2020 -- S 2525 SUBSTITUTE A

========

LC004557/SUB A

========

     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2020

____________

A N   A C T

RELATING TO STATE AFFAIRS AND GOVERNMENT -- THE RHODE ISLAND HEALTH

CARE REFORM ACT OF 2004--HEALTH INSURANCE OVERSIGHT

     Introduced By: Senators Miller, Goldin, Valverde, Satchell, and Goodwin

     Date Introduced: February 25, 2020

     Referred To: Senate Health & Human Services

     It is enacted by the General Assembly as follows:

     SECTION 1. The general assembly finds and declares that:

     (1) It is necessary to foster greater coordination between patients, healthcare providers, and

health insurers to ensure patient health and well-being. Easing administrative burdens imposed on

healthcare providers, such as prior authorization requirements, better facilitates quality patient care,

allows providers to spend more time on patient care, better enables delivery of healthcare services,

and improves timeliness of care.

     (2) During the COVID-19 crisis it has become clear that patients and providers benefit

substantially from having access to telemedicine services that are covered by health insurers on the

same basis as in-person services.

     (3) It is essential to facilitate the delivery of telemedicine services as a convenient, easily

accessible, and affordable option to both health care providers and patients. Low-cost telephone

and other internet-based audio-only and live video technologies are widely available and accessible

to health care providers and patients. These technologies enable the delivery of clinically

appropriate, medically necessary health care services, including behavioral health care services, to

patients in a safe and accessible manner.

     (4) There is a need in this state to embrace efforts that will encourage patients, health

insurers and healthcare providers to support the use of telemedicine, and that will also encourage

all state agencies to evaluate and amend their policies and rules to remove any regulatory barriers

prohibiting the use of telemedicine services or reimbursing for such services on a discriminatory

basis relative to in-person services.

     SECTION 2. Section 42-14.5-3 of the General Laws in Chapter 42-14.5 entitled "The

Rhode Island Health Care Reform Act of 2004 - Health Insurance Oversight" is hereby amended

to read as follows:

     42-14.5-3. Powers and duties.

     The health insurance commissioner shall have the following powers and duties:

     (a) To conduct quarterly public meetings throughout the state, separate and distinct from

rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers

licensed to provide health insurance in the state; the effects of such rates, services, and operations

on consumers, medical care providers, patients, and the market environment in which the insurers

operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less

than ten (10) days of the hearing(s) shall go to the general assembly, the governor, the Rhode Island

Medical Society, the Hospital Association of Rhode Island, the director of health, the attorney

general, and the chambers of commerce. Public notice shall be posted on the department's website

and given in the newspaper of general circulation, and to any entity in writing requesting notice.

     (b) To make recommendations to the governor and the house of representatives and senate

finance committees regarding health-care insurance and the regulations, rates, services,

administrative expenses, reserve requirements, and operations of insurers providing health

insurance in the state, and to prepare or comment on, upon the request of the governor or

chairpersons of the house or senate finance committees, draft legislation to improve the regulation

of health insurance. In making the recommendations, the commissioner shall recognize that it is

the intent of the legislature that the maximum disclosure be provided regarding the reasonableness

of individual administrative expenditures as well as total administrative costs. The commissioner

shall make recommendations on the levels of reserves, including consideration of: targeted reserve

levels; trends in the increase or decrease of reserve levels; and insurer plans for distributing excess

reserves.

     (c) To establish a consumer/business/labor/medical advisory council to obtain information

and present concerns of consumers, business, and medical providers affected by health-insurance

decisions. The council shall develop proposals to allow the market for small business health

insurance to be affordable and fairer. The council shall be involved in the planning and conduct of

the quarterly public meetings in accordance with subsection (a). The advisory council shall develop

measures to inform small businesses of an insurance complaint process to ensure that small

businesses that experience rate increases in a given year may request and receive a formal review

LC004557/SUB A - Page 2 of 12

by the department. The advisory council shall assess views of the health-provider community

relative to insurance rates of reimbursement, billing, and reimbursement procedures, and the

insurers' role in promoting efficient and high-quality health care. The advisory council shall issue

an annual report of findings and recommendations to the governor and the general assembly and

present its findings at hearings before the house and senate finance committees. The advisory

council is to be diverse in interests and shall include representatives of community consumer

organizations; small businesses, other than those involved in the sale of insurance products; and

hospital, medical, and other health-provider organizations. Such representatives shall be nominated

by their respective organizations. The advisory council shall be co-chaired by the health insurance

commissioner and a community consumer organization or small business member to be elected by

the full advisory council.

