2019 -- H 5232

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LC000275

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2019

____________

A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

     Introduced By: Representatives Edwards, Newberry, Azzinaro, Kennedy, and Casey

     Date Introduced: January 30, 2019

     Referred To: House Health, Education & Welfare

     It is enacted by the General Assembly as follows:

     SECTION 1. Section 27-18-76 of the General Laws in Chapter 27-18 entitled "Accident

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

     27-18-76. Emergency services.

     (a) As used in this section:

     (1) "Emergency medical condition" means a medical condition manifesting itself by acute

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

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

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

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

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

part.

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

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

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

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

such emergency medical condition, and

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

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

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

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

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

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

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

emergency services in compliance with this section.

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

following manner:

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

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

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

is a participating network provider with respect to the services;

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

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

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

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

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

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

     (A) The exclusion of or coordination of benefits;

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

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

     (C) Applicable cost-sharing.

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

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

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

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

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

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

subdivision (1) of this subsection shall incur no greater out-of-pocket costs for the emergency

services than the participant or beneficiary would have incurred with an in-network provider

other than the in-network cost sharing. A health insurance carrier complies with the requirements

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

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

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

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

LC000275 - Page 2 of 12

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

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

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

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

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

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

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

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

amount under this subdivision (A) is disregarded.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

apply to out-of-network emergency services.

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

23, 2010.

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

and (9) other limited benefit policies.

     SECTION 2. Section 27-19-66 of the General Laws in Chapter 27-19 entitled "Nonprofit

Hospital Service Corporations" is hereby amended to read as follows:

LC000275 - Page 3 of 12

     27-19-66. Emergency services.

     (a) As used in this section:

     (1) "Emergency medical condition" means a medical condition manifesting itself by acute

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

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

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

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

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

part.

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

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

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

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

such emergency medical condition, and

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

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

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

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

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

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

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

services consistent with the rules of this section.

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

services in the following manner:

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

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

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

is a participating network provider with respect to the services;

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

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

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

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

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

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

LC000275 - Page 4 of 12

     (A) The exclusion of or coordination of benefits;

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

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

     (C) Applicable cost sharing.

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

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

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

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

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

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

(1) of this subsection shall incur no greater out-of-pocket costs for the emergency services than

the participant or beneficiary would have incurred with an in-network provider other than the in-

network cost sharing. A group health plan or health insurance carrier complies with the

requirements of this subsection if it provides benefits with respect to an emergency service in an

amount equal to the greatest of the three amounts specified in subdivisions (A), (B), and (C) of

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

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

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

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

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

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

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

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

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

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

amount under this subdivision (A) is disregarded.

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

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

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

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

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

plan or health insurance coverage with respect to out-of-network services. Thus, for example, if a

plan generally pays seventy percent (70%) of the usual, customary, and reasonable amount for

out-of-network services, the amount in this subdivision (B) for an emergency service is the total,

LC000275 - Page 5 of 12

that is, one hundred percent (100%), of the usual, customary, and reasonable amount for the

service, not reduced by the thirty percent (30%) coinsurance that would generally apply to out-of-

network services (but reduced by the in-network copayment or coinsurance that the individual

would be responsible for if the emergency service had been provided in-network).

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

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

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

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

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

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

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

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

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

apply to out-of-network emergency services.

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

23, 2010.

     (f) This section 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; and (9) Other limited benefit policies.

     SECTION 3. Section 27-20-62 of the General Laws in Chapter 27-20 entitled "Nonprofit

Medical Service Corporations" is hereby amended to read as follows:

     27-20-62. Emergency services.

     (a) As used in this section:

     (1) "Emergency medical condition" means a medical condition manifesting itself by acute

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

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

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

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

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

part.

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

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

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

LC000275 - Page 6 of 12

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

such emergency medical condition, and

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

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

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

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

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

     (b) If a nonprofit medical service corporation offering health insurance coverage provides

any benefits with respect to services in an emergency department of a hospital, it must cover

emergency services consistent with the rules of this section.

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

services in the following manner:

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

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

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

is a participating network provider with respect to the services;

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

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

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

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

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

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

     (A) The exclusion of or coordination of benefits;

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

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

     (C) Applicable cost-sharing.

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

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

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

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

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

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

(1) of this subsection shall incur no greater out-of-pocket costs for the emergency services than

the participant or beneficiary would have incurred with an in-network provider other than the in-

LC000275 - Page 7 of 12

network cost sharing. A group health plan or health insurance carrier complies with the

requirements of this subsection if it provides benefits with respect to an emergency service in an

amount equal to the greatest of the three amounts specified in subdivisions (A), (B), and (C) of

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

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

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

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

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

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

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

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

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

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

amount under this subdivision (A) is disregarded.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

apply to out-of-network emergency services.

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

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

LC000275 - Page 8 of 12

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

     SECTION 4. Section 27-41-79 of the General Laws in Chapter 27-41 entitled "Health

Maintenance Organizations" is hereby amended to read as follows:

     27-41-79. Emergency services.

     (a) As used in this section:

     (1) "Emergency medical condition" means a medical condition manifesting itself by acute

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

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

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

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

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

part.

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

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

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

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

such emergency medical condition, and

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

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

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

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

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

     (b) If a health maintenance organization offering group health insurance coverage

provides any benefits with respect to services in an emergency department of a hospital, it must

cover emergency services consistent with the rules of this section.

     (c) A health maintenance organization shall provide coverage for emergency services in

the following manner:

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

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

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

is a participating network provider with respect to the services;

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

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

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

LC000275 - Page 9 of 12

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

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

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

     (A) The exclusion of or coordination of benefits;

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

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

     (C) Applicable cost sharing.

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

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

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

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

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

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

(1) of this subsection shall incur no greater out-of-pocket costs for the emergency services than

the participant or beneficiary would have incurred with an in-network provider other than the in-

network cost sharing. A health maintenance organization complies with the requirements of this

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

greatest of the three amounts specified in subdivisions (A), (B), and (C) of this subdivision (1)

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

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

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

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

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

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

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

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

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

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

amount under this subdivision (A) is disregarded.

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

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

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

respect to the participant or beneficiary. The amount in this subdivision (B) is determined without

reduction for out-of-network cost sharing that generally applies under the plan or health insurance

LC000275 - Page 10 of 12

coverage with respect to out-of-network services.

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

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

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

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

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

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

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

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

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

apply to out-of-network emergency services.

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

23, 2010.

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

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; and (9) Other limited benefit policies.

     SECTION 5. This act shall take effect upon passage.

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LC000275

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

***

     This act would require that a participant or beneficiary incur no greater out-of-pocket

costs for emergency services than they would have incurred with an in-network provider other

than in-network cost sharing.

     This act would take effect upon passage.

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LC000275

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LC000275 - Page 12 of 12