Chapter 262

2012 -- S 2887 SUBSTITUTE A AS AMENDED

Enacted 06/18/12

 

A N A C T

RELATING TO INSURANCE -- HEALTH INSURANCE - CONSUMER PROTECTION

          

     Introduced By: Senator Rhoda E. Perry

     Date Introduced: April 12, 2012

     

It is enacted by the General Assembly as follows:

 

     SECTION 1. Purpose and intent.

     It is the purpose of this act to amend Rhode Island statutes so as to be consistent with

health insurance consumer protections enacted in federal law. This act is intended to establish

health insurance rules, standards, and policies pursuant to, and in furtherance of, the health

insurance standards established in the federal Patient Protection and Affordable Care Act of 2010,

as amended by the federal Health Care and Education Reconciliation Act of 2010.

 

     SECTION 2. Chapter 27-18 of the General laws entitled "Accident and Sickness

Insurance Policies" is hereby amended by adding thereto the following sections:

 

     27-18-1.1. Definitions. – As used in this chapter:

     (1) “Adverse benefit determination” means any of the following: a denial, reduction, or

termination of, or a failure to provide or make payment (in whole or in part) for, a benefit,

including any such denial, reduction, termination, or failure to provide or make payment that is

based on a determination of an individual’s eligibility to participate in a plan or to receive

coverage under a plan, and including, with respect to group health plans, a denial, reduction, or

termination of, or a failure to provide or make payment (in whole or in part) for, a benefit

resulting from the application of any utilization review, as well as a failure to cover an item or

service for which benefits are otherwise provided because it is determined to be experimental or

investigational or not medically necessary or appropriate. The term also includes a rescission of

coverage determination.

     (2) “Affordable Care Act” means the federal Patient Protection and Affordable Care Act

of 2010, as amended by the federal Health Care and Education Reconciliation Act of 2010, and

federal regulations adopted thereunder.

     (3) “Commissioner” or “health insurance commissioner” means that individual appointed

pursuant to section 42-14.5-1 of the general laws.

     (4) “Essential health benefits” shall have the meaning set forth in section 1302(b) of the

federal Affordable Care Act,

     (5) “Grandfathered health plan” means any group health plan or health insurance

coverage subject to 42 USC section 18011.

     (6) “Group health insurance coverage” means, in connection with a group health plan,

health insurance coverage offered in connection with such plan.

     (7) “Group health plan” means an employee welfare benefit plan, as defined in 29 USC

section 1002(1), to the extent that the plan provides health benefits to employees or their

dependents directly or through insurance, reimbursement, or otherwise.

     (8) “Health benefits” or “covered benefits” means coverage or benefits for the diagnosis,

cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting

any structure or function of the body including coverage or benefits for transportation primarily

for and essential thereto, and including medical services as defined in R.I. Gen. Laws § 27-19-17;

     (9) “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 surgical or treatment centers, skilled nursing centers, residential treatment centers,

diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health

settings.

     (10) “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.

     (11) “Health care provider” or "provider" means a health care professional or a health

care facility.

     (12) “Health care services” means services for the diagnosis, prevention, treatment, cure

or relief of a health condition, illness, injury or disease.

     (13) “Health insurance carrier” means a person, firm, corporation or other entity subject

to the jurisdiction of the commissioner under this chapter. Such term does not include a group

health plan.

     (14) “Health plan” or “health benefit plan” means health insurance coverage and a group

health plan, including coverage provided through an association plan if it covers Rhode Island

residents. Except to the extent specifically provided by the federal Affordable Care Act, the term

“health plan” shall not include a group health plan to the extent state regulation of the health plan

is pre-empted under section 514 of the federal Employee Retirement Income Security Act of

1974. The term also shall not include:

     (A)(i) Coverage only for accident, or disability income insurance, or any combination

thereof.

     (ii) Coverage issued as a supplement to liability insurance.

     (iii) Liability insurance, including general liability insurance and automobile liability

insurance.

     (iv) Workers’ compensation or similar insurance.

     (v) Automobile medical payment insurance.

     (vi) Credit-only insurance.

     (vii) Coverage for on-site medical clinics.

     (viii) Other similar insurance coverage, specified in federal regulations issued pursuant to

Pub. L. No. 104-191, the federal health insurance portability and accountability act of 1996

(“HIPAA”), under which benefits for medical care are secondary or incidental to other insurance

benefits.

     (B) The following benefits if they are provided under a separate policy, certificate or

contract of insurance or are otherwise not an integral part of the plan:

     (i) Limited scope dental or vision benefits.

     (ii) Benefits for long-term care, nursing home care, home health care, community-based

care, or any combination thereof.

     (iii) Other excepted benefits specified in federal regulations issued pursuant to federal

Pub. L. No. 104-191 (“HIPAA”).

     (C) The following benefits if the benefits are provided under a separate policy, certificate

or contract of insurance, there is no coordination between the provision of the benefits and any

exclusion of benefits under any group health plan maintained by the same plan sponsor, and the

benefits are paid with respect to an event without regard to whether benefits are provided with

respect to such an event under any group health plan maintained by the same plan sponsor:

     (i) Coverage only for a specified disease or illness.

     (ii) Hospital indemnity or other fixed indemnity insurance.

     (D) The following if offered as a separate policy, certificate or contract of insurance:

     (i) Medicare supplement health insurance as defined under section 1882(g)(1) of the

federal Social Security Act.

     (ii) Coverage supplemental to the coverage provided under chapter 55 of title 10, United

States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)).

     (iii) Similar supplemental coverage provided to coverage under a group health plan.

     (15) "Office of the health insurance commissioner" means the agency established under

section 42-14.5-1 of the General laws.

     (16) “Rescission" means a cancellation or discontinuance of coverage that has retroactive

effect for reasons unrelated to timely payment of required premiums or contribution to costs of

coverage.

 

     27-18-2.1. Uniform explanation of benefits and coverage. – (a) A health insurance

carrier shall provide a summary of benefits and coverage explanation and definitions to

policyholders and others required by, and at the times and in the format required, by the federal

regulations adopted under section 2715 of the Public Health Service Act, as amended by the

federal Affordable Care Act. The forms required by this section shall be made available to the

commissioner on request. Nothing in this section shall be construed to limit the authority of the

commissioner under existing state law.

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

shall not apply to insurance coverage providing benefits for: (1) hospital confinement indemnity;

(2) disability income; (3) accident only; (4) long term care; (5) Medicare supplement; (6) limited

benefit health; (7) specified disease indemnity; (8) sickness or bodily injury or death by accident

or both; and (9) other limited benefit policies.

     (c) If the commissioner of the office of the health insurance commissioner determines

that the corresponding provision of the federal Patient Protection and Affordable Care Act has

been declared invalid by a final judgment of the federal judicial branch or has been repealed by

an act of Congress, on the date of the commissioner’s determination this section shall have its

effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this

section. Nothing in this section shall be construed to limit the authority of the commissioner

under existing state law.

 

     27-18-71. Prohibition on preexisting condition exclusions. – (a) A health insurance

policy, subscriber contract, or health plan offered, issued, issued for delivery, or issued to cover a

resident of this state by a health insurance company licensed pursuant to this title and/or chapter:

     (1) Shall not limit or exclude coverage for an individual under the age of nineteen (19) by

imposing a preexisting condition exclusion on that individual.

     (2) For plan or policy years beginning on or after January 1, 2014, shall not limit or

exclude coverage for any individual by imposing a preexisting condition exclusion on that

individual.

     (b) As used in this section:

     (1) “Preexisting condition exclusion” means a limitation or exclusion of benefits,

including a denial of coverage, based on the fact that the condition (whether physical or mental)

was present before the effective date of coverage, or if the coverage is denied, the date of denial,

under a health benefit plan whether or not any medical advice, diagnosis, care or treatment was

recommended or received before the effective date of coverage.

     (2) “Preexisting condition exclusion” means any limitation or exclusion of benefits,

including a denial of coverage, applicable to an individual as a result of information relating to an

individual’s health status before the individual’s effective date of coverage, or if the coverage is

denied, the date of denial, under the health benefit plan, such as a condition (whether physical or

mental) identified as a result of a pre-enrollment questionnaire or physical examination given to

the individual, or review of medical records relating to the pre-enrollment period.

     (c) This section shall not apply to grandfathered health plans providing individual health

insurance coverage.

     (d) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5)

Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or

bodily injury or death by accident or both; and (9) Other limited benefit policies.

 

     27-18-72. Prohibition on rescission of coverage. – (a)(1) Coverage under a health

benefit plan subject to the jurisdiction of the commissioner under this chapter with respect to an

individual, including a group to which the individual belongs or family coverage in which the

individual is included, shall not be rescinded after the individual is covered under the plan,

unless:

     (A) The individual or a person seeking coverage on behalf of the individual, performs an

act, practice or omission that constitutes fraud; or

     (B) The individual makes an intentional misrepresentation of material fact, as prohibited

by the terms of the plan or coverage.

     (2) For purposes of paragraph (a)(1)(A), a person seeking coverage on behalf of an

individual does not include an insurance producer or employee or authorized representative of the

health carrier.

     (b) At least thirty (30) days advance written notice shall be provided to each health

benefit plan enrollee or, for individual health insurance coverage, primary subscriber, who would

be affected by the proposed rescission of coverage before coverage under the plan may be

rescinded in accordance with subsection (a) regardless of, in the case of group health insurance

coverage, whether the rescission applies to the entire group or only to an individual within the

group.

