2023 -- H 5495

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LC001501

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2023

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A N   A C T

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

CARE REFORM ACT OF 2004 -- HEALTH INSURANCE OVERSIGHT

     

     Introduced By: Representatives Potter, Casey, Donovan, Cotter, Giraldo, Stewart,
Baginski, Kislak, Dawson, and Voas

     Date Introduced: February 10, 2023

     Referred To: House Corporations

     It is enacted by the General Assembly as follows:

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     SECTION 1. Section 42-14.5-3 of the General Laws in Chapter 42-14.5 entitled "The

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

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to read as follows:

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     42-14.5-3. Powers and duties.

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

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

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

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

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

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

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

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

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

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

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

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finance committees regarding healthcare insurance and the regulations, rates, services,

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

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

 

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

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

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

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

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

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

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reserves.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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the full advisory council.

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

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

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

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

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following information:

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

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

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

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purpose of verifying professional qualifications of participating healthcare providers;

 

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

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

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

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

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

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

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

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

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comparisons;

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

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mechanisms for resolving health plan/provider disputes;

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

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

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

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

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

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their networks; and

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

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

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

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

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

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

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

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

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

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

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current products.

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

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

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

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

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

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

 

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

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

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

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merged market.

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

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

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

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

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

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

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

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

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

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

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

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

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

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care and proprietary information.

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

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

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senate finance committees.

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

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

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streamline healthcare administration that are to be adopted by payors and providers of healthcare

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

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would contribute to the streamlining of healthcare administration and who are selected from

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

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

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

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Rhode Island Health Center Association, and the Hospital Association of Rhode Island. In any year

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that the workgroup meets and submits recommendations to the office of the health insurance

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commissioner, the office of the health insurance commissioner shall submit such recommendations

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in a report to the general assembly by January 1. The report shall include the recommendations the

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commissioner intends to implement, with supporting rationale. The workgroup shall consider and

 

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make recommendations for:

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

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Such standard shall:

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

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

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for Medicare and Medicaid Services;

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

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

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     (iii) Provide reasonably detailed information on a consumer’s eligibility for healthcare

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

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

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

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

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

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and benefits information;

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

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

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

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request of eligibility.

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

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

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providers in the state;

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

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manner that makes for simple retrieval and implementation by providers;

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

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

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

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

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

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

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providers.

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

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

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

 

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

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

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process to challenge the payor’s adjudication decision.

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

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

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prosecution under applicable law of potentially fraudulent billing activities.

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

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to:

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

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

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

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

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

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

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

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

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

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

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

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requirements;

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

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

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authorization number; and transmit an admission notification;

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     (v) Require the use of programs that implement prior authorization requirements,

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uniformly across payors and utilization review agents, based on stratification of health care

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providers’ performance and adherence to evidence-based medicine and develop uniform criteria to

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select and maintain health care providers in such selective prior authorization programs with the

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input of contracted health care providers and/or provider organizations. Such criteria shall be

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transparent and easily accessible to contracted providers. Such selective prior authorization

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programs shall encourage appropriate adjustments to prior authorization requirements when health

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care providers participate in risk-based payment contracts;

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     (vi) Require the review of medical services, including behavioral health services, and

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prescription drugs, subject to prior authorization on at least an annual basis, with the input of

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contracted health care providers and/or provider organizations. Based on this review, require the

 

LC001501 - Page 6 of 12

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revision of prior authorization requirements, including the list of services subject to prior

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authorization, based on the prior year’s data analytics and up-to-date clinical criteria provided to

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the office of the health insurance commissioner by insurers. Any changes to the list of medical

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services, including behavioral health services, and prescription drugs requiring prior authorization,

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shall be shared via provider-accessible websites, and communicated at least annually to health care

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providers;

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     (vii) Improve communication channels between health plans, health care providers, and

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patients by:

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     (A) Requiring transparency and easy accessibility of prior authorization requirements,

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criteria, rationale, and program changes to contracted health care providers and patients/health plan

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enrollees; and

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     (B) Supporting:

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     (I) Timely submission by health care providers of the complete information necessary to

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make a prior authorization determination, as early in the process as possible; and

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     (II) Timely notification of prior authorization determinations by health plans to impacted

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patients, health plan enrollees, and health care providers, including, but not limited to, ordering

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providers, rendering providers, and dispensing pharmacists; and

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     (viii) Increase and strengthen continuity of patient care by:

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     (A) Defining protections for continuity of care during a transition period for patients

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undergoing an active course of treatment, when there is a formulary or treatment coverage change

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or change of health plan that may disrupt their current course of treatment;

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     (B) Requiring continuity of care for medical services, including behavioral health services,

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and prescription medications for patients on appropriate, chronic, stable therapy through

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minimizing repetitive prior authorization requirements; and

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     (C) Requiring communication between health care providers, health plans, and patients to

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facilitate continuity of care and minimize disruptions in needed treatment.

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

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recommendations for establishing guidelines and regulations for systems that give patients

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

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

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

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

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

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

 

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

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

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utilization and cost-sharing expense.

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

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

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

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to the public.

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

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payment methodologies for the payment for healthcare services. Alternative payment

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

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insurance, health outcomes, and performance.

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

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

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

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

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

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information:

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

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

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

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insurance for fully insured employers, subject to available resources;

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

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

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

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Rhode Island mandates exceed other states benefits; and

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

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

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

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

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

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

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

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     (1) Utilization review;

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     (2) Contracting; and

 

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     (3) Licensing and regulation.

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

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

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

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to patients with mental health and substance use disorders.

