2020 -- H 7796 | |
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LC004356 | |
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STATE OF RHODE ISLAND | |
IN GENERAL ASSEMBLY | |
JANUARY SESSION, A.D. 2020 | |
____________ | |
A N A C T | |
RELATING TO HEALTH AND SAFETY -- OVERSIGHT OF RISK-BEARING PROVIDER | |
ORGANIZATIONS | |
| |
Introduced By: Representative Joseph M. McNamara | |
Date Introduced: February 26, 2020 | |
Referred To: House Health, Education & Welfare | |
(OHIC) | |
It is enacted by the General Assembly as follows: | |
1 | SECTION 1. Title 23 of the General Laws entitled "HEALTH AND SAFETY" is hereby |
2 | amended by adding thereto the following chapter: |
3 | CHAPTER 17.28 |
4 | OVERSIGHT OF RISK-BEARING PROVIDER ORGANIZATIONS |
5 | 23-17.28-1. Purpose. |
6 | The general assembly declares that: |
7 | (1) It is in the best interest of the public that health care provider organizations that accept |
8 | financial risk for the delivery of health care services in our state meet the standards of this chapter |
9 | to ensure that patient access to health care services and continuity of care are not unnecessarily |
10 | interrupted; and |
11 | (2) It is a vital state function to establish these standards for the conduct of health care |
12 | provider organizations in Rhode Island; and |
13 | (3) Nothing in this chapter is intended to change the obligation of providers or insurers to |
14 | comply with the provisions of title 27. |
15 | 23-17.28-2. Definitions. |
16 | As used in this chapter: |
17 | (1) "Commissioner" means the health insurance commissioner. |
18 | (2) "Health care risk contract" means a health care contract that holds the provider |
| |
1 | organization financially responsible for a negotiated portion or all costs that exceed a |
2 | predetermined health care services budget and thereby transfers insurer risk to the provider |
3 | organization. |
4 | (3) "Health insurer" means every nonprofit medical service corporation, hospital service |
5 | corporation, health maintenance organization, or other insurer offering or insuring health |
6 | services; the term shall in addition include any entity defined as an insurer under § 42-62-4 and |
7 | any third-party administrator when interacting with health care providers and enrollees on behalf |
8 | of the insurer. |
9 | (4) "Provider organization" means any corporation, partnership, business trust, |
10 | association, or organized group of persons in the business of health care delivery or management, |
11 | whether incorporated or not, that represents one or more health care providers in contracting with |
12 | health insurers for the payments of health care services. "Provider organization" shall include, but |
13 | not be limited to, physician organizations, physician-hospital organizations, independent practice |
14 | associations, provider networks, accountable care organizations, systems of care, and any other |
15 | organization that contracts with health insurers for payment for health care services. |
16 | (5) "Risk-bearing provider organization" means a provider organization that has entered |
17 | into a health care risk contract to manage the treatment of a group of patients. |
18 | 23-17.28-3. Certification for provider organizations entering into health care risk |
19 | contracts for Medicaid enrollees. |
20 | (a) The commissioner shall with the express agreement of the Medicaid program, |
21 | establish a process for certifying provider organizations that intend to enter into health care risk |
22 | contracts for Medicaid enrollees. |
23 | (b) The commissioner shall by regulation establish standards for certification, including |
24 | the forms and information required to apply for certification. The standards may consider the |
25 | provider organization's financial position, corporate structure, or other characteristics. |
26 | (c) The commissioner shall issue a finding regarding certification within sixty (60) days |
27 | of the receipt of a complete request pursuant to subsection (b) of this section. If the commissioner |
28 | denies the request for certification, the commissioner will state the reasons for the denial in |
29 | writing, and the provider organization may reapply without prejudice. |
30 | 23-17.28-4. Financial solvency filing and review. |
31 | (a) Review of financial solvency. |
32 | (1) The commissioner shall establish a process for reviewing the financial solvency of |
33 | risk-bearing provider organizations according to the standards established under subsection (b) of |
34 | this section. The commissioner shall utilize standardized forms and streamlined procedures to the |
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1 | extent possible in an effort to minimize the administrative burden on health insurers and risk- |
2 | bearing provider organizations in order to comply with this chapter. |
3 | (2) The commissioner shall issue a finding regarding financial solvency within sixty (60) |