     (c) For purposes of this section, “to rescind” means to cancel or to discontinue coverage

with retroactive effect for reasons unrelated to timely payment of required premiums or

contribution to costs of coverage.

     (d) This section applies to grandfathered health plans.

 

     27-18-73. Prohibition on annual and lifetime limits. – (a) Annual limits.

     (1) For plan or policy years beginning prior to January 1, 2014, for any individual, a

health insurance carrier and a health benefit plan subject to the jurisdiction of the commissioner

under this chapter may establish an annual limit on the dollar amount of benefits that are essential

health benefits provided the restricted annual limit is not less than the following:

     (A) For a plan or policy year beginning after September 22, 2011, but before September

23, 2012 – one million two hundred fifty thousand dollars ($1,250,000); and

     (B) For a plan or policy year beginning after September 22, 2012, but before January 1,

2014 – two million dollars ($2,000,000).

     (2) For plan or policy years beginning on or after January 1, 2014, a health insurance

carrier and a health benefit plan shall not establish any annual limit on the dollar amount of

essential health benefits for any individual, except:

     (A) A health flexible spending arrangement, as defined in Section 106(c)(2)(i) of the

Federal Internal Revenue Code, a medical savings account, as defined in section 220 of the

federal Internal Revenue Code, and a health savings account, as defined in Section 223 of the

federal Internal Revenue Code are not subject to the requirements of subdivisions (1) and (2) of

this subsection.

     (B) The provisions of this subsection shall not prevent a health insurance carrier and a

health benefit plan from placing annual dollar limits for any individual on specific covered

benefits that are not essential health benefits to the extent that such limits are otherwise permitted

under applicable federal law or the laws and regulations of this state.

     (3) In determining whether an individual has received benefits that meet or exceed the

allowable limits, as provided in subdivision (1) of this subsection, a health insurance carrier and a

health benefit plan shall take into account only essential health benefits.

     (b) Lifetime limits.

     (1) A health insurance carrier and health benefit plan offering group or individual health

insurance coverage shall not establish a lifetime limit on the dollar value of essential health

benefits for any individual.

     (2) Notwithstanding subdivision (1) above, a health insurance carrier and health benefit

plan is not prohibited from placing lifetime dollar limits for any individual on specific covered

benefits that are not essential health benefits, in accordance with federal laws and regulations.

     (c)(1) The provisions of this section relating to lifetime limits apply to any health

insurance carrier providing coverage under an individual or group health plan, including

grandfathered health plans.

     (2) The provisions of this section relating to annual limits apply to any health insurance

carrier providing coverage under a group health plan, including grandfathered health plans, but

the prohibition and limits on annual limits do not apply to grandfathered health plans providing

individual health insurance coverage.

     (d) This section shall not apply to a plan or to policy years prior to January 1, 2014 for

which the Secretary of the U.S. Department of Health and Human Services issued a waiver

pursuant to 45 C.F.R. § 147.126(d)(3). This section also shall not apply to insurance coverage

providing benefits for: (1) hospital confinement indemnity; (2) disability income; (3) accident

only; (4) long term care; (5) Medicare supplement; (6) limited benefit health; (7) specified disease

indemnity; (8) sickness or bodily injury or death by accident or both; and (9) other limited benefit

policies.

     (e) If the commissioner of the office of the health insurance commissioner determines

that the corresponding provision of the federal Patient Protection and Affordable Care Act has

been declared invalid by a final judgment of the federal judicial branch or has been repealed by

an act of Congress, on the date of the commissioner’s determination this section shall have its

effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this

section. Nothing in this subsection shall be construed to limit the authority of the Commissioner

to regulate health insurance under existing state law.

 

     27-18-74. Coverage for individuals participating in approved clinical trials. – (a) As

used in this section,

     (1) “Approved clinical trial” means a phase I, phase II, phase III or phase IV clinical trial

that is conducted in relation to the prevention, detection or treatment of cancer or a life-

threatening disease or condition and is described in any of the following:

     (A) The study or investigation is approved or funded, which may include funding through

in-kind contributions, by one or more of the following:

     (i) The federal National Institutes of Health;

     (ii) The federal Centers for Disease Control and Prevention;

     (iii) The federal Agency for Health Care Research and Quality;

     (iv) The federal Centers for Medicare & Medicaid Services;

     (v) A cooperative group or center of any of the entities described in items (i) through (iv)

or the U.S. Department of Defense or the U.S. Department of Veteran Affairs;

     (vi) A qualified non-governmental research entity identified in the guidelines issued by

the federal National Institutes of Health for center support grants; or

     (vii) A study or investigation conducted by the U.S. Department of Veteran Affairs, the

U.S. Department of Defense, or the U.S. Department of Energy, if the study or investigation has

been reviewed and approved through a system of peer review that the Secretary of U.S.

Department of Health and Human Services determines:

     (I) Is comparable to the system of peer review of studies and investigations used by the

federal National Institutes of Health; and

     (II) Assures unbiased review of the highest scientific standards by qualified individuals

who have no interest in the outcome of the review.

     (B) The study or investigation is conducted under an investigational new drug application

reviewed by the U.S. Food and Drug Administration; or

     (C) The study or investigation is a drug trial that is exempt from having such an

investigational new drug application.

     (2) “Participant” has the meaning stated in section 3(7) of federal ERISA.

     (3) “Participating provider” means a health care provider that, under a contract with the

health carrier or with its contractor or subcontractor, has agreed to provide health care services to

covered persons with an expectation of receiving payment, other than coinsurance, copayments or

deductibles, directly or indirectly from the health carrier.

     (4) “Qualified individual” means a participant or beneficiary who meets the following

conditions:

     (A) The individual is eligible to participate in an approved clinical trial according to the

trial protocol with respect to the treatment of cancer or other life-threatening disease or condition;

and

     (B)(i) The referring health care professional is a participating provider and has concluded

that the individual’s participation in such trial would be appropriate based on the individual

meeting the conditions described in subdivision (A) of this subdivision (3); or

     (ii) The participant or beneficiary provides medical and scientific information

establishing the individual’s participation in such trial would be appropriate based on the

individual meeting the conditions described in subdivision (A) of this subdivision (3).

     (5) “Life-threatening condition” means any disease or condition from which the

likelihood of death is probable unless the course of the disease or condition is interrupted.

     (b)(1) If a health insurance carrier offering group or individual health insurance coverage

provides coverage to a qualified individual, the health insurance carrier:

     (A) Shall not deny the individual participation in an approved clinical trial.

     (B) Subject to subdivision (3) of this subsection, shall not deny or limit or impose

additional conditions on the coverage of routine patient costs for items and services furnished in

connection with participation in the approved clinical trial; and

     (C) Shall not discriminate against the individual on the basis of the individual’s

participation in the approved clinical trial.

     (2)(A) Subject to subdivision (B) of this subdivision (2), routine patient costs include all

items and services consistent with the coverage typically covered for a qualified individual who is

not enrolled in an approved clinical trial.

     (B) For purposes of subdivision (B) of this subdivision (2), routine patient costs do not

include:

     (i) The investigational item, device or service itself;

     (ii) Items and services that are provided solely to satisfy data collection and analysis

needs and that are not used in the direct clinical management of the patient; or

     (iii) A service that is clearly inconsistent with widely accepted and established standards

of care for a particular diagnosis.

     (3) If one or more participating providers are participating in a clinical trial, nothing in

subdivision (1) of this subsection shall be construed as preventing a health carrier from requiring

that a qualified individual participate in the trial through such a participating provider if the

provider will accept the individual as a participant in the trial.

     (4) Notwithstanding subdivision (3) of this subsection, subdivision (1) of this subsection

shall apply to a qualified individual participating in an approved clinical trial that is conducted

outside this state.

     (5) This section shall not be construed to require a health insurance carrier offering group

or individual health insurance coverage to provide benefits for routine patient care services

provided outside of the coverage’s health care provider network unless out-of-network benefits

are otherwise provided under the coverage.

     (6) Nothing in this section shall be construed to limit a health insurance carrier’s

coverage with respect to clinical trials.

     (c) The requirements of this section shall be in addition to the requirements of Rhode

Island general laws sections 27-18-36 through 27-18-36.3.

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

to insurance coverage providing benefits for: (1) hospital confinement indemnity; (2) disability

income; (3) accident only; (4) long term care; (5) Medicare supplement; (6) limited benefit

health; (7) specified disease indemnity; (8) sickness or bodily injury or death by accident or both;

and (9) other limited benefit policies.

     (e) This section shall be effective for plan years beginning on or after January 1, 2014.

 

     27-18-75. Medical loss ratio reporting and rebates. – (a) A health insurance carrier

offering group or individual health insurance coverage of a health benefit plan, including a

grandfathered health plan, shall comply with the provisions of Section 2718 of the Public Health

Services Act as amended by the federal Affordable Care Act, in accordance with regulations

adopted thereunder.

     (b) Health insurance carriers required to report medical loss ratio and rebate calculations

and other medical loss ratio and rebate information to the U.S. Department of Health and Human

Services shall concurrently file such information with the commissioner.

 

     27-18-76. Emergency services. – (a) As used in this section:

     (1) “Emergency medical condition” means a medical condition manifesting itself by

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

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

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

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

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

part.

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

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

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

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

such emergency medical condition, and

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

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

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

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

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

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

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

emergency services in compliance with this section.