     (d) To establish and provide guidance and assistance to a subcommittee ("the professional-

provider-health-plan work group") of the advisory council created pursuant to subsection (c),

composed of health-care providers and Rhode Island licensed health plans. This subcommittee shall

include in its annual report and presentation before the house and senate finance committees the

following information:

     (1) A method whereby health plans shall disclose to contracted providers the fee schedules

used to provide payment to those providers for services rendered to covered patients;

     (2) A standardized provider application and credentials-verification process, for the

purpose of verifying professional qualifications of participating health-care providers;

     (3) The uniform health plan claim form utilized by participating providers;

     (4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit

hospital or medical-service corporations, as defined by chapters 19 and 20 of title 27, to make

facility-specific data and other medical service-specific data available in reasonably consistent

formats to patients regarding quality and costs. This information would help consumers make

informed choices regarding the facilities and clinicians or physician practices at which to seek care.

Among the items considered would be the unique health services and other public goods provided

by facilities and clinicians or physician practices in establishing the most appropriate cost

comparisons;

     (5) All activities related to contractual disclosure to participating providers of the

mechanisms for resolving health plan/provider disputes;

     (6) The uniform process being utilized for confirming, in real time, patient insurance

enrollment status, benefits coverage, including co-pays and deductibles;

     (7) Information related to temporary credentialing of providers seeking to participate in the

LC004557/SUB A - Page 3 of 12

plan's network and the impact of the activity on health-plan accreditation;

     (8) The feasibility of regular contract renegotiations between plans and the providers in

their networks; and

     (9) Efforts conducted related to reviewing impact of silent PPOs on physician practices.

     (e) To enforce the provisions of Title 27 and Title 42 as set forth in § 42-14-5(d).

     (f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The

fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17.

     (g) To analyze the impact of changing the rating guidelines and/or merging the individual

health-insurance market, as defined in chapter 18.5 of title 27, and the small-employer-health-

insurance market, as defined in chapter 50 of title 27, in accordance with the following:

     (1) The analysis shall forecast the likely rate increases required to effect the changes

recommended pursuant to the preceding subsection (g) in the direct-pay market and small-

employer-health-insurance market over the next five (5) years, based on the current rating structure

and current products.

     (2) The analysis shall include examining the impact of merging the individual and small-

employer markets on premiums charged to individuals and small-employer groups.

     (3) The analysis shall include examining the impact on rates in each of the individual and

small-employer health-insurance markets and the number of insureds in the context of possible

changes to the rating guidelines used for small-employer groups, including: community rating

principles; expanding small-employer rate bonds beyond the current range; increasing the employer

group size in the small-group market; and/or adding rating factors for broker and/or tobacco use.

     (4) The analysis shall include examining the adequacy of current statutory and regulatory

oversight of the rating process and factors employed by the participants in the proposed, new

merged market.

     (5) The analysis shall include assessment of possible reinsurance mechanisms and/or

federal high-risk pool structures and funding to support the health-insurance market in Rhode Island

by reducing the risk of adverse selection and the incremental insurance premiums charged for this

risk, and/or by making health insurance affordable for a selected at-risk population.

     (6) The health insurance commissioner shall work with an insurance market merger task

force to assist with the analysis. The task force shall be chaired by the health insurance

commissioner and shall include, but not be limited to, representatives of the general assembly, the

business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage in

the individual market in Rhode Island, health-insurance brokers, and members of the general

public.