4 | days of the receipt of a complete filing pursuant to subsection (c) or (d) of this section. The |
5 | commissioner shall find one of the following: |
6 | (i) The risk-bearing provider organization meets the standards of financial solvency. |
7 | (ii) The risk-bearing provider organization does not meet the standards of financial |
8 | solvency. Such a finding may be appealed pursuant to, chapter 35 of title 42 (the "administrative |
9 | procedures act"). |
10 | (3) Regardless of the findings pursuant to subsection (a)(2) of this section, the |
11 | commissioner may include additional observations concerning the risk-bearing provider |
12 | organization's financial solvency, including the identification of material risks facing the provider |
13 | organization. |
14 | (b) The commissioner shall establish standards for evaluating financial solvency of risk- |
15 | bearing provider organizations. The standards shall consider all the health care risk contracts that |
16 | a provider organization has entered into at the time of a financial solvency review and will be |
17 | based on factors directly related to the risk-bearing provider organization's financial viability, |
18 | experience managing risk, and risk mitigation strategies to cover potential losses under health |
19 | care risk contracts. |
20 | (c) Within thirty (30) days of executing a health care risk contract, a provider |
21 | organization shall submit to the commissioner a financial report, and any other materials |
22 | necessary to support the financial solvency review. The commissioner shall establish the form |
23 | and content of this filing by regulation, including, but not limited to: |
24 | (1) Material terms of all the health care risk contracts that a provider organization has |
25 | entered into at the time of a financial solvency review; and |
26 | (2) The provider organization's assets, liabilities, reserves, sources of working capital, |
27 | and other sources of financial support. |
28 | Materials submitted under this subsection shall be considered confidential commercial |
29 | information for the purposes of § 38-2-2(4)(B) and shall not be deemed public records. This |
30 | requirement shall not apply to any risk-bearing provider organization that has submitted materials |
31 | under subsection (d) of this section within the previous twelve (12) months. |
32 | (d) Risk-bearing provider organizations shall annually submit to the commissioner a |
33 | financial report, and any other materials necessary to support the financial solvency review. The |
34 | commissioner shall establish the timing, form, and content of this filing by regulation, including, |
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1 | but not limited to: |
2 | (1) Material terms of all the health care risk contracts that a provider organization has |
3 | entered into at the time of a financial solvency review; and |
4 | (2) The provider organization's assets, liabilities, reserves, sources of working capital, |
5 | and other sources of financial support. |
6 | Materials submitted under this subsection shall be considered confidential commercial |
7 | information for the purposes of § 38-2-2(4)(B) and shall not be deemed public records. |
8 | (e) If the commissioner has established one or more categories of risk contracts under § |
9 | 42-14.5-3(t), the commissioner shall establish standards and requirements for risk-bearing |
10 | provider organizations that have entered into specific categories of risk contracts. The |
11 | commissioner may waive all requirements for certain risk contracts or categories of risk contracts |
12 | based on a determination that such contracts pose little risk to consumers. |
13 | 23-17.28-5. Corrective action plan. |
14 | (a) If the commissioner finds that a risk-bearing provider organization does not meet the |
15 | standards of financial solvency under § 23-17.28-4(a): |
16 | (1) The commissioner will identify specific deficiencies with respect to the standards of |
17 | financial solvency that need to be addressed by the risk-bearing provider organization. |
18 | (2) The commissioner will notify the executive office of health and human services and |
19 | any health insurers that have informed the office of the health insurance commissioner that they |
20 | are holding health care risk contracts with the provider organization. |
21 | (3) The risk-bearing provider organization will establish a corrective action plan to |
22 | address the deficiencies identified by the commissioner, submit the plan to the commissioner, and |
23 | update the commissioner on the status of corrective actions on an ongoing basis as requested. The |
24 | commissioner may establish standards for such corrective action plans by regulation. |
25 | (b) Ninety (90) days following a finding that a risk-bearing provider organization does |
26 | not meet the standards of financial solvency under § 23-17.28-4(a), the risk-bearing provider |