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

following manner:

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

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

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

is a participating network provider with respect to the services;

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

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

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

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

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

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

     (A) The exclusion of or coordination of benefits;

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

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

     (C) Applicable cost-sharing.

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

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

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

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

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

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

subdivision (1) of this subsection. A health insurance carrier complies with the requirements of

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

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

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

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

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

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

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

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

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

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

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

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

amount under this subdivision (A) is disregarded.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

apply to out-of-network emergency services.

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

23, 2010.

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

to insurance coverage providing benefits for: (1) hospital confinement indemnity; (2) disability

income; (3) accident only; (4) long term care; (5) Medicare supplement; (6) limited benefit

health; (7) specified disease indemnity; (8) sickness or bodily injury or death by accident or both;

and (9) other limited benefit policies.

 

     27-18-77. Internal and external appeal of adverse benefit determinations. – (a) The

commissioner shall adopt regulations to implement standards and procedures with respect to

internal claims and appeals of adverse benefit determinations, and with respect to external appeals

of adverse benefit determinations.

     (b) The regulations adopted by the commissioner shall apply only to those adverse

benefit determinations which are not subject to the jurisdiction of the department of health

pursuant to R.I. Gen. Laws § 23-17.12 et seq. (Utilization Review Act).

     (c) This section shall not apply to insurance coverage providing benefits for: (1) hospital

confinement indemnity; (2) disability income; (3) accident only; (4) long term care; (5) Medicare

supplement; (6) limited benefit health; (7) specified disease indemnity; (8) sickness or bodily

injury or death by accident or both; and (9) other limited benefit policies. This section also shall

not apply to grandfathered health plans.

 

     SECTION 3. Sections 27-18-8, 27-18-44 and 27-18-59 of the General laws in Chapter

27-18 entitled "Accident and Sickness Insurance Policies" are hereby amended to read as follows:

 

     27-18-8. Filing of accident and sickness insurance policy forms. – (a) Any insurance

company authorized to do an accident and sickness business within this state in accordance with

the provisions of this title shall file all accident and sickness insurance policy forms and rates

used by it in the state with the insurance commissioner, including the forms of any rider,

endorsement, application blank, and other matter generally used or incorporated by reference in

its policies or contracts of insurance. No such form shall be used if disapproved by the

commissioner under this section, or if the commissioner’s approval has been withdrawn under

section 27-18-8.3, or until the expiration of the waiting period established under section 27-18-

8.3. Such a company shall comply with its filed and approved forms. If the commissioner finds

from a examination of any form that it is contrary to the public interest, or the requirements of

this code or duly promulgated regulations, he or she shall forbid its use, and shall notify the

company in writing as provided in section 27-18-8.2. Each form shall include a certification by a

qualified actuary that to the best of the actuary's knowledge and judgment, the entire rate is in

compliance with applicable laws and that the benefits are reasonable in relation to the premium to

be charged.

     (b) Each rate filing shall include a certification by a qualified actuary that to the best of

the actuary's knowledge and judgment, the entire rate filing is in compliance with applicable laws

and that the benefits offered or proposed to be offered are reasonable in relation to the premium

to be charged. A health insurance carrier shall comply with its filed and approved rates and forms.

 

     27-18-44. Primary and preventive obstetric and gynecological care. – (a) Any insurer

or health plan, nonprofit health medical service plan, or nonprofit hospital service plan that

provides coverage for obstetric and gynecological care for issuance or delivery in the state to any

group or individual on an expense-incurred basis, including a health plan offered or issued by a

health insurance carrier or a health maintenance organization, shall permit a woman to receive an

annual visit to an in-network obstetrician/gynecologist for routine gynecological care without

requiring the woman to first obtain a referral from a primary care provider.

     (b)(1)(A) Any health plan, nonprofit medical service plan or nonprofit hospital service

plan, including a health insurance carrier or a health maintenance organization which requires or

provides for the designation by a covered person of a participating primary health care

professional shall permit each covered person to:

     (i) Designate any participating primary care health care professional who is available to

accept the covered person; and

     (ii) For a child, designate any participating physician who specializes in pediatrics as the

child’s primary care health care professional and is available to accept the child.

     (2) The provisions of subdivision (1) of this subsection shall not be construed to waive

any exclusions of coverage under the terms and conditions of the health benefit plan with respect

to coverage of pediatric care.

     (c)(1) If a health plan, nonprofit medical service plan or nonprofit hospital service plan,

including a health insurance carrier or a health maintenance organization, provides coverage for

obstetrical or gynecological care and requires the designation by a covered person of a

participating primary care health care professional, then it:

     (A) Shall not require any person’s, including a primary care health care professional’s,

prior authorization or referral in the case of a female covered person who seeks coverage for

obstetrical or gynecological care provided by a participating health care professional who

specializes in obstetrics or gynecology; and

     (B) Shall treat the provision of obstetrical and gynecological care, and the ordering of

related obstetrical and gynecological items and services, pursuant to subdivision (A) of this

subdivision (c)(1), by a participating health care professional who specializes in obstetrics or

gynecology as the authorization of the primary care health care professional.

     (2)(A) A health plan, nonprofit medical service plan or nonprofit hospital service plan,

including a health insurance carrier or a health maintenance organization may require the health

care professional to agree to otherwise adhere to its policies and procedures, including procedures

relating to referrals, obtaining prior authorization, and providing services in accordance with a

treatment plan, if any, approved by the plan, carrier or health maintenance organization.

     (B)For purposes of subdivision (A) of this subdivision (c)(1), a health care professional,

who specializes in obstetrics or gynecology, means any individual, including an individual other

than a physician, who is authorized under state law to provide obstetrical or gynecological care.

     (3) The provisions of subdivision (A) of this subdivision (c)(1) shall not be construed to:

     (A) Waive any exclusions of coverage under the terms and conditions of the health

benefit plan with respect to coverage of obstetrical or gynecological care; or

     (B) Preclude the health plan, nonprofit medical service plan or nonprofit hospital service

plan, including a health insurance carrier or a health maintenance organization involved from

requiring that the participating health care professional providing obstetrical or gynecological

care notify the primary care health care professional or the plan, carrier or health maintenance

organization of treatment decisions.

     (d) Notice Requirements:

     (1) A health plan, nonprofit medical service plan or nonprofit hospital service plan,

including a health insurance carrier or a health maintenance organization subject to this section

shall provide notice to covered persons of the terms and conditions of the plan related to the

designation of a participating health care professional and of a covered person’s rights with

respect to those provisions.

     (2)(A) In the case of group health insurance coverage, the notice described in subdivision

(1) of this subsection shall be included whenever the a participant is provided with a summary

plan description or other similar description of benefits under the health benefit plan.

     (B) In the case of individual health insurance coverage, the notice described in

subdivision (1) of this subsection shall be included whenever the primary subscriber is provided

with a policy, certificate or contract of health insurance.

     (C) A health plan, nonprofit medical service plan or nonprofit hospital service plan,

including a health insurance carrier or a health maintenance organization, may use the model

language in federal regulation 45 CFR section 147.138(a)(4)(iii) to satisfy the requirements of

this subsection.

     (e) The requirements of subsections (b), (c), and (d) shall not apply to grandfathered

health plans. This section shall not apply to insurance coverage providing benefits for: (1)

hospital confinement indemnity; (2) disability income; (3) accident only; (4) long term care; (5)

Medicare supplement; (6) limited benefit health; (7) specified disease indemnity; (8) sickness or

bodily injury or death by accident or both; and (9) other limited benefit policies.

 

     27-18-59. Termination of children's benefits Eligibility for children’s benefits. --

(a)(1) Every individual health insurance contract, plan, or policy health benefit plan delivered,

issued for delivery, or renewed in this state and every group health insurance contract, plan, or

policy delivered, issued for delivery or renewed in this state which provides medical health

benefits coverage for dependent children that includes coverage for physician services in a

physician's office, and every policy which provides major medical or similar comprehensive type

coverage dependents, except for supplemental policies which only provide coverage for specified

diseases and other supplemental policies, shall provide make coverage available of an unmarried

child under the age of nineteen (19) years, an unmarried child who is a student under the age of

twenty-five (25) years and who is financially dependent upon the parent and an unmarried child

of any age who is financially dependent upon the parent and medically determined to have a

physical or mental impairment which can be expected to result in death or which has lasted or can

be expected to last for a continuous period of not less than twelve (12) months for children until

attainment of twenty-six (26) years of age, and an unmarried child of any age who is financially

dependent upon the parent and medically determined to have a physical or mental impairment

which can be expected to result in death or which has lasted or can be expected to last for a

continuous period of not less than twelve (12) months. Such contract, plan or policy shall also

include a provision that policyholders shall receive no less than thirty (30) days notice from the

accident and sickness insurer that a child covered as a dependent by the policy holder is about to

lose his or her coverage as a result of reaching the maximum age for a dependent child, and that

the child will only continue to be covered upon documentation being provided of current full or

part-time enrollment in a post-secondary educational institution or that the child may purchase a

conversion policy if he or she is not an eligible student. Nothing in this section prohibits an

accident and sickness insurer from requiring a policyholder to annually provide proof of a child's

current full or part-time enrollment in a post-secondary educational institution in order to

maintain the child's coverage. Provided, nothing in this section requires coverage inconsistent

with the membership criteria in effect under the policyholder's health benefits coverage.