LC004557/SUB A - Page 4 of 12

     (7) For the purposes of conducting this analysis, the commissioner may contract with an

outside organization with expertise in fiscal analysis of the private-insurance market. In conducting

its study, the organization shall, to the extent possible, obtain and use actual health-plan data. Said

data shall be subject to state and federal laws and regulations governing confidentiality of health

care and proprietary information.

     (8) The task force shall meet as necessary and include its findings in the annual report, and

the commissioner shall include the information in the annual presentation before the house and

senate finance committees.

     (h) To establish and convene a workgroup representing health-care providers and health

insurers for the purpose of coordinating the development of processes, guidelines, and standards to

streamline health-care administration that are to be adopted by payors and providers of health-care

services operating in the state. This workgroup shall include representatives with expertise who

would contribute to the streamlining of health-care administration and who are selected from

hospitals, physician practices, community behavioral-health organizations, each health insurer, and

other affected entities. The workgroup shall also include at least one designee each from the Rhode

Island Medical Society, Rhode Island Council of Community Mental Health Organizations, the

Rhode Island Health Center Association, and the Hospital Association of Rhode Island. The

workgroup shall consider and make recommendations for:

     (1) Establishing a consistent standard for electronic eligibility and coverage verification.

Such standard shall:

     (i) Include standards for eligibility inquiry and response and, wherever possible, be

consistent with the standards adopted by nationally recognized organizations, such as the Centers

for Medicare and Medicaid Services;

     (ii) Enable providers and payors to exchange eligibility requests and responses on a system-

to-system basis or using a payor-supported web browser;

     (iii) Provide reasonably detailed information on a consumer's eligibility for health-care

coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing

requirements for specific services at the specific time of the inquiry; current deductible amounts;

accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and

other information required for the provider to collect the patient's portion of the bill;

     (iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility

and benefits information;

     (v) Recommend a standard or common process to protect all providers from the costs of

services to patients who are ineligible for insurance coverage in circumstances where a payor

LC004557/SUB A - Page 5 of 12

provides eligibility verification based on best information available to the payor at the date of the

request of eligibility.

     (2) Developing implementation guidelines and promoting adoption of the guidelines for:

     (i) The use of the National Correct Coding Initiative code-edit policy by payors and

providers in the state;

     (ii) Publishing any variations from codes and mutually exclusive codes by payors in a

manner that makes for simple retrieval and implementation by providers;

     (iii) Use of Health Insurance Portability and Accountability Act standard group codes,

reason codes, and remark codes by payors in electronic remittances sent to providers;

     (iv) The processing of corrections to claims by providers and payors.

     (v) A standard payor-denial review process for providers when they request a

reconsideration of a denial of a claim that results from differences in clinical edits where no single,

common-standards body or process exists and multiple conflicting sources are in use by payors and

providers.

     (vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual

payor's ability to employ, and not disclose to providers, temporary code edits for the purpose of

detecting and deterring fraudulent billing activities. The guidelines shall require that each payor

disclose to the provider its adjudication decision on a claim that was denied or adjusted based on

the application of such edits and that the provider have access to the payor's review and appeal

process to challenge the payor's adjudication decision.

     (vii) Nothing in this subsection shall be construed to modify the rights or obligations of

payors or providers with respect to procedures relating to the investigation, reporting, appeal, or

prosecution under applicable law of potentially fraudulent billing activities.

     (3) Developing and promoting widespread adoption by payors and providers of guidelines

to:

     (i) Ensure payors do not automatically deny claims for services when extenuating

circumstances make it impossible for the provider to obtain a preauthorization before services are

performed or notify a payor within an appropriate standardized timeline of a patient's admission;

     (ii) Require payors to use common and consistent processes and time frames when

responding to provider requests for medical management approvals. Whenever possible, such time

frames shall be consistent with those established by leading national organizations and be based

upon the acuity of the patient's need for care or treatment. For the purposes of this section, medical

management includes prior authorization of services, preauthorization of services, precertification

of services, post-service review, medical-necessity review, and benefits advisory;

LC004557/SUB A - Page 6 of 12

     (iii) Develop, maintain, and promote widespread adoption of a single, common website

where providers can obtain payors' preauthorization, benefits advisory, and preadmission

requirements;

     (iv) Establish guidelines for payors to develop and maintain a website that providers can

use to request a preauthorization, including a prospective clinical necessity review; receive an

authorization number; and transmit an admission notification.

