2018 -- H 7931 | |
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LC003175 | |
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STATE OF RHODE ISLAND | |
IN GENERAL ASSEMBLY | |
JANUARY SESSION, A.D. 2018 | |
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A N A C T | |
RELATING TO STATE AFFAIRS AND GOVERNMENT -- THE RHODE ISLAND HEALTH | |
CARE REFORM ACT OF 2004--HEALTH INSURANCE OVERSIGHT | |
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Introduced By: Representatives Ranglin-Vassell, Donovan, and Regunberg | |
Date Introduced: March 07, 2018 | |
Referred To: House Corporations | |
It is enacted by the General Assembly as follows: | |
1 | SECTION 1. Section 42-14.5-3 of the General Laws in Chapter 42-14.5 entitled "The |
2 | Rhode Island Health Care Reform Act of 2004 - Health Insurance Oversight" is hereby amended |
3 | to read as follows: |
4 | 42-14.5-3. Powers and duties [Contingent effective date; see effective dates under |
5 | this section. |
6 | The health insurance commissioner shall have the following powers and duties: |
7 | (a) To conduct quarterly public meetings throughout the state, separate and distinct from |
8 | rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers |
9 | licensed to provide health insurance in the state; the effects of such rates, services, and operations |
10 | on consumers, medical care providers, patients, and the market environment in which such |
11 | insurers operate; and efforts to bring new health insurers into the Rhode Island market. Notice of |
12 | not less than ten (10) days of said hearing(s) shall go to the general assembly, the governor, the |
13 | Rhode Island Medical Society, the Hospital Association of Rhode Island, the director of health, |
14 | the attorney general, and the chambers of commerce. Public notice shall be posted on the |
15 | department's web site and given in the newspaper of general circulation, and to any entity in |
16 | writing requesting notice. |
17 | (b) To make recommendations to the governor and the house of representatives and |
18 | senate finance committees regarding health-care insurance and the regulations, rates, services, |
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1 | administrative expenses, reserve requirements, and operations of insurers providing health |
2 | insurance in the state, and to prepare or comment on, upon the request of the governor or |
3 | chairpersons of the house or senate finance committees, draft legislation to improve the regulation |
4 | of health insurance. In making such recommendations, the commissioner shall recognize that it is |
5 | the intent of the legislature that the maximum disclosure be provided regarding the |
6 | reasonableness of individual administrative expenditures as well as total administrative costs. The |
7 | commissioner shall make recommendations on the levels of reserves, including consideration of: |
8 | targeted reserve levels; trends in the increase or decrease of reserve levels; and insurer plans for |
9 | distributing excess reserves. |
10 | (c) To establish a consumer/business/labor/medical advisory council to obtain |
11 | information and present concerns of consumers, business, and medical providers affected by |
12 | health-insurance decisions. The council shall develop proposals to allow the market for small |
13 | business health insurance to be affordable and fairer. The council shall be involved in the |
14 | planning and conduct of the quarterly public meetings in accordance with subsection (a). The |
15 | advisory council shall develop measures to inform small businesses of an insurance complaint |
16 | process to ensure that small businesses that experience rate increases in a given year may request |
17 | and receive a formal review by the department. The advisory council shall assess views of the |
18 | health-provider community relative to insurance rates of reimbursement, billing, and |
19 | reimbursement procedures, and the insurers' role in promoting efficient and high-quality health |
20 | care. The advisory council shall issue an annual report of findings and recommendations to the |
21 | governor and the general assembly and present its findings at hearings before the house and |
22 | senate finance committees. The advisory council is to be diverse in interests and shall include |
23 | representatives of community consumer organizations; small businesses, other than those |
24 | involved in the sale of insurance products; and hospital, medical, and other health-provider |
25 | organizations. Such representatives shall be nominated by their respective organizations. The |
26 | advisory council shall be co-chaired by the health insurance commissioner and a community |
27 | consumer organization or small business member to be elected by the full advisory council. |
28 | (d) To establish and provide guidance and assistance to a subcommittee ("the |
29 | professional-provider-health-plan work group") of the advisory council created pursuant to |
30 | subsection (c) of this section, composed of health-care providers and Rhode Island licensed health |
31 | plans. This subcommittee shall include in its annual report and presentation before the house and |
32 | senate finance committees the following information: |
33 | (1) A method whereby health plans shall disclose to contracted providers the fee |
34 | schedules used to provide payment to those providers for services rendered to covered patients; |