     (2) With respect to a child who has not attained twenty-six (26) years of age, a health

insurance carrier shall not define “dependent” for purposes of eligibility for dependent coverage

of children other than the terms of a relationship between a child and the plan participant, or

subscriber.

     (3) A health insurance carrier shall not deny or restrict coverage for a child who has not

attained twenty-six (26) years of age based on the presence or absence of the child’s financial

dependency upon the participant, primary subscriber or any other person, residency with the

participant and in the individual market the primary subscriber, or with any other person, marital

status, student status, employment or any combination of those factors. A health carrier shall not

deny or restrict coverage of a child based on eligibility for other coverage, except as provided in

subparagraph (b)(1) of this section.

     (4) Nothing in this section shall be construed to require a health insurance carrier to make

coverage available for the child of a child receiving dependent coverage, unless the grandparent

becomes the legal guardian or adoptive parent of that grandchild.

     (5) The terms of coverage in a health benefit plan offered by a health insurance carrier

providing dependent coverage of children cannot vary based on age except for children who are

twenty-six (26) years of age or older.

     (b)(1) For plan years beginning before January 1, 2014, a health insurance carrier

providing group health insurance coverage that is a grandfathered health plan and makes

available dependent coverage of children may exclude an adult child who has not attained twenty-

six (26) years of age from coverage only if the adult child is eligible to enroll in an eligible

employer-sponsored health benefit plan, as defined in section 5000A(f)(2) of the federal Internal

Revenue Code, other than the group health plan of a parent.

     (2) For plan years, beginning on or after January 1, 2014, a health insurance carrier

providing group health insurance coverage that is a grandfathered health plan shall comply with

the requirements of subsections (a) through (e) of this section.

     (b)(c)This section does not apply to insurance coverage providing benefits for: (1)

hospital confinement indemnity; (2) disability income; (3) accident only; (4) long term care; (5)

Medicare supplement; (6) limited benefit health; (7) specified diseased indemnity; or (8) sickness

or bodily injury or death by accident or both; or (9) other limited benefit policies.

 

     SECTION 4. Chapter 27-18.5 of the General Laws entitled “Individual Health Insurance

Coverage” is hereby amended by adding thereto the following section:

 

     27-18.5-10. Prohibition on preexisting condition exclusions. -- (a) A health insurance

policy, subscriber contract, or health plan offered, issued, issued for delivery, or issued to cover a

resident of this state by a health insurance company licensed pursuant to this title and/or chapter:

     (1) Shall not limit or exclude coverage for an individual under the age of nineteen (19) by

imposing a preexisting condition exclusion on that individual.

     (2) For plan or policy years beginning on or after January 1, 2014, shall not limit or

exclude coverage for any individual by imposing a preexisting condition exclusion on that

individual.

     (b) As used in this section:

     (1) “Preexisting condition exclusion” means a limitation or exclusion of benefits,

including a denial of coverage, based on the fact that the condition (whether physical or mental)

was present before the effective date of coverage, or if the coverage is denied, the date of denial,

under a health benefit plan whether or not any medical advice, diagnosis, care or treatment was

recommended or received before the effective date of coverage.

     (2) “Preexisting condition exclusion” means any limitation or exclusion of benefits,

including a denial of coverage, applicable to an individual as a result of information relating to an

individual’s health status before the individual’s effective date of coverage, or if the coverage is

denied, the date of denial, under the health benefit plan, such as a condition (whether physical or

mental) identified as a result of a pre-enrollment questionnaire or physical examination given to

the individual, or review of medical records relating to the pre-enrollment period.

     (c) This section shall not apply to grandfathered health plans providing individual health

insurance coverage.

     (d) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5)

Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or

bodily injury or death by accident or both; and (9) Other limited benefit policies.

 

     SECTION 5. Sections 27-19-1 and 27-19-50 of the General laws in Chapter 27-19

entitled "Nonprofit Hospital Service Corporations" are hereby amended to read as follows:

 

     27-19-1. Definitions. -- As used in this chapter:

     (1) "Contracting hospital" means an eligible hospital which has contracted with a

nonprofit hospital service corporation to render hospital care to subscribers to the nonprofit

hospital service plan operated by the corporation;

     (2) "Adverse benefit determination" means any of the following: a denial, reduction, or

termination of, or a failure to provide or make payment (in whole or in part) for, a benefit,

including any such denial, reduction, termination, or failure to provide or make payment that is

based on a determination of an individual's eligibility to participate in a plan or to receive

coverage under a plan, and including, with respect to group health plans, a denial, reduction, or

termination of, or a failure to provide or make payment (in whole or in part) for, a benefit

resulting from the application of any utilization review, as well as a failure to cover an item or

service for which benefits are otherwise provided because it is determined to be experimental or

investigational or not medically necessary or appropriate. The term also includes a rescission of

coverage determination.

     (3) "Affordable Care Act" means the federal Patient Protection and Affordable Care Act

of 2010, as amended by the federal Health Care and Education Reconciliation Act of 2010, and

federal regulations adopted thereunder;

     (4) “Commissioner” or “health insurance commissioner” means that individual appointed

pursuant to section 42-14.5-1 of the General laws;

     (5) "Eligible hospital" is one which is maintained either by the state or by any of its

political subdivisions or by a corporation organized for hospital purposes under the laws of this

state or of any other state or of the United States, which is designated as an eligible hospital by a

majority of the directors of the nonprofit hospital service corporation;

     (6) "Essential health benefits" shall have the meaning set forth in section 1302(b) of the

federal Affordable Care Act.

     (7) “Grandfathered health plan” means any group health plan or health insurance

coverage subject to 42 USC section 18011;

     (8) “Group health insurance coverage” means, in connection with a group health plan,

health insurance coverage offered in connection with such plan;

     (9) “Group health plan” means an employee welfare benefit plan as defined 29 USC

section 1002(1), to the extent that the plan provides health benefits to employees or their

dependents directly or through insurance, reimbursement, or otherwise;

     (10) “Health benefits” or “covered benefits” means coverage or benefits for the

diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose

of affecting any structure or function of the body including coverage or benefits for transportation

primarily for and essential thereto, and including medical services as defined in R.I. Gen. Laws §

27-19-17;

     (11) “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

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

laboratory and imaging centers, and rehabilitation and other therapeutic health settings;

     (12) "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;

     (13) "Health care provider" or "provider" means a health care professional or a health

care facility;

     (14) "Health care services" means services for the diagnosis, prevention, treatment, cure

or relief of a health condition, illness, injury or disease;

     (15) “Health insurance carrier” means a person, firm, corporation or other entity subject

to the jurisdiction of the commissioner under this chapter, and includes nonprofit hospital service

corporations. Such term does not include a group health plan. The use of this term shall not be

construed to subject a nonprofit hospital service corporation to the insurance laws of this state

other than as set forth in R.I. Gen. Laws § 27-19-2;

     (16) "Health plan" or "health benefit plan" means health insurance coverage and a group

health plan, including coverage provided through an association plan if it covers Rhode Island

residents. Except to the extent specifically provided by the federal Affordable Care Act, the term

“health plan” shall not include a group health plan to the extent state regulation of the health plan

is pre- empted under section 514 of the federal Employee Retirement Income Security Act of

1974. The term also shall not include:

     (A)(i) Coverage only for accident, or disability income insurance, or any combination

thereof.

     (ii) Coverage issued as a supplement to liability insurance.

     (iii) Liability insurance, including general liability insurance and automobile liability

insurance.

     (iv) Workers’ compensation or similar insurance.

     (v) Automobile medical payment insurance.

     (vi) Credit-only insurance.

     (vii) Coverage for on-site medical clinics.

     (viii) Other similar insurance coverage, specified in federal regulations issued pursuant to

federal Pub. L. No. 104-191, the federal health insurance portability and accountability act of

1996 (“HIPAA”), under which benefits for medical care are secondary or incidental to other

insurance benefits.

     (B) The following benefits if they are provided under a separate policy, certificate or

contract of insurance or are otherwise not an integral part of the plan:

     (i) Limited scope dental or vision benefits.

     (ii) Benefits for long-term care, nursing home care, home health care, community-based

care, or any combination thereof.

     (iii) Other excepted benefits specified in federal regulations issued pursuant to federal

Pub. L. No. 104-191 (“HIPAA”).

     (C) The following benefits if the benefits are provided under a separate policy, certificate

or contract of insurance, there is no coordination between the provision of the benefits and any

exclusion of benefits under any group health plan maintained by the same plan sponsor, and the

benefits are paid with respect to an event without regard to whether benefits are provided with

respect to such an event under any group health plan maintained by the same plan sponsor:

     (i) Coverage only for a specified disease or illness.

     (ii) Hospital indemnity or other fixed indemnity insurance.

     (D) The following if offered as a separate policy, certificate or contract of insurance:

     (i) Medicare supplement health insurance as defined under section 1882(g)(1) of the

federal Social Security Act.

     (ii) Coverage supplemental to the coverage provided under chapter 55 of title 10, United

States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)).

     (iii) Similar supplemental coverage provided to coverage under a group health plan.