27 | organization shall demonstrate compliance with the corrective action plan under subsection (a)(3) |
28 | of this section. |
29 | 23-17.28-6. Prohibition on contracting with certain risk-bearing provider |
30 | organizations. |
31 | (a) If the commissioner has issued a finding that a risk-bearing provider organization |
32 | does not meet the standards of financial solvency, the provider organization may not enter into or |
33 | renew a health care risk contract without prior approval of the commissioner until such time as |
34 | the commissioner issues a finding that the provider organization meets the standards of financial |
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1 | solvency. |
2 | (b) A provider organization may not enter into or renew a health care risk contract for |
3 | Medicaid members if the provider organization has not been certified under § 23-17.28-3. |
4 | 23-17.28-7. Duty to update. |
5 | Risk-bearing provider organizations that have previously submitted an annual financial |
6 | report to the commissioner under § 23-17.28-4(c) shall: |
7 | (1) Notify the commissioner within thirty (30) days of any material changes to its |
8 | financial position, including changes to health care risk contracts that increase the amount of risk |
9 | borne by the provider organization, or reduces risk mitigation, such as through a reduction in stop |
10 | loss insurance coverage, and; |
11 | (2) Notify the commissioner within two (2) days should the risk-bearing organization |
12 | become insolvent, or recognize it is in the process of becoming insolvent. |
13 | 23-17.28-8. Administrative penalties. |
14 | (a) Whenever the commissioner shall have cause to believe that a violation of this chapter |
15 | has occurred by any provider organization, the commissioner may, in accordance with the |
16 | requirements of, chapter 35 of title 42 (the "administrative procedures act"): |
17 | (1) Levy an administrative penalty in an amount not less than one thousand dollars |
18 | ($1000) nor more than fifty thousand dollars ($50,000); |
19 | (2) Order the violator to cease such actions; |
20 | (3) Require the provider organization to take such actions as are necessary to comply |
21 | with this chapter, or the regulations thereunder; or |
22 | (4) Any combination of the above penalties. |
23 | (b) Any monetary penalties assessed pursuant to this section shall be deposited as general |
24 | revenues. |
25 | SECTION 2. Section 27-20.9-1 of the General Laws in Chapter 27-20.9 entitled |
26 | "Contract With Health Care Providers" is hereby amended to read as follows: |
27 | 27-20.9-1. Health care contracts -- Required provisions -- Definitions. |
28 | (a) On and after January 1, 2008, a health insurer that contracts with a health care |
29 | provider shall comply with the provisions of this chapter and shall include the provisions required |
30 | by this chapter in the health care contract. A contract in existence prior to January 1, 2008, that is |
31 | renewed or renews by its terms shall comply with the provisions of this chapter no later than |
32 | December 31, 2008. |
33 | (b) As used in this chapter, unless the context otherwise requires: |
34 | (1) "Health care contract" means a contract entered into or renewed between a health |
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1 | insurer and a health care provider for the delivery of health care services to others. |
2 | (2) "Health care provider" means a person licensed or certified in this state to practice |
3 | medicine, pharmacy, chiropractic, nursing, physical therapy, podiatry, dentistry, optometry, |
4 | occupational therapy, or other healing arts. |
5 | (3) "Health care risk contract" means a health care contract that holds the provider |
6 | organization financially responsible for a negotiated portion or all of the costs that exceed a |
7 | predetermined health care services budget and thereby transfers insurer risk to the provider |
8 | organization. |
9 | (3)(4) "Health insurer" means every nonprofit medical service corporation, hospital |
10 | service corporation, health maintenance organization, or other insurer offering and/or insuring |
11 | health services; the term shall in addition include any entity defined as an insurer under § 42-62-4 |
12 | and any third-party administrator when interacting with health care providers and enrollees on |
13 | behalf of such an insurer. |
14 | (5) "Provider organization" means any corporation, partnership, business, trust, |
15 | association, or organized group of persons in the business of health care delivery or management |
16 | whether incorporated or not that represents one or more health care providers in contracting with |
17 | health insurers for the payments of health care services. "Provider organization" shall include, but |
18 | not be limited to, physician organizations, physician-hospital organizations, independent practice |
19 | associations, provider networks, accountable care organizations, systems of care, and any other |
