Chapter 214

Chapter 214

2003 -- H 6005 SUBSTITUTE A

Enacted 07/15/03








     Introduced By: Representative Peter N. Wasylyk

     Date Introduced: February 12, 2003




It is enacted by the General Assembly as follows:


     SECTION 1. Sections 23-17.13-2 and 23-17.13-3 of the General Laws in Chapter 23-

17.13 entitled "Health Care Accessibility and Quality Assurance Act" are hereby amended to read

as follows:

     23-17.13-2. Definitions. -- As used in this chapter:

      (1) "Adverse decision" means any decision by a review agent not to certify an admission,

service, procedure, or extension of stay. A decision by a reviewing agent to certify an admission,

service, or procedure in an alternative treatment setting, or to certify a modified extension of stay,

shall not constitute an adverse decision if the reviewing agent and the requesting provider are in

agreement regarding the decision.

      (2) "Contractor" means a person/entity that:

      (i) Establishes, operates or maintains a network of participating providers;

      (ii) Contracts with an insurance company, a hospital or medical or dental service plan, an

employer, whether under written or self insured, an employee organization, or any other entity

providing coverage for health care services to administer a plan; and/or

      (iii) Conducts or arranges for utilization review activities pursuant to chapter 17.12 of

this title.

      (3) "Direct service ratio" means the amount of premium dollars expended by the plan for

covered services provided to enrollees on a plan's fiscal year basis.

      (4) "Director" means the director of the department of health.

      (5) "Emergency services" has the same meaning as the meaning contained in the rules

and regulations promulgated pursuant to chapter 12.3 of title 42, as may be amended from time to

time, and includes the sudden onset of a medical or mental condition that the absence of

immediate medical attention could reasonably be expected to result in placing the patient's health

in serious jeopardy, serious impairment to bodily or mental functions, or serious dysfunction of

any bodily organ or part.

      (6) "Health care entity" means a licensed insurance company, hospital, or dental or

medical service plan or health maintenance organization, or a contractor as described in

subdivision (2), that operates a health plan.

      (7) "Health care services" includes, but is not limited to, medical, mental health,

substance abuse, and dental services.

      (8) "Health plan" means a plan operated by a health care entity as described in

subdivision (6) that provides for the delivery of care services to persons enrolled in the plan


      (i) Arrangements with selected providers to furnish health care services; and/or

      (ii) Financial incentives for persons enrolled in the plan to use the participating providers

and procedures provided for by the plan.

      (9) "Provider" means a physician, hospital, pharmacy, laboratory, dentist, or other state

licensed or other state recognized provider of health care services or supplies, and whose services

are recognized pursuant to 213(d) of the Internal Revenue Code, 26 U.S.C. section 213(d), that

has entered into an agreement with a health care entity as described in subdivision (6) or

contractor as described in subdivision (2) to provide these services or supplies to a patient

enrolled in a plan.

      (10) "Provider incentive plan" means any compensation arrangement between a health

care entity or plan and a provider or provider group that may directly or indirectly have the effect

of reducing or limiting services provided with respect to an individual enrolled in a plan.

      (11) "Qualified health plan" means a plan that the director of the department of health

certified, upon application by the program, as meeting the requirements of this chapter.

      (12) "Qualified utilization review program" means utilization review program that meets

the requirements of chapter 17.12 of this title.

     (13) “Most favored rate clause” means a provision in a provider contract whereby the

rates or fees to be paid by a health plan are fixed, established or adjusted to be equal to or lower

than the rates or fees paid to the provider by any other health plan or third party payor.

     23-17.13-3. Certification of health plans. -- (a) Certification process.

      (1) Certification.

      (i) The director shall establish a process for certification of health plans meeting the

requirements of certification in subsection (b).

      (ii) The director shall act upon the health plan's completed application for certification

within ninety (90) days of receipt of such application for certification.