      (17) "Nonprofit hospital service corporation" means any corporation organized pursuant

to this chapter for the purpose of establishing, maintaining, and operating a nonprofit hospital

service plan;

     (18) "Nonprofit hospital service plan" means a plan by which specified hospital care is to

be provided to subscribers to the plan by a contracting hospital; 

     (19) "Office of the health insurance commissioner" means the agency established under

section 42-14.5-1 of the General Law;

     (20) “Rescission" means a cancellation or discontinuance of coverage that has retroactive

effect for reasons unrelated to timely payment of required premiums or contribution to costs of

coverage; and

     (21) "Subscribers" mean those persons, whether or not residents of this state, who have

contracted with a nonprofit hospital service corporation for hospital care pursuant to a nonprofit

hospital service plan operated by the corporation.

 

     27-19-50. Termination of children’s benefits Eligibility for children's benefits. --

 (a)(1) Every individual health insurance contract, plan, or policy health benefit plan delivered,

issued for delivery, or renewed in this state which provides medical health benefits coverage for

dependent children that includes coverage for physician services in a physician’s office, and

every policy which provides major medical or similar comprehensive type coverage dependents,

except for supplemental policies which only provide coverage for specified diseases and other

supplemental policies, shall provide make coverage available of an unmarried child under the age

of nineteen (19) years, an unmarried child who is a student under the age of twenty-five (25)

years and who is financially dependent upon the parent and an unmarried child of any age who is

financially dependent upon the parent and medically determined to have a physical or mental

impairment which can be expected to result in death or which has lasted or can be expected to last

for a continuous period of not less than twelve (12) months for children until attainment of

twenty-six (26) years of age, and an unmarried child of any age who is financially dependent

upon the parent and medically determined to have a physical or mental impairment which can be

expected to result in death or which has lasted or can be expected to last for a continuous period

of not less than twelve (12) months. Such contract, plan or policy shall also include a provision

that policyholders shall receive no less than thirty (30) days notice from the accident and sickness

insurer that a child covered as a dependent by the policy holder is about to lose his or her

coverage as a result of reaching the maximum age for a dependent child, and that the child will

only continue to be covered upon documentation being provided of current full or part-time

enrollment in a post-secondary educational institution or that the child may purchase a conversion

policy if he or she is not an eligible student.

     (b) Nothing in this section prohibits a nonprofit hospital service corporation from

requiring a policyholder to annually provide proof of a child's current full or part-time enrollment

in a post-secondary educational institution in order to maintain the child's coverage. Provided,

nothing in this section requires coverage inconsistent with the membership criteria in effect under

the policyholder's health benefits coverage.

     (2) With respect to a child who has not attained twenty-six (26) years of age, a health

insurance carrier shall not define “dependent” for purposes of eligibility for dependent coverage

of children other than the terms of a relationship between a child and the plan participant or

subscriber.

     (3) A health insurance carrier shall not deny or restrict coverage for a child who has not

attained twenty-six (26) years of age based on the presence or absence of the child’s financial

dependency upon the participant, primary subscriber or any other person, residency with the

participant and in the individual market the primary subscriber, or with any other person, marital

status, student status, employment or any combination of those factors. A health carrier shall not

deny or restrict coverage of a child based on eligibility for other coverage, except as provided in

(b)(1) of this section.

     (4) Nothing in this section shall be construed to require a health insurance carrier to make

coverage available for the child of a child receiving dependent coverage, unless the grandparent

becomes the legal guardian or adoptive parent of that grandchild.

     (5) The terms of coverage in a health benefit plan offered by a health insurance carrier

providing dependent coverage of children cannot vary based on age except for children who are

twenty-six (26) years of age or older.

     (b)(1) For plan years beginning before January 1, 2014, a group health plan providing

group health insurance coverage that is a grandfathered health plan and makes available

dependent coverage of children may exclude an adult child who has not attained twenty-six (26)

years of age from coverage only if the adult child is eligible to enroll in an eligible employer-

sponsored health benefit plan, as defined in section 5000A(f)(2) of the federal Internal Revenue

Code, other than the group health plan of a parent.

     (2) For plan years, beginning on or after January 1, 2014, a group health plan providing

group health insurance coverage that is a grandfathered health plan shall comply with the

requirements of this section.

     (c) This section does not apply to insurance coverage providing benefits for: (1) Hospital

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5)

Medicare supplement; (6) Limited benefit health; (7) Specified diseased indemnity; or (8) Other

limited benefit policies.

 

     SECTION 6. Chapter 27-19 of the General laws entitled "Nonprofit Hospital Service

Corporations" is hereby amended by adding thereto the following sections:

 

     27-19-7.1. Uniform explanation of benefits and coverage. –  (a) A nonprofit hospital

service corporation shall provide a summary of benefits and coverage explanation and definitions

to policyholders and others required by, and at the times and in the format required, by the federal

regulations adopted under section 2715 of the Public Health Service Act, as amended by the

federal Affordable Care Act. The forms required by this section shall be made available to the

commissioner on request. Nothing in this section shall be construed to limit the authority of the

commissioner under existing state law.

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

shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity;

(2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6)

Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by

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

     (c) If the commissioner of the office of the health insurance commissioner determines

that the corresponding provision of the federal Patient Protection and Affordable Care Act has

been declared invalid by a final judgment of the federal judicial branch or has been repealed by

an act of Congress, on the date of the commissioner’s determination this section shall have its

effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this

section. Nothing in this section shall be construed to limit the authority of the commissioner

under existing state law.

 

     27-19-7.2. Filing of policy forms. – (a) A nonprofit hospital service corporation shall file all

policy forms and rates used by it in the state with the commissioner, including the forms of any

rider, endorsement, application blank, and other matter generally used or incorporated by

reference in its policies or contracts of insurance. No such form shall be used if disapproved by

the commissioner under this section, or if the commissioner’s approval has been withdrawn after

notice and an opportunity to be heard, or until the expiration of sixty (60) days following the

filing of the form. Such a company shall comply with its filed and approved forms. . If the

commissioner finds from an examination of any form that it is contrary to the public interest, or

the requirements of this code or duly promulgated regulations, he or she shall forbid its use, and

shall notify the corporation in writing.

     (b) Each rate filing shall include a certification by a qualified actuary that to the best of

the actuary's knowledge and judgment, the entire rate filing is in compliance with applicable laws

and that the benefits offered or proposed to be offered are reasonable in relation to the premium

to be charged. A health insurance carrier shall comply with its filed and approved rates and

forms.

 

     27-19-62. Prohibition on rescission of coverage. – (a)(1) Coverage under a health plan

subject to the jurisdiction of the commissioner under this chapter with respect to an individual,

including a group to which the individual belongs or family coverage in which the individual is

included, shall not be rescinded after the individual is covered under the plan, unless:

     (A) The individual or a person seeking coverage on behalf of the individual, performs an

act, practice or omission that constitutes fraud; or

     (B) The individual makes an intentional misrepresentation of material fact, as prohibited

by the terms of the plan or coverage.

     (2) For purposes of paragraph (1)(A), a person seeking coverage on behalf of an

individual does not include an insurance producer or employee or authorized representative of the

health carrier.

     (b) At least thirty (30) days advance written notice shall be provided to each health

benefit plan enrollee or, for individual health insurance coverage, primary subscriber, who would

be affected by the proposed rescission of coverage before coverage under the plan may be

rescinded in accordance with subsection (a) regardless of, in the case of group health insurance

coverage, whether the rescission applies to the entire group or only to an individual within the

group.

     (c) For purposes of this section, “to rescind” means to cancel or to discontinue coverage

with retroactive effect for reasons unrelated to timely payment of required premiums or

contribution to costs of coverage.

     (d) This section applies to grandfathered health plans.

 

     27-19-63. Prohibition on annual and lifetime limits. – (a) Annual limits. (1) For plan or

policy years beginning prior to January 1, 2014, for any individual, a health insurance carrier and

health benefit plan subject to the jurisdiction of the commissioner under this chapter may

establish an annual limit on the dollar amount of benefits that are essential health benefits

provided the restricted annual limit is not less than the following:

     (A) For a plan or policy year beginning after September 22, 2011, but before September

23, 2012 – one million two hundred fifty thousand dollars ($1,250,000); and

     (B) For a plan or policy year beginning after September 22, 2012, but before January 1,

2014 – two million dollars ($2,000,000).

     (2) For plan or policy years beginning on or after January 1, 2014, a health insurance

carrier and health benefit plan shall not establish any annual limit on the dollar amount of

essential health benefits for any individual, except:

     (A) A health flexible spending arrangement, as defined in Section 106(c)(2)(i) of the

federal Internal Revenue Code, a medical savings account, as defined in Section 220 of the

federal Internal Revenue Code, and a health savings account, as defined in Section 223 of the

federal Internal Revenue Code, are not subject to the requirements of subdivisions (1) and (2) of

this subsection.

     (B) The provisions of this subsection shall not prevent a health insurance carrier and

health benefit plan from placing annual dollar limits for any individual on specific covered

benefits that are not essential health benefits to the extent that such limits are otherwise permitted

under applicable federal law or the laws and regulations of this state.

     (3) In determining whether an individual has received benefits that meet or exceed the

allowable limits, as provided in subdivision (1) of this subsection, a health insurance carrier and

health benefit plan shall take into account only essential health benefits.

     (b) Lifetime limits.

     (1) A health insurance carrier and health benefit plan offering group or individual health

insurance coverage shall not establish a lifetime limit on the dollar value of essential health

benefits for any individual.

     (2) Notwithstanding subdivision (1) above, a health insurance carrier and health benefit

plan is not prohibited from placing lifetime dollar limits for any individual on specific covered

benefits that are not essential health benefits in accordance with federal laws and regulations.