     (4) To provide a report to the house and senate, on or before January 1, 2017, with

recommendations for establishing guidelines and regulations for systems that give patients

electronic access to their claims information, particularly to information regarding their obligations

to pay for received medical services, pursuant to 45 C.F.R. 164.524.

     (i) To issue an anti-cancer medication report. Not later than June 30, 2014 and annually

thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate

committee on health and human services, and the house committee on corporations, with: (1)

Information on the availability in the commercial market of coverage for anti-cancer medication

options; (2) For the state employee's health benefit plan, the costs of various cancer-treatment

options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member

utilization and cost-sharing expense.

     (j) To monitor the adequacy of each health plan's compliance with the provisions of the

federal Mental Health Parity Act, including a review of related claims processing and

reimbursement procedures. Findings, recommendations, and assessments shall be made available

to the public.

     (k) To monitor the transition from fee-for-service and toward global and other alternative

payment methodologies for the payment for health-care services. Alternative payment

methodologies should be assessed for their likelihood to promote access to affordable health

insurance, health outcomes, and performance.

     (l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital

payment variation, including findings and recommendations, subject to available resources.

     (m) Notwithstanding any provision of the general or public laws or regulation to the

contrary, provide a report with findings and recommendations to the president of the senate and the

speaker of the house, on or before April 1, 2014, including, but not limited to, the following

information:

     (1) The impact of the current, mandated health-care benefits as defined in §§ 27-18-48.1,

27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41, of title 27, and §§ 27-

18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health

LC004557/SUB A - Page 7 of 12

insurance for fully insured employers, subject to available resources;

     (2) Current provider and insurer mandates that are unnecessary and/or duplicative due to

the existing standards of care and/or delivery of services in the health-care system;

     (3) A state-by-state comparison of health-insurance mandates and the extent to which

Rhode Island mandates exceed other states benefits; and

     (4) Recommendations for amendments to existing mandated benefits based on the findings

in (m)(1), (m)(2), and (m)(3) above.

     (n) On or before July 1, 2014, the office of the health insurance commissioner, in

collaboration with the director of health and lieutenant governor's office, shall submit a report to

the general assembly and the governor to inform the design of accountable care organizations

(ACOs) in Rhode Island as unique structures for comprehensive health-care delivery and value-

based payment arrangements, that shall include, but not be limited to:

     (1) Utilization review;

     (2) Contracting; and

     (3) Licensing and regulation.

     (o) On or before February 3, 2015, the office of the health insurance commissioner shall

submit a report to the general assembly and the governor that describes, analyzes, and proposes

recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard

to patients with mental-health and substance-use disorders.

     (p) To work to ensure the health insurance coverage of behavioral health care under the

same terms and conditions as other health care, and to integrate behavioral health parity

requirements into the office of the health insurance commissioner insurance oversight and health

care transformation efforts.

     (q) To work with other state agencies to seek delivery system improvements that enhance

access to a continuum of mental-health and substance-use disorder treatment in the state; and

integrate that treatment with primary and other medical care to the fullest extent possible.

     (r) To direct insurers toward policies and practices that address the behavioral health needs

of the public and greater integration of physical and behavioral health care delivery.

     (s) The office of the health insurance commissioner shall conduct an analysis of the impact

of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and

submit a report of its findings to the general assembly on or before June 1, 2023.

     (t) On or before January 1, 2021, the office of the health insurance commissioner shall

adopt a uniform set of medical criteria for prior authorization and create and disseminate a

standardized electronic or written prior authorization form that shall be used by a health insurer

LC004557/SUB A - Page 8 of 12

whenever prior authorization is required by the health insurer.