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1 | (2) A standardized provider application and credentials-verification process, for the |
2 | purpose of verifying professional qualifications of participating health-care providers; |
3 | (3) The uniform health plan claim form utilized by participating providers; |
4 | (4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit |
5 | hospital or medical-service corporations, as defined by chapters 19 and 20 of title 27, to make |
6 | facility-specific data and other medical service-specific data available in reasonably consistent |
7 | formats to patients regarding quality and costs. This information would help consumers make |
8 | informed choices regarding the facilities and/or clinicians or physician practices at which to seek |
9 | care. Among the items considered would be the unique health services and other public goods |
10 | provided by facilities and/or clinicians or physician practices in establishing the most appropriate |
11 | cost comparisons; |
12 | (5) All activities related to contractual disclosure to participating providers of the |
13 | mechanisms for resolving health plan/provider disputes; |
14 | (6) The uniform process being utilized for confirming, in real time, patient insurance |
15 | enrollment status, benefits coverage, including co-pays and deductibles; |
16 | (7) Information related to temporary credentialing of providers seeking to participate in |
17 | the plan's network and the impact of said activity on health-plan accreditation; |
18 | (8) The feasibility of regular contract renegotiations between plans and the providers in |
19 | their networks; and |
20 | (9) Efforts conducted related to reviewing impact of silent PPOs on physician practices. |
21 | (e) To enforce the provisions of Title 27 and Title 42 as set forth in § 42-14-5(d). |
22 | (f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The |
23 | fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17. |
24 | (g) To analyze the impact of changing the rating guidelines and/or merging the individual |
25 | health-insurance market as defined in chapter 18.5 of title 27 and the small-employer-health- |
26 | insurance market as defined in chapter 50 of title 27 in accordance with the following: |
27 | (1) The analysis shall forecast the likely rate increases required to effect the changes |
28 | recommended pursuant to the preceding subsection (g) in the direct-pay market and small- |
29 | employer-health-insurance market over the next five (5) years, based on the current rating |
30 | structure and current products. |
31 | (2) The analysis shall include examining the impact of merging the individual and small- |
32 | employer markets on premiums charged to individuals and small-employer groups. |
33 | (3) The analysis shall include examining the impact on rates in each of the individual and |
34 | small-employer-health-insurance markets and the number of insureds in the context of possible |
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1 | changes to the rating guidelines used for small-employer groups, including: community rating |
2 | principles; expanding small-employer rate bonds beyond the current range; increasing the |
3 | employer group size in the small-group market; and/or adding rating factors for broker and/or |
4 | tobacco use. |
5 | (4) The analysis shall include examining the adequacy of current statutory and regulatory |
6 | oversight of the rating process and factors employed by the participants in the proposed, new |
7 | merged market. |
8 | (5) The analysis shall include assessment of possible reinsurance mechanisms and/or |
9 | federal high-risk pool structures and funding to support the health-insurance market in Rhode |
10 | Island by reducing the risk of adverse selection and the incremental insurance premiums charged |
11 | for this risk, and/or by making health insurance affordable for a selected at-risk population. |
12 | (6) The health insurance commissioner shall work with an insurance market merger task |
13 | force to assist with the analysis. The task force shall be chaired by the health insurance |
14 | commissioner and shall include, but not be limited to, representatives of the general assembly, the |
15 | business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage |
16 | in the individual market in Rhode Island, health-insurance brokers, and members of the general |
17 | public. |
18 | (7) For the purposes of conducting this analysis, the commissioner may contract with an |
19 | outside organization with expertise in fiscal analysis of the private-insurance market. In |
20 | conducting its study, the organization shall, to the extent possible, obtain and use actual health- |
21 | plan data. Said data shall be subject to state and federal laws and regulations governing |
22 | confidentiality of health care and proprietary information. |
23 | (8) The task force shall meet as necessary and include its findings in the annual report, |
24 | and the commissioner shall include the information in the annual presentation before the house |
25 | and senate finance committees. |
26 | (h) To establish and convene a workgroup representing health-care providers and health |
27 | insurers for the purpose of coordinating the development of processes, guidelines, and standards |
28 | to streamline health-care administration that are to be adopted by payors and providers of health- |
29 | care services operating in the state. This workgroup shall include representatives with expertise |
30 | who would contribute to the streamlining of health-care administration and who are selected from |