     (c)(1) The provisions of this section relating to lifetime limits apply to any health

insurance carrier providing coverage under an individual or group health plan, including

grandfathered health plans.

     (2) The provisions of this section relating to annual limits apply to any health insurance

carrier providing coverage under a group health plan, including grandfathered health plans, but

the prohibition and limits on annual limits do not apply to grandfathered health plans providing

individual health insurance coverage.

     (d) This section shall not apply to a plan or to policy years prior to January 1, 2014 for

which the Secretary of the U.S. Department of Health and Human Services issued a waiver

pursuant to 45 C.F.R. § 147.126(d)(3)This section also shall not apply to insurance coverage

providing benefits for: (1) Hospital confinement indemnity; (2) Disability income; (3) Accident

only; (4) Long-term care; (5) Medicare supplement; (6) Limited benefit health; (7) Specified

disease indemnity; (8) Sickness or bodily injury or death by accident or both; and (9) Other

limited benefit policies.

     (e) If the commissioner of the office of the health insurance commissioner determines

that the corresponding provision of the federal Patient Protection and Affordable Care Act has

been declared invalid by a final judgment of the federal judicial branch or has been repealed by

an act of Congress, on the date of the commissioner’s determination this section shall have its

effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this

section. Nothing in this subsection shall be construed to limit the authority of the Commissioner

to regulate health insurance under existing state law.

 

     27-19-64. Coverage for individuals participating in approved clinical trials. – (a) As

used in this section:

     (1) “Approved clinical trial” means a phase I, phase II, phase III or phase IV clinical trial

that is conducted in relation to the prevention, detection or treatment of cancer or a life-

threatening disease or condition and is described in any of the following:

     (A) The study or investigation is approved or funded, which may include funding through

in-kind contributions, by one or more of the following:

     (i) The federal National Institutes of Health;

     (ii) The federal Centers for Disease Control and Prevention;

     (iii) The federal Agency for Health Care Research and Quality;

     (iv) The federal Centers for Medicare & Medicaid Services;

     (v) A cooperative group or center of any of the entities described in items (i) through (iv)

or the U.S. Department of Defense or the U.S. Department of Veterans’ Affairs;

     (vi) A qualified non-governmental research entity identified in the guidelines issued by

the federal National Institutes of Health for center support grants; or

     (vii) A study or investigation conducted by the U.S. Department of Veterans’ Affairs, the

     U.S. Department of Defense, or the U.S. Department of Energy, if the study or

investigation has been reviewed and approved through a system of peer review that the Secretary

of U.S. Department of Health and Human Services determines:

     (I) Is comparable to the system of peer review of studies and investigations used by the

Federal National Institutes of Health; and

     (II) Assures unbiased review of the highest scientific standards by qualified individuals

who have no interest in the outcome of the review.

     (B) The study or investigation is conducted under an investigational new drug application

reviewed by the U.S. Food and Drug Administration; or

     (C) The study or investigation is a drug trial that is exempt from having such an

investigational new drug application.

     (2) “Participant” has the meaning stated in section 3(7) of federal ERISA.

     (3) “Participating provider” means a health care provider that, under a contract with the

health carrier or with its contractor or subcontractor, has agreed to provide health care services to

covered persons with an expectation of receiving payment, other than coinsurance, copayments or

deductibles, directly or indirectly from the health carrier.

     (4) “Qualified individual” means a participant or beneficiary who meets the following

conditions:

     (A) The individual is eligible to participate in an approved clinical trial according to the

trial protocol with respect to the treatment of cancer or other life-threatening disease or condition;

and

     (B)(i) The referring health care professional is a participating provider and has concluded

that the individual’s participation in such trial would be appropriate based on the individual

meeting the conditions described in subdivision (A) of this subdivision (3); or

     (ii) The participant or beneficiary provides medical and scientific information

establishing the individual’s participation in such trial would be appropriate based on the

individual meeting the conditions described in subdivision (A) of this subdivision (3).

     (5) “Life-threatening condition” means any disease or condition from which the

likelihood of death is probable unless the course of the disease or condition is interrupted.

     (b)(1) If a health insurance carrier offering group or individual health insurance coverage

provides coverage to a qualified individual, the health carrier:

     (A) Shall not deny the individual participation in an approved clinical trial.

     (B) Subject to subdivision (3) of this subsection, shall not deny or limit or impose

additional conditions on the coverage of routine patient costs for items and services furnished in

connection with participation in the approved clinical trial; and

     (C) Shall not discriminate against the individual on the basis of the individual’s

participation in the approved clinical trial.

     (2)(A) Subject to subdivision (B) of this subdivision (2), routine patient costs include all

items and services consistent with the coverage typically covered for a qualified individual who is

not enrolled in an approved clinical trial.

     (B) For purposes of subdivision (B) of this subdivision (2), routine patient costs do not

include:

     (i) The investigational item, device or service itself;

     (ii) Items and services that are provided solely to satisfy data collection and analysis

needs and that are not used in the direct clinical management of the patient; or

     (iii) A service that is clearly inconsistent with widely accepted and established standards

of care for a particular diagnosis.

     (3) If one or more participating providers are participating in a clinical trial, nothing in

subdivision (1) of this subsection shall be construed as preventing a health carrier from requiring

that a qualified individual participate in the trial through such a participating provider if the

provider will accept the individual as a participant in the trial.

     (4) Notwithstanding subdivision (3) of this subsection, subdivision (1) of this subsection

shall apply to a qualified individual participating in an approved clinical trial that is conducted

outside this state.

     (5) This section shall not be construed to require a health carrier offering group or

individual health insurance coverage to provide benefits for routine patient care services provided

outside of the coverage’s health care provider network unless out-of-network benefits are

otherwise provided under the coverage.

     (6) Nothing in this section shall be construed to limit a health carrier’s coverage with

respect to clinical trials.

     (c) The requirements of this section shall be in addition to the requirements of Rhode

Island general laws sections 27-18-32 through 27-19-32.2.

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

shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity;

(2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6)

Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by

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

     (e) This section shall be effective for plan years beginning on or after January 1, 2014.

 

     27-19-65. Medical loss ratio reporting and rebates. – (a) A nonprofit hospital service

corporation offering group or individual health insurance coverage of a health benefit plan,

including a grandfathered health plan, shall comply with the provisions of Section 2718 of the

Public Health Services Act as amended by the federal Affordable Care Act, in accordance with

regulations adopted thereunder.

     (b) Health insurance carriers required to report medical loss ratio and rebate calculations

and other medical loss ratio and rebate information to the U.S. Department of Health and Human

Services shall concurrently file such information with the commissioner.

 

     27-19-66. Emergency services. – (a) As used in this section:

     (1) “Emergency medical condition” means a medical condition manifesting itself by

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

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

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

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

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

part.

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

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

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

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

such emergency medical condition, and

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

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

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

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

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

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

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

services consistent with the rules of this section.

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

services in the following manner:

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

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

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

is a participating network provider with respect to the services;

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

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

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

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

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

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

     (A) The exclusion of or coordination of benefits;

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

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

     (C) Applicable cost sharing.

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

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

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

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

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

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

subdivision (1) of this subsection. A group health plan or health insurance carrier complies with

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

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

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

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

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

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

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

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

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

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

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

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

amount under this subdivision (A) is disregarded.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

apply to out-of-network emergency services.

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

23, 2010.

     (f) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5)

Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or

bodily injury or death by accident or both; and (9) Other limited benefit policies.

 

     27-19-67. Internal and external appeal of adverse benefit determinations. – (a) The

commissioner shall adopt regulations to implement standards and procedures with respect to

internal claims and appeals of adverse benefit determinations, and with respect to external appeals

of adverse benefit determinations.

     (b) The regulations adopted by the commissioner shall apply only to those adverse

benefit determinations which are not subject to the jurisdiction of the department of health

pursuant to R.I. Gen. Laws § 23-17.12 et seq. (Utilization Review Act).

     (c) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5)

Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or

bodily injury or death by accident or both; and (9) Other limited benefit policies. This section also

shall not apply to grandfathered health plans.

 

     27-19-68. Prohibition on preexisting condition exclusions. -- (a) A health insurance

policy, subscriber contract, or health plan offered, issued, issued for delivery, or issued to cover a

resident of this state by a health insurance company licensed pursuant to this title and/or chapter:

     (1) Shall not limit or exclude coverage for an individual under the age of nineteen (19) by

imposing a preexisting condition exclusion on that individual.

     (2) For plan or policy years beginning on or after January 1, 2014, shall not limit or

exclude coverage for any individual by imposing a preexisting condition exclusion on that

individual.

     (b) As used in this section:

     (1) “Preexisting condition exclusion” means a limitation or exclusion of benefits,

including a denial of coverage, based on the fact that the condition (whether physical or mental)

was present before the effective date of coverage, or if the coverage is denied, the date of denial,

under a health benefit plan whether or not any medical advice, diagnosis, care or treatment was

recommended or received before the effective date of coverage.

     (2) “Preexisting condition exclusion” means any limitation or exclusion of benefits,

including a denial of coverage, applicable to an individual as a result of information relating to an

individual’s health status before the individual’s effective date of coverage, or if the coverage is

denied, the date of denial, under the health benefit plan, such as a condition (whether physical or

mental) identified as a result of a pre-enrollment questionnaire or physical examination given to

the individual, or review of medical records relating to the pre-enrollment period.