     SECTION 3. Sections 27-81-2, 27-81-3 and 27-81-4 of the General Laws in Chapter 27-

81 entitled "The Telemedicine Coverage Act" are hereby amended to read as follows:

     27-81-2. Purpose.

     The general assembly hereby finds and declares that:

     (1) The advancements and continued development of medical and communications

technology have had a profound impact on the practice of medicine and offer opportunities for

improving the delivery, cost, and accessibility of health care, particularly in the area of

telemedicine.

     (2) Geography, weather, availability of specialists, transportation, and other factors can

create barriers to accessing the appropriate health care, including behavioral health care, and one

way to provide, ensure, or enhance access to health care given these barriers is through the

appropriate use of technology to allow health-care consumers access to qualified health-care

providers.

     (3) During the COVID-19 crisis, it has become clear that patients and providers benefit

substantially from having access to telemedicine services that are covered by health insurers on the

same basis as in-person services.

     (4) It is essential to facilitate the delivery of telemedicine services as a convenient, easily

accessible, and affordable option to both health care providers and patients. Low-cost telephone

and other internet-based audio-only and live video technologies are widely available and accessible

to health care providers and patients. These technologies enable the delivery of clinically

appropriate, medically necessary health care services, including behavioral health care services, to

patients in a safe and accessible manner.

     (3)(5) There is a need in this state to embrace efforts that will encourage patients, health

insurers and health-care providers to support the use of telemedicine, and that will also encourage

all state agencies to evaluate and amend their policies and rules to remove any regulatory barriers

prohibiting the use of telemedicine services or reimbursing for such services on a discriminatory

basis relative to in-person services.

     27-81-3. Definitions.

     As used in this chapter:

     (1) "Distant site" means a site at which a health-care provider is located while providing

health-care services by means of telemedicine.

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

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

LC004557/SUB A - Page 9 of 12

surgical or treatment centers; skilled nursing centers; residential treatment centers; diagnostic,

laboratory and imaging centers; and rehabilitation and other therapeutic-health settings.

     (3) "Health-care professional" means a physician or other health-care practitioner licensed,

accredited, or certified to perform specified health-care services consistent with state law.

     (4) "Health-care provider" means a health-care professional or a health-care facility.

     (5) "Health-care services" means any services included in the furnishing to any individual

of medical, podiatric, or dental care, or hospitalization, or incident to the furnishing of that care or

hospitalization, and the furnishing to any person of any and all other services for the purpose of

preventing, alleviating, curing, or healing human illness, injury, or physical disability.

     (6) "Health insurer" means any person, firm, or corporation offering and/or insuring health-

care services on a prepaid basis, including, but not limited to, a nonprofit service corporation, a

health-maintenance organization, or an entity offering a policy of accident and sickness insurance.

     (7) "Health-maintenance organization" means a health-maintenance organization as

defined in chapter 41 of this title.

     (8) "Nonprofit service corporation" means a nonprofit, hospital-service corporation as

defined in chapter 19 of this title, or a nonprofit, medical-service corporation as defined in chapter

20 of this title.

     (9) "Originating site" means a site at which a patient is located at the time health-care

services are provided to them by means of telemedicine., which can be a patient's home where

medically appropriate; provided, however, notwithstanding any other provision of law, health

insurers and health-care providers may agree to alternative siting arrangements deemed appropriate

by the parties. Patients may receive telemedicine at any location.

     (10) "Policy of accident and sickness insurance" means a policy of accident and sickness

insurance as defined in chapter 18 of this title.

     (11) "Store-and-forward technology" means the technology used to enable the transmission

of a patient's medical information from an originating site to the health-care provider at the distant

site without the patient being present.