20 | organization that contracts with health insurers for payment for health care services. |
21 | (6) "Risk-bearing provider organization" means a provider organization that has entered |
22 | into a health care risk contract to manage the treatment of a group of patients. For the purposes of |
23 | this chapter, Programs of All-Inclusive Care for the Elderly (PACE) shall not be considered a |
24 | provider organization. |
25 | SECTION 3. Chapter 27-20.9 of the General Laws entitled "Contract With Health Care |
26 | Providers" is hereby amended by adding thereto the following section: |
27 | 27-20.9-4. Health care risk contracts. |
28 | (a) A health insurer shall submit information about each health care risk contract as |
29 | directed by the health insurance commissioner set forth by regulation. The commissioner will |
30 | utilize standardized forms and streamlined procedures to the extent possible in an effort to |
31 | minimize the administrative burden on health insurers and risk-bearing provider organizations in |
32 | order to comply with this chapter. |
33 | (b) A health insurer shall submit health care risk contracts and relevant related material to |
34 | the commissioner within thirty (30) days of a request of such information. Such contracts shall be |
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1 | considered confidential and privileged commercial information for the purposes of § 38-2-2(4)(B) |
2 | and shall not be deemed public records. |
3 | (c) A health insurer shall not enter into or renew a health care risk contract with a |
4 | provider organization for which the commissioner has issued a finding that the provider |
5 | organization does not meet the standards of financial solvency under § 23-17.28-4, until such |
6 | time as the commissioner issues a finding that the provider organization meets the standards of |
7 | financial solvency. |
8 | (d) A health insurer shall not enter into or renew a health care risk contract for Medicaid |
9 | members with a provider organization that has not been certified as provided in § 23-17.28-3. |
10 | (e) Each health insurer shall provide the commissioner with a list of all provider |
11 | organizations with which it has entered into a health care risk contract on an annual basis. If the |
12 | commissioner has established one or more categories of risk contracts under § 42-14.5-3(t), the |
13 | health insurer will indicate which category of risk contract each risk-bearing provider |
14 | organization holds. |
15 | (f) The commissioner may establish additional requirements for health care risk contracts |
16 | by regulation. |
17 | SECTION 4. Section 42-14.5-3 of the General Laws in Chapter 42-14.5 entitled "The |
18 | Rhode Island Health Care Reform Act of 2004 - Health Insurance Oversight" is hereby amended |
19 | to read as follows: |
20 | 42-14.5-3. Powers and duties. |
21 | The health insurance commissioner shall have the following powers and duties: |
22 | (a) To conduct quarterly public meetings throughout the state, separate and distinct from |
23 | rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers |
24 | licensed to provide health insurance in the state; the effects of such rates, services, and operations |
25 | on consumers, medical care providers, patients, and the market environment in which the insurers |
26 | operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less |
27 | than ten (10) days of the hearing(s) shall go to the general assembly, the governor, the Rhode |
28 | Island Medical Society, the Hospital Association of Rhode Island, the director of health, the |
29 | attorney general, and the chambers of commerce. Public notice shall be posted on the |
30 | department's website and given in the newspaper of general circulation, and to any entity in |
31 | writing requesting notice. |
32 | (b) To make recommendations to the governor and the house of representatives and |
33 | senate finance committees regarding health-care insurance and the regulations, rates, services, |
34 | administrative expenses, reserve requirements, and operations of insurers providing health |
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1 | insurance in the state, and to prepare or comment on, upon the request of the governor or |
2 | chairpersons of the house or senate finance committees, draft legislation to improve the regulation |
3 | of health insurance. In making the recommendations, the commissioner shall recognize that it is |
4 | the intent of the legislature that the maximum disclosure be provided regarding the |
5 | reasonableness of individual administrative expenditures as well as total administrative costs. The |
6 | commissioner shall make recommendations on the levels of reserves, including consideration of: |
7 | targeted reserve levels; trends in the increase or decrease of reserve levels; and insurer plans for |
8 | distributing excess reserves. |
9 | (c) To establish a consumer/business/labor/medical advisory council to obtain |