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

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

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

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care transformation efforts.

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

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

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

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

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of the public and greater integration of physical and behavioral healthcare delivery.

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

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

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

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     (t) To undertake the analyses, reports, and studies contained in this section:

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     (1) The office shall hire the necessary staff and prepare a request for proposal for a qualified

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and competent firm or firms to undertake the following analyses, reports, and studies:

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     (i) The firm shall undertake a comprehensive review of all social and human service

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programs having a contract with or licensed by the state or any subdivision of the department of

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children, youth and families (DCYF), the department of behavioral healthcare, developmental

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disabilities and hospitals (BHDDH), the department of human services (DHS), the department of

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health (DOH), and Medicaid for the purposes of:

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     (A) Establishing a baseline of the eligibility factors for receiving services;

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     (B) Establishing a baseline of the service offering through each agency for those

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determined eligible;

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     (C) Establishing a baseline understanding of reimbursement rates for all social and human

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service programs including rates currently being paid, the date of the last increase, and a proposed

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model that the state may use to conduct future studies and analyses;

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     (D) Ensuring accurate and adequate reimbursement to social and human service providers

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that facilitate the availability of high-quality services to individuals receiving home and

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community-based long-term services and supports provided by social and human service providers;

 

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     (E) Ensuring the general assembly is provided accurate financial projections on social and

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human service program costs, demand for services, and workforce needs to ensure access to entitled

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beneficiaries and services;

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     (F) Establishing a baseline and determining the relationship between state government and

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the provider network including functions, responsibilities, and duties;

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     (G) Determining a set of measures and accountability standards to be used by EOHHS and

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the general assembly to measure the outcomes of the provision of services including budgetary

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reporting requirements, transparency portals, and other methods; and

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     (H) Reporting the findings of human services analyses and reports to the speaker of the

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house, senate president, chairs of the house and senate finance committees, chairs of the house and

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senate health and human services committees, and the governor.

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     (2) The analyses, reports, and studies required pursuant to this section shall be

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accomplished and published as follows and shall provide:

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     (i) An assessment and detailed reporting on all social and human service program rates to

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be completed by January 1, 2023, including rates currently being paid and the date of the last

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increase;

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     (ii) An assessment and detailed reporting on eligibility standards and processes of all

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mandatory and discretionary social and human service programs to be completed by January 1,

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2023;

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     (iii) An assessment and detailed reporting on utilization trends from the period of January

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1, 2017, through December 31, 2021, for social and human service programs to be completed by

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January 1, 2023;

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     (iv) An assessment and detailed reporting on the structure of the state government as it

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relates to the provision of services by social and human service providers including eligibility and

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functions of the provider network to be completed by January 1, 2023;

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     (v) An assessment and detailed reporting on accountability standards for services for social

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and human service programs to be completed by January 1, 2023;

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     (vi) An assessment and detailed reporting by April 1, 2023, on all professional licensed

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and unlicensed personnel requirements for established rates for social and human service programs

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pursuant to a contract or established fee schedule;

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     (vii) An assessment and reporting on access to social and human service programs, to

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include any wait lists and length of time on wait lists, in each service category by April 1, 2023;

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     (viii) An assessment and reporting of national and regional Medicaid rates in comparison

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to Rhode Island social and human service provider rates by April 1, 2023;

 

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     (ix) An assessment and reporting on usual and customary rates paid by private insurers and

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private pay for similar social and human service providers, both nationally and regionally, by April

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1, 2023; and

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     (x) Completion of the development of an assessment and review process that includes the

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following components: eligibility; scope of services; relationship of social and human service

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provider and the state; national and regional rate comparisons and accountability standards that

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result in recommended rate adjustments; and this process shall be completed by September 1, 2023,

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and conducted biennially hereafter. The biennial rate setting shall be consistent with payment

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requirements established in § 1902(a)(30)(A) of the Social Security Act, 42 U.S.C. §

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1396a(a)(30)(A), and all federal and state law, regulations, and quality and safety standards. The

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results and findings of this process shall be transparent, and public meetings shall be conducted to

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allow providers, recipients, and other interested parties an opportunity to ask questions and provide

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comment beginning in September 2023 and biennially thereafter.

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     (3) In fulfillment of the responsibilities defined in subsection (t), the office of the health

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insurance commissioner shall consult with the Executive Office of Health and Human Services.

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     (u) Annually, each department (namely, EOHHS, DCYF, DOH, DHS, and BHDDH) shall

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include the corresponding components of the assessment and review (i.e., eligibility; scope of

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services; relationship of social and human service provider and the state; and national and regional

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rate comparisons and accountability standards including any changes or substantive issues between

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biennial reviews) including the recommended rates from the most recent assessment and review

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with their annual budget submission to the office of management and budget and provide a detailed

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explanation and impact statement if any rate variances exist between submitted recommended

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budget and the corresponding recommended rate from the most recent assessment and review

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process starting October 1, 2023, and biennially thereafter.

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     (v) The general assembly shall appropriate adequate funding as it deems necessary to

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undertake the analyses, reports, and studies contained in this section relating to the powers and

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duties of the office of the health insurance commissioner.

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     SECTION 2. This act shall take effect upon passage.

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LC001501

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

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

CARE REFORM ACT OF 2004 -- HEALTH INSURANCE OVERSIGHT

***

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     This act would require a workgroup of health care providers and health insurers convened

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by the office of the health commissioner, to make recommendations regarding prior authorization

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policies.

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     This act would take effect upon passage.

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LC001501

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