31 | hospitals, physician practices, community behavioral-health organizations, each health insurer, |
32 | and other affected entities. The workgroup shall also include at least one designee each from the |
33 | Rhode Island Medical Society, Rhode Island Council of Community Mental Health |
34 | Organizations, the Rhode Island Health Center Association, and the Hospital Association of |
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1 | Rhode Island. The workgroup shall consider and make recommendations for: |
2 | (1) Establishing a consistent standard for electronic eligibility and coverage verification. |
3 | Such standard shall: |
4 | (i) Include standards for eligibility inquiry and response and, wherever possible, be |
5 | consistent with the standards adopted by nationally recognized organizations, such as the Centers |
6 | for Medicare and Medicaid Services; |
7 | (ii) Enable providers and payors to exchange eligibility requests and responses on a |
8 | system-to-system basis or using a payor-supported web browser; |
9 | (iii) Provide reasonably detailed information on a consumer's eligibility for health-care |
10 | coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing |
11 | requirements for specific services at the specific time of the inquiry; current deductible amounts; |
12 | accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and |
13 | other information required for the provider to collect the patient's portion of the bill; |
14 | (iv) Reflect the necessary limitations imposed on payors by the originator of the |
15 | eligibility and benefits information; |
16 | (v) Recommend a standard or common process to protect all providers from the costs of |
17 | services to patients who are ineligible for insurance coverage in circumstances where a payor |
18 | provides eligibility verification based on best information available to the payor at the date of the |
19 | request of eligibility. |
20 | (2) Developing implementation guidelines and promoting adoption of such guidelines |
21 | for: |
22 | (i) The use of the National Correct Coding Initiative code-edit policy by payors and |
23 | providers in the state; |
24 | (ii) Publishing any variations from codes and mutually exclusive codes by payors in a |
25 | manner that makes for simple retrieval and implementation by providers; |
26 | (iii) Use of Health Insurance Portability and Accountability Act standard group codes, |
27 | reason codes, and remark codes by payors in electronic remittances sent to providers; |
28 | (iv) The processing of corrections to claims by providers and payors. |
29 | (v) A standard payor-denial review process for providers when they request a |
30 | reconsideration of a denial of a claim that results from differences in clinical edits where no |
31 | single, common-standards body or process exists and multiple conflicting sources are in use by |
32 | payors and providers. |
33 | (vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual |
34 | payor's ability to employ, and not disclose to providers, temporary code edits for the purpose of |
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1 | detecting and deterring fraudulent billing activities. The guidelines shall require that each payor |
2 | disclose to the provider its adjudication decision on a claim that was denied or adjusted based on |
3 | the application of such edits and that the provider have access to the payor's review and appeal |
4 | process to challenge the payor's adjudication decision. |
5 | (vii) Nothing in this subsection shall be construed to modify the rights or obligations of |
6 | payors or providers with respect to procedures relating to the investigation, reporting, appeal, or |
7 | prosecution under applicable law of potentially fraudulent billing activities. |
8 | (3) Developing and promoting widespread adoption by payors and providers of |
9 | guidelines to: |
10 | (i) Ensure payors do not automatically deny claims for services when extenuating |
11 | circumstances make it impossible for the provider to obtain a preauthorization before services are |
12 | performed or notify a payor within an appropriate standardized timeline of a patient's admission; |
13 | (ii) Require payors to use common and consistent processes and time frames when |
14 | responding to provider requests for medical management approvals. Whenever possible, such |
15 | time frames shall be consistent with those established by leading national organizations and be |
16 | based upon the acuity of the patient's need for care or treatment. For the purposes of this section, |
17 | medical management includes prior authorization of services, preauthorization of services, |
18 | precertification of services, post-service review, medical-necessity review, and benefits advisory; |
19 | (iii) Develop, maintain, and promote widespread adoption of a single, common website |
20 | where providers can obtain payors' preauthorization, benefits advisory, and preadmission |
21 | requirements; |
22 | (iv) Establish guidelines for payors to develop and maintain a website that providers can |
23 | use to request a preauthorization, including a prospective clinical necessity review; receive an |
24 | authorization number; and transmit an admission notification. |
25 | (4) To provide a report to the house and senate, on or before January 1, 2017, with |
26 | recommendations for establishing guidelines and regulations for systems that give patients |