10 | information and present concerns of consumers, business, and medical providers affected by |
11 | health-insurance decisions. The council shall develop proposals to allow the market for small |
12 | business health insurance to be affordable and fairer. The council shall be involved in the |
13 | planning and conduct of the quarterly public meetings in accordance with subsection (a). The |
14 | advisory council shall develop measures to inform small businesses of an insurance complaint |
15 | process to ensure that small businesses that experience rate increases in a given year may request |
16 | and receive a formal review by the department. The advisory council shall assess views of the |
17 | health-provider community relative to insurance rates of reimbursement, billing, and |
18 | reimbursement procedures, and the insurers' role in promoting efficient and high-quality health |
19 | care. The advisory council shall issue an annual report of findings and recommendations to the |
20 | governor and the general assembly and present its findings at hearings before the house and |
21 | senate finance committees. The advisory council is to be diverse in interests and shall include |
22 | representatives of community consumer organizations; small businesses, other than those |
23 | involved in the sale of insurance products; and hospital, medical, and other health-provider |
24 | organizations. Such representatives shall be nominated by their respective organizations. The |
25 | advisory council shall be co-chaired by the health insurance commissioner and a community |
26 | consumer organization or small business member to be elected by the full advisory council. |
27 | (d) To establish and provide guidance and assistance to a subcommittee ("the |
28 | professional-provider-health-plan work group") of the advisory council created pursuant to |
29 | subsection (c), composed of health-care providers and Rhode Island licensed health plans. This |
30 | subcommittee shall include in its annual report and presentation before the house and senate |
31 | finance committees the following information: |
32 | (1) A method whereby health plans shall disclose to contracted providers the fee |
33 | schedules used to provide payment to those providers for services rendered to covered patients; |
34 | (2) A standardized provider application and credentials-verification process, for the |
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1 | purpose of verifying professional qualifications of participating health-care providers; |
2 | (3) The uniform health plan claim form utilized by participating providers; |
3 | (4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit |
4 | hospital or medical-service corporations, as defined by chapters 19 and 20 of title 27, to make |
5 | facility-specific data and other medical service-specific data available in reasonably consistent |
6 | formats to patients regarding quality and costs. This information would help consumers make |
7 | informed choices regarding the facilities and clinicians or physician practices at which to seek |
8 | care. Among the items considered would be the unique health services and other public goods |
9 | provided by facilities and clinicians or physician practices in establishing the most appropriate |
10 | cost comparisons; |
11 | (5) All activities related to contractual disclosure to participating providers of the |
12 | mechanisms for resolving health plan/provider disputes; |
13 | (6) The uniform process being utilized for confirming, in real time, patient insurance |
14 | enrollment status, benefits coverage, including co-pays and deductibles; |
15 | (7) Information related to temporary credentialing of providers seeking to participate in |
16 | the plan's network and the impact of the activity on health-plan accreditation; |
17 | (8) The feasibility of regular contract renegotiations between plans and the providers in |
18 | their networks; and |
19 | (9) Efforts conducted related to reviewing impact of silent PPOs on physician practices. |
20 | (e) To enforce the provisions of Title 27 and Title 42 as set forth in § 42-14-5(d). |
21 | (f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The |
22 | fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17. |
23 | (g) To analyze the impact of changing the rating guidelines and/or merging the individual |
24 | health-insurance market, as defined in chapter 18.5 of title 27, and the small-employer-health- |
25 | insurance market, as defined in chapter 50 of title 27, in accordance with the following: |
26 | (1) The analysis shall forecast the likely rate increases required to effect the changes |
27 | recommended pursuant to the preceding subsection (g) in the direct-pay market and small- |
28 | employer-health-insurance market over the next five (5) years, based on the current rating |
29 | structure and current products. |