     (c) This section shall not apply to grandfathered health plans providing individual health

insurance coverage.

     (d) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5)

Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or

bodily injury or death by accident or both; and (9) Other limited benefit policies.

 

     SECTION 7. Sections 27-20-1 and 27-20-45 of the General laws in Chapter 27-20

entitled "Nonprofit Medical Service Corporations" are hereby amended to read as follows:

 

     27-20-1. Definitions. -- As used in this chapter:

     (1) "Adverse benefit determination" means any of the following: a denial, reduction, or

termination of, or a failure to provide or make payment (in whole or in part) for, a benefit,

including any such denial, reduction, termination, or failure to provide or make payment that is

based on a determination of a an individual’s eligibility to participate in a plan or to receive

coverage under a plan, and including, with respect to group health plans, a denial, reduction, or

termination of, or a failure to provide or make payment (in whole or in part) for, a benefit

resulting from the application of any utilization review, as well as a failure to cover an item or

service for which benefits are otherwise provided because it is determined to be experimental or

investigational or not medically necessary or appropriate. The term also includes a rescission of

coverage determination.

     (2) "Affordable Care Act" means the federal Patient Protection and Affordable Care Act

of 2010, as amended by the federal Health Care and Education Reconciliation Act of 2010, and

federal regulations adopted thereunder;

     (1)(3) "Certified registered nurse practitioners" is an expanded role utilizing independent

knowledge of physical assessment and management of health care and illnesses. The practice

includes collaboration with other licensed health care professionals including, but not limited to,

physicians, pharmacists, podiatrists, dentists, and nurses;

     (4) “Commissioner” or “health insurance commissioner” means that individual appointed

pursuant to section 42-14.5-1 of the General laws.

     (2)(5) "Counselor in mental health" means a person who has been licensed pursuant to

section 5-63.2-9.

     (6) "Essential health benefits" shall have the meaning set forth in section 1302(b) of the

federal Affordable Care Act.

     (7) “Grandfathered health plan” means any group health plan or health insurance

coverage subject to 42 USC section 18011.

     (8) “Group health insurance coverage” means, in connection with a group health plan,

health insurance coverage offered in connection with such plan.

     (9) “Group health plan” means an employee welfare benefit plan as defined in 29 USC

section 1002(1) to the extent that the plan provides health benefits to employees or their

dependents directly or through insurance, reimbursement, or otherwise.

     (10) “Health benefits” or “covered benefits” means coverage or benefits for the

diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose

of affecting any structure or function of the body including coverage or benefits for transportation

primarily for and essential thereto, and including medical services as defined in R.I. Gen. Laws §

27-19-17;

     (11) “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

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

laboratory and imaging centers, and rehabilitation and other therapeutic health settings.

     (12) "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.

     (13) "Health care provider" or "provider" means a health care professional or a health

care facility.

     (14) "Health care services" means services for the diagnosis, prevention, treatment, cure

or relief of a health condition, illness, injury or disease.

     (15) “Health insurance carrier” means a person, firm, corporation or other entity subject

to the jurisdiction of the commissioner under this chapter, and includes a nonprofit medical

service corporation. Such term does not include a group health plan.

     (16) "Health plan" or “health benefit plan” means health insurance coverage and a group

health plan, including coverage provided through an association plan if it covers Rhode Island

residents. Except to the extent specifically provided by the federal Affordable Care Act, the term

‘‘health plan’’ shall not include a group health plan to the extent state regulation of the health

plan is pre- empted under section 514 of the federal Employee Retirement Income Security Act of

1974. The term also shall not include:

     (A)(i) Coverage only for accident, or disability income insurance, or any combination

thereof.

     (ii) Coverage issued as a supplement to liability insurance.

     (iii) Liability insurance, including general liability insurance and automobile liability

insurance.

     (iv) Workers’ compensation or similar insurance.

     (v) Automobile medical payment insurance.

     (vi) Credit-only insurance.

     (vii) Coverage for on-site medical clinics.

     (viii) Other similar insurance coverage,

specified in federal regulations issued pursuant to Federal Pub. L. No. 104-191, the federal health

insurance portability and accountability act of 1996 (“HIPAA”), under which benefits for medical

care are secondary or incidental to other insurance benefits.

     (B) The following benefits if they are provided under a separate policy, certificate or

contract of insurance or are otherwise not an integral part of the plan:

     (i) Limited scope dental or vision benefits.

     (ii) Benefits for long-term care, nursing home care, home health care, community-based

care, or any combination thereof.

     (iii) Other excepted benefits specified in federal regulations issued pursuant to federal

Pub. L. No. 104-191 (“HIPAA”).

     (C) The following benefits if the benefits are provided under a separate policy, certificate

or contract of insurance, there is no coordination between the provision of the benefits and any

exclusion of benefits under any group health plan maintained by the same plan sponsor, and the

benefits are paid with respect to an event without regard to whether benefits are provided with

respect to such an event under any group health plan maintained by the same plan sponsor:

     (i) Coverage only for a specified disease or illness.

     (ii) Hospital indemnity or other fixed indemnity insurance.

     (D) The following if offered as a separate policy, certificate or contract of insurance:

     (i) Medicare supplement health insurance as defined under section 1882(g)(1) of the

federal Social Security Act.

     (ii) Coverage supplemental to the coverage provided under chapter 55 of title 10, United

States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)).

     (iii) Similar supplemental coverage provided to coverage under a group health plan.

     (3)(17)"Licensed midwife" means any midwife licensed under section 23-13-9;

     (4)(18) "Medical services" means those professional services rendered by persons duly

licensed under the laws of this state to practice medicine, surgery, chiropractic, podiatry, and

other professional services rendered by a licensed midwife, certified registered nurse

practitioners, and psychiatric and mental health nurse clinical specialists, and appliances, drugs,

medicines, supplies, and nursing care necessary in connection with the services, or the expense

indemnity for the services, appliances, drugs, medicines, supplies, and care, as may be specified

in any nonprofit medical service plan. Medical service shall not be construed to include hospital

services;

      (5)(19) "Nonprofit medical service corporation" means any corporation organized

pursuant hereto for the purpose of establishing, maintaining, and operating a nonprofit medical

service plan;

      (6)(20) "Nonprofit medical service plan" means a plan by which specified medical

service is provided to subscribers to the plan by a nonprofit medical service corporation;

     (21) "Office of the health insurance commissioner" means the agency established under

section 42-14.5-1 of the General laws.

      (7)(22) "Psychiatric and mental health nurse clinical specialist" is an expanded role

utilizing independent knowledge and management of mental health and illnesses. The practice

includes collaboration with other licensed health care professionals, including, but not limited to,

psychiatrists, psychologists, physicians, pharmacists, and nurses;

     (23) “Rescission" means a cancellation or discontinuance of coverage that has retroactive

effect for reasons unrelated to timely payment of required premiums or contribution to costs of

coverage.

      (8)(24) "Subscribers" means those persons or groups of persons who contract with a

nonprofit medical service corporation for medical service pursuant to a nonprofit medical service

plan; and

      (9)(25) "Therapist in marriage and family practice" means a person who has been

licensed pursuant to section 5-63.2-10.

 

     27-20-45. Termination of children's benefits Eligibility for children's benefits. --

(a)(1) Every individual health insurance contract, plan, or policy health benefit plan delivered,

issued for delivery, or renewed in this state and every group health insurance contract, plan, or

policy delivered, issued for delivery or renewed in this state which provides medical health

benefits coverage for dependent children that includes coverage for physician services in a

physician's office, and every policy which provides major medical or similar comprehensive type

coverage dependents, except for supplemental policies which only provide coverage for specified

diseases and other supplemental policies, shall provide make coverage available of an unmarried

child under the age of nineteen (19) years, an unmarried child who is a student under the age of

twenty-five (25) years and who is financially dependent upon the parent and an unmarried child

of any age who is financially dependent upon the parent and medically determined to have a

physical or mental impairment which can be expected to result in death or which has lasted or can

be expected to last for a continuous period of not less than twelve (12) months for children until

attainment of twenty-six (26) years of age, and an unmarried child of any age who is financially

dependent upon the parent and medically determined to have a physical or mental impairment

which can be expected to result in death or which has lasted or can be expected to last for a

continuous period of not less than twelve (12) months. Such contract, plan or policy shall also

include a provision that policyholders shall receive no less than thirty (30) days notice from the

accident and sickness insurer that a child covered as a dependent by the policy holder is about to

lose his or her coverage as a result of reaching the maximum age for a dependent child, and that

the child will only continue to be covered upon documentation being provided of current full or

part-time enrollment in a post-secondary educational institution or that the child may purchase a

conversion policy if he or she is not an eligible student.

     (b) Nothing in this section prohibits a nonprofit medical service corporation from

requiring a policyholder to annually provide proof of a child’s current full or part-time enrollment

in a post-secondary educational institution in order to maintain the child’s coverage.

     (2) With respect to a child who has not attained twenty-six (26) years of age, a nonprofit

medical service corporation shall not define “dependent” for purposes of eligibility for dependent

coverage of children other than the terms of a relationship between a child and the plan

participant or subscriber.

     (3) A nonprofit medical service corporation shall not deny or restrict coverage for a child

who has not attained twenty-six (26) years of age based on the presence or absence of the child’s

financial dependency upon the participant, primary subscriber or any other person, residency with

the participant and in the individual market the primary subscriber, or with any other person,

marital status, student status, employment or any combination of those factors. A nonprofit

medical service corporation shall not deny or restrict coverage of a child based on eligibility for

other coverage, except as provided in (b)(1) of this section.