27 | electronic access to their claims information, particularly to information regarding their |
28 | obligations to pay for received medical services, pursuant to 45 C.F.R. 164.524. |
29 | (i) To issue an anti-cancer medication report. Not later than June 30, 2014 and annually |
30 | thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate |
31 | committee on health and human services, and the house committee on corporations, with: (1) |
32 | Information on the availability in the commercial market of coverage for anti-cancer medication |
33 | options; (2) For the state employee's health benefit plan, the costs of various cancer-treatment |
34 | options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member |
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1 | utilization and cost-sharing expense. |
2 | (j) To monitor the adequacy of each health plan's compliance with the provisions of the |
3 | federal Mental Health Parity Act, including a review of related claims processing and |
4 | reimbursement procedures. Findings, recommendations, and assessments shall be made available |
5 | to the public. |
6 | (k) To monitor the transition from fee-for-service and toward global and other alternative |
7 | payment methodologies for the payment for health-care services. Alternative payment |
8 | methodologies should be assessed for their likelihood to promote access to affordable health |
9 | insurance, health outcomes, and performance. |
10 | (l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital |
11 | payment variation, including findings and recommendations, subject to available resources. |
12 | (m) Notwithstanding any provision of the general or public laws or regulation to the |
13 | contrary, provide a report with findings and recommendations to the president of the senate and |
14 | the speaker of the house, on or before April 1, 2014, including, but not limited to, the following |
15 | information: |
16 | (1) The impact of the current, mandated health-care benefits as defined in §§ 27-18-48.1, |
17 | 27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41, of title 27, and §§ 27- |
18 | 18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health |
19 | insurance for fully insured employers, subject to available resources; |
20 | (2) Current provider and insurer mandates that are unnecessary and/or duplicative due to |
21 | the existing standards of care and/or delivery of services in the health-care system; |
22 | (3) A state-by-state comparison of health-insurance mandates and the extent to which |
23 | Rhode Island mandates exceed other states benefits; and |
24 | (4) Recommendations for amendments to existing mandated benefits based on the |
25 | findings in subsections (m)(1), (m)(2), and (m)(3) above of this section. |
26 | (n) On or before July 1, 2014, the office of the health insurance commissioner, in |
27 | collaboration with the director of health and lieutenant governor's office, shall submit a report to |
28 | the general assembly and the governor to inform the design of accountable care organizations |
29 | (ACOs) in Rhode Island as unique structures for comprehensive health-care delivery and value- |
30 | based payment arrangements, that shall include, but not be limited to: |
31 | (1) Utilization review; |
32 | (2) Contracting; and |
33 | (3) Licensing and regulation. |
34 | (o) On or before February 3, 2015, the office of the health insurance commissioner shall |
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1 | submit a report to the general assembly and the governor that describes, analyzes, and proposes |
2 | recommendations to improve compliance of insurers with the provisions of § 27-18-76 with |
3 | regard to patients with mental-health and substance-use disorders. |
4 | (p) On or before January 1, 2019, the office of the health insurance commissioner shall |
5 | submit recommendations to the general assembly and the governor that ensure compliance of |
6 | insurers with the mental health parity provisions of §27-38.2-1. |
7 | (q) On or before January 1, 2019, the commissioner shall make recommendations |
8 | regarding: |
9 | (1) Strategies to reduce unreasonable prior authorizations and utilization review |
10 | requirements that result in barriers to access both quantitative and non-quantitative treatments; |
11 | (2) Methods to remediate areas of insurer noncompliance with the mental health parity |
12 | provisions of §27-38.2-1; |
13 | (3) Adequate telemedicine reimbursement rates that will ensure quality access to mental |
14 | health and behavioral health providers; and |
15 | (4) Innovative cost-sharing methodologies that ensure that patient payment obligations |
16 | are not a barrier to care for mental health and behavioral health patients. |
17 | SECTION 2. This act shall take effect upon passage. |
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LC003175 | |
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EXPLANATION | |
BY THE LEGISLATIVE COUNCIL | |
OF | |
A N A C T | |
RELATING TO STATE AFFAIRS AND GOVERNMENT -- THE RHODE ISLAND HEALTH | |
CARE REFORM ACT OF 2004--HEALTH INSURANCE OVERSIGHT | |
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1 | This act would require the health insurance commissioner to make recommendations to |
2 | the general assembly to ensure compliance with mental health parity provisions required by |
3 | existing law. |
4 | This act would take effect upon passage. |
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LC003175 | |
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