30 | (2) The analysis shall include examining the impact of merging the individual and small- |
31 | employer markets on premiums charged to individuals and small-employer groups. |
32 | (3) The analysis shall include examining the impact on rates in each of the individual and |
33 | small-employer health-insurance markets and the number of insureds in the context of possible |
34 | changes to the rating guidelines used for small-employer groups, including: community rating |
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1 | principles; expanding small-employer rate bonds beyond the current range; increasing the |
2 | employer group size in the small-group market; and/or adding rating factors for broker and/or |
3 | tobacco use. |
4 | (4) The analysis shall include examining the adequacy of current statutory and regulatory |
5 | oversight of the rating process and factors employed by the participants in the proposed, new |
6 | merged market. |
7 | (5) The analysis shall include assessment of possible reinsurance mechanisms and/or |
8 | federal high-risk pool structures and funding to support the health-insurance market in Rhode |
9 | Island by reducing the risk of adverse selection and the incremental insurance premiums charged |
10 | for this risk, and/or by making health insurance affordable for a selected at-risk population. |
11 | (6) The health insurance commissioner shall work with an insurance market merger task |
12 | force to assist with the analysis. The task force shall be chaired by the health insurance |
13 | commissioner and shall include, but not be limited to, representatives of the general assembly, the |
14 | business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage |
15 | in the individual market in Rhode Island, health-insurance brokers, and members of the general |
16 | public. |
17 | (7) For the purposes of conducting this analysis, the commissioner may contract with an |
18 | outside organization with expertise in fiscal analysis of the private-insurance market. In |
19 | conducting its study, the organization shall, to the extent possible, obtain and use actual health- |
20 | plan data. Said data shall be subject to state and federal laws and regulations governing |
21 | confidentiality of health care and proprietary information. |
22 | (8) The task force shall meet as necessary and include its findings in the annual report, |
23 | and the commissioner shall include the information in the annual presentation before the house |
24 | and senate finance committees. |
25 | (h) To establish and convene a workgroup representing health-care providers and health |
26 | insurers for the purpose of coordinating the development of processes, guidelines, and standards |
27 | to streamline health-care administration that are to be adopted by payors and providers of health- |
28 | care services operating in the state. This workgroup shall include representatives with expertise |
29 | who would contribute to the streamlining of health-care administration and who are selected from |
30 | hospitals, physician practices, community behavioral-health organizations, each health insurer, |
31 | and other affected entities. The workgroup shall also include at least one designee each from the |
32 | Rhode Island Medical Society, Rhode Island Council of Community Mental Health |
33 | Organizations, the Rhode Island Health Center Association, and the Hospital Association of |
34 | Rhode Island. The workgroup shall consider and make recommendations for: |
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1 | (1) Establishing a consistent standard for electronic eligibility and coverage verification. |
2 | Such standard shall: |
3 | (i) Include standards for eligibility inquiry and response and, wherever possible, be |
4 | consistent with the standards adopted by nationally recognized organizations, such as the Centers |
5 | for Medicare and Medicaid Services; |
6 | (ii) Enable providers and payors to exchange eligibility requests and responses on a |
7 | system-to-system basis or using a payor-supported web browser; |
8 | (iii) Provide reasonably detailed information on a consumer's eligibility for health-care |
9 | coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing |
10 | requirements for specific services at the specific time of the inquiry; current deductible amounts; |
11 | accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and |
12 | other information required for the provider to collect the patient's portion of the bill; |
13 | (iv) Reflect the necessary limitations imposed on payors by the originator of the |
14 | eligibility and benefits information; |
15 | (v) Recommend a standard or common process to protect all providers from the costs of |
16 | services to patients who are ineligible for insurance coverage in circumstances where a payor |
17 | provides eligibility verification based on best information available to the payor at the date of the |
18 | request of eligibility. |
