment of mental

illness and substance abuse.

      (5) "Community residential care services" mean those facilities as defined and licensed

in accordance with chapter 24 of title 40.1.

     27-38.2-3. Medical necessity and appropriateness of treatment. -- (a) Upon request of

the reimbursing health insurers, all providers of treatment of mental illness shall furnish medical

records or other necessary data which substantiates that initial or continued treatment is at all

times medically necessary and appropriate. When the provider cannot establish the medical

necessity and/or appropriateness of the treatment modality being provided, neither the health

insurer nor the patient shall be obligated to reimburse for that period or type of care that was not

established. The exception to the preceding can only be made if the patient has been informed of

the provisions of this subsection and has agreed in writing to continue to receive treatment at his

or her own expense.

      (b) The health insurers, when making the determination of medically necessary and

appropriate treatment, must do so in a manner consistent with that used to make the determination

for the treatment of other diseases or injuries covered under the health insurance policy or

agreement and in particular, for illnesses and diseases commonly treated by primary care

providers.

      (c) Any subscriber who is aggrieved by a denial of benefits provided under this chapter

may appeal a denial in accordance with the rules and regulations promulgated by the department

of health pursuant to chapter 17.12 of title 23.

     27-38.2-4. Limitations of coverage. -- (a) The health care benefits outlined in this

chapter apply only to services delivered within the state of Rhode Island; provided, that all health

insurers shall be required to provide coverage for those benefits mandated by this chapter outside

of the state of Rhode Island where it can be established through a pre-authorization process that

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the required services are not available in the state of Rhode Island from a provider in the health

insurer's network.

      (b) For the purposes of this chapter, outpatient services, with the exception of outpatient

medication visits, shall be provided for up to thirty (30) as many visits in any calendar year as are

determined to meet the medical necessity criteria; outpatient services for substance abuse

treatment shall be provided for up to up to thirty (30) as many in any calendar year as are

determined to meet the medical necessity criteria; community residential care services for

substance abuse treatment shall be provided for up to thirty (30) days in any calendar year; and

detoxification benefits shall be provided for up to five (5) detoxification occurrences or thirty (30)

days in any calendar year, whichever comes first.

     SECTION 17. Sections 27-41-2 and 27-41-26.1 of the General Laws in Chapter 27-41

entitled "Health Maintenance Organizations" are hereby amended to read as follows:

     27-41-2. Definitions. -- As used in this chapter:

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

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

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

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

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

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

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

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

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

coverage determination.

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

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

federal regulations adopted thereunder;

      (c) "Commissioner" or "health insurance commissioner" means that individual appointed

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

      (d) "Covered health services" means the services that a health maintenance organization

contracts with enrollees and enrolled groups to provide or make available to an enrolled

participant.

      (e) "Director" means the director of the department of business regulation or his or her

duly appointed agents.