      (2) Review and recertification. - To ensure compliance with subsection (b), the director

shall establish procedures for the periodic review and recertification of qualified health plans not

less than every five (5) years; provided, however, that the director may review the certification of

a qualified health plan at any time if there exists evidence that a qualified health plan may be in

violation of subsection (b).

      (3) Cost of certification. - The total cost of obtaining and maintaining certification under

this title and compliance with the requirements of the applicable rules and regulations are borne

by the entities so certified and shall be one hundred and fifty percent (150%) of the total salaries

paid to the certifying personnel of the department engaged in those certifications less any salary

reimbursements and shall be paid to the director to and for the use of the department. That

assessment shall be in addition to any taxes and fees otherwise payable to the state.

      (4) Standard definitions. - To help ensure a patient's ability to make informed decisions

regarding their health care, the director shall promulgate regulation(s) to provide for standardized

definitions (unless defined in existing statute) of the following terms in this subdivision,

provided, however, that no definition shall be construed to require a health care entity to add any

benefit, to increase the scope of any benefit, or to increase any benefit under any contract:

      (i) Allowable charge;

      (ii) Capitation;

      (iii) Co-payments;

      (iv) Co-insurance;

      (v) Credentialing;

      (vi) Formulary;

      (vii) Grace period;

      (viii) Indemnity insurance;

      (ix) In-patient care;

      (x) Maximum lifetime cap;

      (xi) Medical necessity;

      (xii) Out-of-network;

      (xiii) Out-patient;

      (xiv) Pre-existing conditions;

      (xv) Point of service;

      (xvi) Risk sharing;

      (xvii) Second opinion;

      (xviii) Provider network;

      (xix) Urgent care.

      (b) Requirements for certification. - The director shall establish standards and procedures

for the certification of qualified health plans that conduct business in this state and who have

demonstrated the ability to ensure that health care services will be provided in a manner to assure

availability and accessibility, adequate personnel and facilities, and continuity of service, and has

demonstrated arrangements for ongoing quality assurance programs regarding care processes and

outcomes; other standards shall consist of, but are not limited to, the following:

      (1) Prospective and current enrollees in health plans must be provided information as to

the terms and conditions of the plan consistent with the rules and regulations promulgated under

chapter 12.3 of title 42 so that they can make informed decisions about accepting and utilizing the

health care services of the health plan. This must be standardized so that customers can compare

the attributes of the plans, and all information required by this paragraph shall be updated at

intervals determined by the director. Of those items required under this section, the director shall

also determine which items shall be routinely distributed to prospective and current enrollees as

listed in this subsection and which items may be made available upon request. The items to be

disclosed are:

      (i) Coverage provisions, benefits, and any restriction or limitations on health care

services, including but not limited to, any exclusions as follows: by category of service, and if

applicable, by specific service, by technology, procedure, medication, provider or treatment

modality, diagnosis and condition, the latter three (3) of which shall be listed by name.

      (ii) Experimental treatment modalities that are subject to change with the advent of new

technology, may be listed solely by the broad category "Experimental Treatments". The

information provided to consumers shall include the plan's telephone number and address where

enrollees may call or write for more information or to register a complaint regarding the plan or

coverage provision.

      (2) Written statement of the enrollee's right to seek a second opinion, and reimbursement

if applicable.

      (3) Written disclosure regarding the appeals process described in section 23-17.12-1 et

seq. and in the rules and regulations for the utilization review of care services, promulgated by the

department of health, the telephone numbers and addresses for the plan's office which handles

complaints as well as for the office which handles the appeals process under section 23-17.12-1 et

seq. and the rules and regulations for the utilization of health.

      (4) Written statement of prospective and current enrollees' right to confidentiality of all

health care record and information in the possession and/or control of the plan, its employees, its

agents and parties with whom a contractual agreement exists to provide utilization review or who

in any way have access to care information. A summary statement of the measures taken by the

plan to ensure confidentiality of an individual's health care records shall be disclosed.