     (12) "Telemedicine" means the delivery of clinical health-care services by means of real

time audio-only telephone conversation or, two-way electronic audiovisual communications,

including the application of secure video conferencing or store-and-forward technology to provide

or support health-care delivery, which facilitate the assessment, diagnosis, treatment, and care

management of a patient's health care while such patient is at an originating site and the health-care

provider is at a distant site, consistent with applicable federal laws and regulations. Telemedicine

does not include an audio-only telephone conversation, email message, or facsimile transmission

LC004557/SUB A - Page 10 of 12

between the provider and patient, or an automated computer program used to diagnose and/or treat

ocular or refractive conditions.

     27-81-4. Coverage of telemedicine services.

     (a) Each health insurer that issues individual or group accident-and-sickness insurance

policies for health-care services and/or provides a health-care plan for health-care services shall

provide coverage for the cost of such covered health-care services provided through telemedicine

services, as provided in this section.

     (b) A health insurer shall not exclude a health-care service for coverage solely because the

health-care service is provided through telemedicine and is not provided through in-person

consultation or contact, so long as such health-care services are medically appropriate to be

provided through telemedicine services and, as such, may be subject to the terms and conditions of

a telemedicine agreement between the insurer and the participating health-care provider or provider

group.

      All telemedicine services delivered by in-network providers shall be reimbursed at rates

not lower than the same services would have been had they been delivered in-person. Telemedicine

services shall be subject to the same health insurer policies as in-person services, including medical

necessity determinations and appeal rights.

     (c) Benefit plans offered by a health insurer may shall not impose a deductible, copayment,

or coinsurance, or other cost sharing requirement for a covered health-care service provided

through telemedicine.

     (d) Benefit plans offered by a health insurer shall not require prior authorization for health-

care services provided through telemedicine.

     (d)(e) The requirements of this section shall apply to all policies and health plans issued,

reissued, or delivered in the state of Rhode Island on and after January 1, 2018.

     (e)(f) This chapter shall not apply to: short-term travel, accident-only, limited or specified

disease; or individual conversion policies or health plans; nor to policies or health plans designed

for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known

as Medicare; or any other similar coverage under state or federal governmental plans.

     (g) Health insurers shall establish reasonable requirements for the coverage of telemedicine

services, in accordance with guidance issued by the Office of the Health Insurance Commissioner,

including with respect to documentation and recordkeeping, but may not impose any requirements

more restrictive than those contained in “The Rhode Island Office of Health Insurance

Commissioner and Medicaid Program Instructions During the COVID-19 State of Emergency”

issued March 13, 2020; “Emergency Telemedicine Measures to Address and Stop the Spread of

LC004557/SUB A - Page 11 of 12

COVID-19” issued on March 20, 2020; “Rhode Island Office of the Health Insurance

Commissioner & Medicaid Program Guidance for Preventive Care Visits During COVID-19 State

of Emergency” issued May 7, 2020; and the Telehealth Benefits for Medicare beneficiaries; and

any subsequent guidance issued by the Office of the Health Insurance Commissioner or the state

Medicaid program. No health insurer shall impose any specific requirements on the technologies

used to deliver telemedicine services, including any limitations on audio-only or live video

technologies.

     (h) The Office of the Health Insurance Commissioner may promulgate rules and

regulations consistent with the provisions of this chapter.

     (i) Pursuant to § 40-8-17 of the General Laws, the Executive Office of Health and Human

Services shall apply for and use its best efforts to obtain any necessary waiver(s), waiver

amendment(s) and/or state plan amendment(s) from the Secretary of the United States Department

of Health and Human Services, necessary to ensure that individual Medicaid beneficiaries have

access to telemedicine services consistent with this chapter. EOHHS may promulgate rules and

regulations in accordance with this chapter.

     SECTION 4. This act shall take effect upon passage.

========

LC004557/SUB A

========

LC004557/SUB A - Page 12 of 12

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

***

     This act would have the health insurance commissioner adopt a uniform set of medical

criteria for prior authorization and create required forms to be used by a health insurer, including

telemedicine coverage.

     This act would take effect upon passage.

========

LC004557/SUB A

========

LC004557/SUB A - Page 13 of 12