19 | (2) Developing implementation guidelines and promoting adoption of the guidelines for: |
20 | (i) The use of the National Correct Coding Initiative code-edit policy by payors and |
21 | providers in the state; |
22 | (ii) Publishing any variations from codes and mutually exclusive codes by payors in a |
23 | manner that makes for simple retrieval and implementation by providers; |
24 | (iii) Use of Health Insurance Portability and Accountability Act standard group codes, |
25 | reason codes, and remark codes by payors in electronic remittances sent to providers; |
26 | (iv) The processing of corrections to claims by providers and payors. |
27 | (v) A standard payor-denial review process for providers when they request a |
28 | reconsideration of a denial of a claim that results from differences in clinical edits where no |
29 | single, common-standards body or process exists and multiple conflicting sources are in use by |
30 | payors and providers. |
31 | (vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual |
32 | payor's ability to employ, and not disclose to providers, temporary code edits for the purpose of |
33 | detecting and deterring fraudulent billing activities. The guidelines shall require that each payor |
34 | disclose to the provider its adjudication decision on a claim that was denied or adjusted based on |
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1 | the application of such edits and that the provider have access to the payor's review and appeal |
2 | process to challenge the payor's adjudication decision. |
3 | (vii) Nothing in this subsection shall be construed to modify the rights or obligations of |
4 | payors or providers with respect to procedures relating to the investigation, reporting, appeal, or |
5 | prosecution under applicable law of potentially fraudulent billing activities. |
6 | (3) Developing and promoting widespread adoption by payors and providers of |
7 | guidelines to: |
8 | (i) Ensure payors do not automatically deny claims for services when extenuating |
9 | circumstances make it impossible for the provider to obtain a preauthorization before services are |
10 | performed or notify a payor within an appropriate standardized timeline of a patient's admission; |
11 | (ii) Require payors to use common and consistent processes and time frames when |
12 | responding to provider requests for medical management approvals. Whenever possible, such |
13 | time frames shall be consistent with those established by leading national organizations and be |
14 | based upon the acuity of the patient's need for care or treatment. For the purposes of this section, |
15 | medical management includes prior authorization of services, preauthorization of services, |
16 | precertification of services, post-service review, medical-necessity review, and benefits advisory; |
17 | (iii) Develop, maintain, and promote widespread adoption of a single, common website |
18 | where providers can obtain payors' preauthorization, benefits advisory, and preadmission |
19 | requirements; |
20 | (iv) Establish guidelines for payors to develop and maintain a website that providers can |
21 | use to request a preauthorization, including a prospective clinical necessity review; receive an |
22 | authorization number; and transmit an admission notification. |
23 | (4) To provide a report to the house and senate, on or before January 1, 2017, with |
24 | recommendations for establishing guidelines and regulations for systems that give patients |
25 | electronic access to their claims information, particularly to information regarding their |
26 | obligations to pay for received medical services, pursuant to 45 C.F.R. 164.524. |
27 | (i) To issue an anti-cancer medication report. Not later than June 30, 2014 and annually |
28 | thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate |
29 | committee on health and human services, and the house committee on corporations, with: (1) |
30 | Information on the availability in the commercial market of coverage for anti-cancer medication |
31 | options; (2) For the state employee's health benefit plan, the costs of various cancer-treatment |
32 | options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member |
33 | utilization and cost-sharing expense. |
34 | (j) To monitor the adequacy of each health plan's compliance with the provisions of the |
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1 | federal Mental Health Parity Act, including a review of related claims processing and |
2 | reimbursement procedures. Findings, recommendations, and assessments shall be made available |
3 | to the public. |
4 | (k) To monitor the transition from fee-for-service and toward global and other alternative |
5 | payment methodologies for the payment for health-care services. Alternative payment |
6 | methodologies should be assessed for their likelihood to promote access to affordable health |
7 | insurance, health outcomes, and performance. |
8 | (l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital |
9 | payment variation, including findings and recommendations, subject to available resources. |
10 | (m) Notwithstanding any provision of the general or public laws or regulation to the |
11 | contrary, provide a report with findings and recommendations to the president of the senate and |
12 | the speaker of the house, on or before April 1, 2014, including, but not limited to, the following |
13 | information: |
14 | (1) The impact of the current, mandated health-care benefits as defined in §§ 27-18-48.1, |
15 | 27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41, of title 27, and §§ 27- |
16 | 18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health |
17 | insurance for fully insured employers, subject to available resources; |
18 | (2) Current provider and insurer mandates that are unnecessary and/or duplicative due to |
19 | the existing standards of care and/or delivery of services in the health-care system; |
20 | (3) A state-by-state comparison of health-insurance mandates and the extent to which |
21 | Rhode Island mandates exceed other states benefits; and |
22 | (4) Recommendations for amendments to existing mandated benefits based on the |
23 | findings in (m)(1), (m)(2), and (m)(3) above. |
24 | (n) On or before July 1, 2014, the office of the health insurance commissioner, in |
25 | collaboration with the director of health and lieutenant governor's office, shall submit a report to |
26 | the general assembly and the governor to inform the design of accountable care organizations |
27 | (ACOs) in Rhode Island as unique structures for comprehensive health-care delivery and value- |
28 | based payment arrangements, that shall include, but not be limited to: |
29 | (1) Utilization review; |
30 | (2) Contracting; and |
31 | (3) Licensing and regulation. |
32 | (o) On or before February 3, 2015, the office of the health insurance commissioner shall |
33 | submit a report to the general assembly and the governor that describes, analyzes, and proposes |
34 | recommendations to improve compliance of insurers with the provisions of § 27-18-76 with |
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1 | regard to patients with mental-health and substance-use disorders. |
2 | (p) To work to ensure the health insurance coverage of behavioral health care under the |
3 | same terms and conditions as other health care, and to integrate behavioral health parity |
4 | requirements into the office of the health insurance commissioner insurance oversight and health |
5 | care transformation efforts. |
6 | (q) To work with other state agencies to seek delivery system improvements that enhance |
7 | access to a continuum of mental-health and substance-use disorder treatment in the state; and |
8 | integrate that treatment with primary and other medical care to the fullest extent possible. |
9 | (r) To direct insurers toward policies and practices that address the behavioral health |
10 | needs of the public and greater integration of physical and behavioral health care delivery. |
11 | (s) The office of the health insurance commissioner shall conduct an analysis of the |
12 | impact of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode |
13 | Island and submit a report of its findings to the general assembly on or before June 1, 2023. |
14 | (t) To protect the consumer interest through establishment, monitoring and enforcement |
15 | of requirements related to health care risk contracts as defined in § 27-20.9-1 and risk-bearing |
16 | provider organizations as defined in § 23-17.28-2, including the following: |
17 | (1) To certify certain provider organizations as eligible to enter into health care risk |
18 | contracts for Medicaid populations, pursuant to chapter 17.28 of title 23. |
19 | (2) To establish multiple categories of health care risk contracts based on the amount of |
20 | risk to which the risk-bearing provider organization is exposed. The health insurance |
21 | commissioner may apply different standards and requirements related to health care risk contracts |
22 | based on the category of the relevant risk contract. |
23 | (3) To evaluate the financial solvency of risk-bearing provider organizations and take |
24 | additional actions pursuant to chapter 17.28 of title 23 and chapter 20.9 of title 27. |
25 | (4) To enact appropriate regulations to protect the consumer interest with respect to |
26 | health care risk contracts. |
27 | SECTION 5. This act shall take effect upon passage. |
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EXPLANATION | |
BY THE LEGISLATIVE COUNCIL | |
OF | |
A N A C T | |
RELATING TO HEALTH AND SAFETY -- OVERSIGHT OF RISK-BEARING PROVIDER | |
ORGANIZATIONS | |
*** | |
1 | This act would provide the office of the health insurance commissioner (OHIC) with |
2 | oversight of risk-bearing provider organizations and health care risk contracts. |
3 | This act would take effect upon passage. |
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