      (5) Written disclosure of the enrollee's right to be free from discrimination by the health

plan and the right to refuse treatment without jeopardizing future treatment.

      (6) Written disclosure of a plan's policy to direct enrollees to particular providers. Any

limitations on reimbursement should the enrollee refuse the referral must be disclosed.

      (7) A summary of prior authorization or other review requirements including

preauthorization review, concurrent review, post-service review, post-payment review and any

procedure that may lead the patient to be denied coverage for or not be provided a particular


      (8) Any health plan that operates a provider incentive plan shall not enter into any

compensation agreement with any provider of covered services or pharmaceutical manufacturer

pursuant to which specific payment is made directly or indirectly to the provider as an

inducement or incentive to reduce or limit services, to reduce the length of stay or the use of

alternative treatment settings or the use of a particular medication with respect to an individual

patient, provided however, that capitation agreements and similar risk sharing arrangements are

not prohibited.

      (9) Health plans must disclose to prospective and current enrollees the existence of

financial arrangements for capitated or other risk sharing arrangements that exist with providers

in a manner described in paragraphs (i), (ii), and (iii):

      (i) "This health plan utilizes capitated arrangements, with its participating providers, or

contains other similar risk sharing arrangements;

      (ii) This health plan may include a capitated reimbursement arrangement or other similar

risk sharing arrangement, and other financial arrangements with your provider;

      (iii) This health plan is not capitated and does not contain other risk sharing


      (10) Written disclosure of criteria for accessing emergency health care services as well

as a statement of the plan's policies regarding payment for examinations to determine if

emergency health care services are necessary, the emergency care itself, and the necessary

services following emergency treatment or stabilization. The health plan must respond to the

request of the treating provider for post-stabilization treatment by approving or denying it as soon

as possible.

      (11) Explanation of how health plan limitations impact enrollees, including information

on enrollee financial responsibility for payment for co-insurance, co-payment, or other non-

covered, out-of-pocket, or out-of-plan services. This shall include information on deductibles and

benefits limitations including, but not limited to, annual limits and maximum lifetime benefits.

      (12) The terms under which the health plan may be renewed by the plan enrollee,

including any reservation by the plan of any right to increase premiums.

      (13) Summary of criteria used to authorize treatment.

      (14) A schedule of revenues and expenses, including direct service ratios and other

statistical information which meets the requirements set forth below on a form prescribed by the


      (15) Plan costs of health care services, including but not limited to all of the following:

      (i) Physician services;

      (ii) Hospital services, including both inpatients and outpatient services;

      (iii) Other professional services;

      (iv) Pharmacy services, excluding pharmaceutical products dispensed in a physician's


      (v) Health education;

      (vi) Substance abuse services and mental health services.

      (16) Plan complaint, adverse decision, and prior authorization statistics. This statistical

data shall be updated annually:

      (i) The ratio of the number of complaints received to the total number of covered

persons, reported by category, listed in paragraphs (b)(15)(i) -- (vi);

      (ii) The ratio of the number of adverse decisions issued to the number of complaints

received, reported by category;

      (iii) The ratio of the number of prior authorizations denied to the number of prior

authorizations requested, reported by category;

      (iv) The ratio of the number of successful enrollee appeals to the total number of appeals


      (17) Plans must demonstrate that:

      (i) They have reasonable access to providers, so that all covered health care services will

be provided. This requirement cannot be waived and must be met in all areas where the health

plan has enrollees;

      (ii) Urgent health care services, if covered, shall be available within a time frame that

meets standards set by the director.

      (18) A comprehensive list of participating providers listed by office location, specialty if

applicable, and other information as determined by the director, updated annually.

      (19) Plans must provide to the director, at intervals determined by the director, enrollee

satisfaction measures. The director is authorized to specify reasonable requirements for these

measures consistent with industry standards to assure an acceptable degree of statistical validity

and comparability of satisfaction measures over time and among plans. The director shall publish

periodic reports for the public providing information on health plan enrollee satisfaction.

      (c) Issuance of certification.

      (1) Upon receipt of an application for certification, the director shall notify and afford

the public an opportunity to comment upon the application.

      (2) A health care plan will meet the requirements of certification, subsection (b) by

providing information required in subsection (b) to any state or federal agency in conformance

with any other applicable state or federal law, or in conformity with standards adopted by an

accrediting organization provided that the director determines that the information is substantially

similar to the previously mentioned requirements and is presented in a format that provides a

meaningful comparison between health plans.

      (3) All health plans shall be required to establish a mechanism, under which providers,

including local providers participating in the plan, provide input into the plan's health care policy,

including technology, medications and procedures, utilization review criteria and procedures,

quality and credentialing criteria, and medical management procedures.

      (4) All health plans shall be required to establish a mechanism under which local

individual subscribers to the plan provide input into the plan's procedures and processes regarding

the delivery of health care services.

      (5) A health plan shall not refuse to contract with or compensate for covered services an

otherwise eligible provider or non-participating provider solely because that provider has in good

faith communicated with one or more of his or her patients regarding the provisions, terms or

requirements of the insurer's products as they relate to the needs of that provider's patients.

      (6) (i) All health plans shall be required to publicly notify providers within the health

plans' geographic service area of the opportunity to apply for credentials. This notification

process shall be required only when the plan contemplates adding additional providers and may

be specific as to geographic area and provider specialty. Any provider not selected by the health

plan may be placed on a waiting list.

      (ii) This credentialing process shall begin upon acceptance of an application from a

provider to the plan for inclusion.

      (iii) Each application shall be reviewed by the plan's credentialing body.

      (iv) All health plans shall develop and maintain credentialing criteria to be utilized in

adding providers from the plans' network. Credentialing criteria shall be based on input from

providers credentialed in the plan and these standards shall be available to applicants. When

economic considerations are part of the decisions, the criteria must be available to applicants.

Any economic profiling must factor the specialty utilization and practice patterns and general

information comparing the applicant to his or her peers in the same speciality will be made

available. Any economic profiling of providers must be adjusted to recognize case mix, severity

of illness, age of patients and other features of a provider's practice that may account for higher

than or lower than expected costs. Profiles must be made available to those so profiled.

      (7) A health plan shall not exclude a provider of covered services from participation in

its provider network based solely on:

      (i) The provider's degree or license as applicable under state law; or

      (ii) The provider of covered services lack of affiliation with, or admitting privileges at a

hospital, if that lack of affiliation is due solely to the provider's type of license.

      (8) Health plans shall not discriminate against providers solely because the provider

treats a substantial number of patients who require expensive or uncompensated medical care.

      (9) The applicant shall be provided with all reasons used if the application is denied.

      (10) Plans shall not be allowed to include clauses in physician or other provider contracts

that allow for the plan to terminate the contract "without cause"; provided, however, cause shall

include lack of need due to economic considerations.

      (11) (i) There shall be due process for non-institutional providers for all adverse

decisions resulting in a change of privileges of a credentialed non-institutional provider. The

details of the health plan's due process shall be included in the plan's provider contracts.

      (ii) A health plan is deemed to have met the adequate notice and hearing requirement of

this section with respect to a non-institutional provider if the following conditions are met (or are

waived voluntarily by the non-institutional provider):

      (A) The provider shall be notified of the proposed actions and the reasons for the

proposed action.

      (B) The provider shall be given the opportunity to contest the proposed action.

      (C) The health plan has developed an internal appeals process that has reasonable time

limits for the resolution of an internal appeal.

      (12) If the plan places a provider or provider group at financial risk for services not

provided by the provider or provider group, the plan must require that a provider or group has met

all appropriate standards of the department of business regulation.

     (13) A health plan shall not include a most favored rate clause in a provider contract.

     SECTION 2. This act shall take effect January 1, 2004.



LC02088/SUB A