     (4) Nothing in this section shall be construed to require a health insurance carrier to make

coverage available for the child of a child receiving dependent coverage, unless the grandparent

becomes the legal guardian or adoptive parent of that grandchild.

     (5) The terms of coverage in a health benefit plan offered by a nonprofit medical service

corporation or providing dependent coverage of children cannot vary based on age except for

children who are twenty-six (26) years of age or older.

     (b)(1) For plan years beginning before January 1, 2014, a group health plan providing

group health insurance coverage that is a grandfathered health plan and makes available

dependent coverage of children may exclude an adult child who has not attained twenty-six (26)

years of age from coverage only if the adult child is eligible to enroll in an eligible employer-

sponsored health benefit plan, as defined in section 5000A(f)(2) of the federal Internal Revenue

Code, other than the group health plan of a parent.

     (2) For plan years, beginning on or after January 1, 2014, a health insurance carrier

providing group health insurance coverage that is a grandfathered health plan shall comply with

the requirements of this section.

     (c)This section does not apply to insurance coverage providing benefits for: (1) hospital

confinement indemnity; (2) disability income; (3) accident only; (4) long term care; (5) Medicare

supplement; (6) limited benefit health; (7) specified diseased indemnity; or (8) other limited

benefit policies.

 

     SECTION 8. Chapter 27-20 of the General laws entitled "Nonprofit Medical Service

Corporations" is hereby amended by adding thereto the following sections:

 

     27-20-6.1. Uniform explanation of benefits and coverage.   (a) A nonprofit medical

service corporation shall provide a summary of benefits and coverage explanation and definitions

to policyholders and others required by, and at the times and in the format required, by the federal

regulations adopted under section 2715 of the Public Health Service Act, as amended by the

federal Affordable Care Act. The forms required by this section shall be made available to the

commissioner on request. Nothing in this section shall be construed to limit the authority of the

commissioner under existing state law.

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

shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity;

(2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6)

Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by

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

     (c) If the commissioner of the office of the health insurance commissioner determines

that the corresponding provision of the federal Patient Protection and Affordable Care Act has

been declared invalid by a final judgment of the federal judicial branch or has been repealed by

an act of Congress, on the date of the commissioner’s determination this section shall have its

effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this

section. Nothing in this section shall be construed to limit the authority of the commissioner

under existing state law.

 

     27-20-6.2. Filing of policy forms. – (a) A nonprofit medical service corporation shall file all

policy forms and rates used by it in the state with the commissioner, including the forms of any

rider, endorsement, application blank, and other matter generally used or incorporated by

reference in its policies or contracts of insurance. No such form shall be used if disapproved by

the commissioner under this section, or if the commissioner’s approval has been withdrawn after

notice and an opportunity to be heard, or until the expiration of sixty (60) days following the

filing of the form. Such a company shall comply with its filed and approved forms.  If the

commissioner finds from an examination of any form that it is contrary to the public interest, or

the requirements of this code or duly promulgated regulations, he or she shall forbid its use, and

shall notify the corporation in writing.

     (b) Each rate filing shall include a certification by a qualified actuary that to the best of

the actuary's knowledge and judgment, the entire rate filing is in compliance with applicable laws

and that the benefits offered or proposed to be offered are reasonable in relation to the premium

to be charged. A health insurance carrier shall comply with its filed and approved rates and forms.

     

     27-20-57. Prohibition on preexisting condition exclusions. -- (a) A health insurance

policy, subscriber contract, or health plan offered, issued, issued for delivery, or issued to cover a

resident of this state by a health insurance company licensed pursuant to this title and/or chapter:

     (1) Shall not limit or exclude coverage for an individual under the age of nineteen (19) by

imposing a preexisting condition exclusion on that individual.

     (2) For plan or policy years beginning on or after January 1, 2014, shall not limit or

exclude coverage for any individual by imposing a preexisting condition exclusion on that

individual.

     (b) As used in this section:

     (1) “Preexisting condition exclusion” means a limitation or exclusion of benefits,

including a denial of coverage, based on the fact that the condition (whether physical or mental)

was present before the effective date of coverage, or if the coverage is denied, the date of denial,

under a health benefit plan whether or not any medical advice, diagnosis, care or treatment was

recommended or received before the effective date of coverage.

     (2) “Preexisting condition exclusion” means any limitation or exclusion of benefits,

including a denial of coverage, applicable to an individual as a result of information relating to an

individual’s health status before the individual’s effective date of coverage, or if the coverage is

denied, the date of denial, under the health benefit plan, such as a condition (whether physical or

mental) identified as a result of a pre-enrollment questionnaire or physical examination given to

the individual, or review of medical records relating to the pre-enrollment period.

     (c) This section shall not apply to grandfathered health plans providing individual health

insurance coverage.

     (d) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5)

Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or

bodily injury or death by accident or both; and (9) Other limited benefit policies.

 

     27-20-58. Prohibition on rescission of coverage. – (a)(1) Coverage under a health

benefit plan subject to the jurisdiction of the commissioner under this chapter with respect to an

individual, including a group to which the individual belongs or family coverage in which the

individual is included, shall not be subject to rescission after the individual is covered under the

plan, unless:

     (A)The individual or a person seeking coverage on behalf of the individual, performs an

act, practice or omission that constitutes fraud; or

     (B)The individual makes an intentional misrepresentation of material fact, as prohibited

by the terms of the plan or coverage.

     (2) For purposes of paragraph (1)(A), a person seeking coverage on behalf of an

individual does not include an insurance producer or employee or authorized representative of the

health carrier.

     (b) At least thirty (30) days advance written notice shall be provided to each plan enrollee

or, for individual health insurance coverage, primary subscriber, who would be affected by the

proposed rescission of coverage before coverage under the plan may be rescinded in accordance

with subsection (a) regardless of, in the case of group health insurance coverage, whether the

rescission applies to the entire group or only to an individual within the group.

     (c) This section applies to grandfathered health plans.

 

     27-20-59. Annual and lifetime limits. – (a) Annual limits.

     (1) For plan or policy years beginning prior to January 1, 2014, for any individual, a

health insurance carrier and health benefit plan subject to the jurisdiction of the commissioner

under this chapter may establish an annual limit on the dollar amount of benefits that are essential

health benefits provided the restricted annual limit is not less than the following:

     (A) For a plan or policy year beginning after September 22, 2011, but before September

23, 2012 – one million two hundred fifty thousand dollars ($1,250,000); and

     (B) For a plan or policy year beginning after September 22, 2012, but before January 1,

2014 – two million dollars ($2,000,000).

     (2) For plan or policy years beginning on or after January 1, 2014, a health insurance

carrier and health benefit plan shall not establish any annual limit on the dollar amount of

essential health benefits for any individual, except:

     (A) A health flexible spending arrangement, as defined in section 106(c)(2)(i) of the

federal Internal Revenue Code, a medical savings account, as defined in section 220 of the federal

Internal Revenue Code, and a health savings account, as defined in section 223 of the federal

Internal Revenue Code are not subject to the requirements of subdivisions (1) and (2) of this

subsection.

     (B) The provisions of this subsection shall not prevent a health insurance carrier from

placing annual dollar limits for any individual on specific covered benefits that are not essential

health benefits to the extent that such limits are otherwise permitted under applicable federal law

or the laws and regulations of this state.

     (3) In determining whether an individual has received benefits that meet or exceed the

allowable limits, as provided in subdivision (1) of this subsection, a health insurance carrier shall

take into account only essential health benefits.

     (b) Lifetime limits.

     (1) A health insurance carrier and health benefit plan offering group or individual health

insurance coverage shall not establish a lifetime limit on the dollar value of essential health

benefits for any individual.

     (2) Notwithstanding subdivision (1) above, a health insurance carrier and health benefit

plan is not prohibited from placing lifetime dollar limits for any individual on specific covered

benefits that are not essential health benefits, as designated pursuant to a state determination and

in accordance with federal laws and regulations.

     (c)(1) Except as provided in subdivision (2) of this subsection, this section applies to any

health insurance carrier providing coverage under an individual or group health plan.

     (2)(A) The prohibition on lifetime limits applies to grandfathered health plans.

     (B) The prohibition and limits on annual limits apply to grandfathered health plans

providing group health insurance coverage, but the prohibition and limits on annual limits do not

apply to grandfathered health plans providing individual health insurance coverage.

     (d) This section shall not apply to a plan or to policy years prior to January 1, 2014 for

which the Secretary of the U.S. Department of Health and Human Services issued a waiver

pursuant to 45 C.F.R. §147.126(d)(3). This section also shall not apply to insurance coverage

providing benefits for: (1) Hospital confinement indemnity; (2) Disability income; (3) Accident

only; (4) Long-term care; (5) Medicare supplement; (6) Limited benefit health; (7) Specified

disease indemnity; (8) Sickness or bodily injury or death by accident or both; and (9) Other

limited benefit policies.

     (e) If the commissioner of the office of the health insurance commissioner determines

that the corresponding provision of the federal Patient Protection and Affordable Care Act has

been declared invalid by a final judgment of the federal judicial branch or has been repealed by

an act of Congress, on the date of the commissioner’s determination this section shall have its

effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this

section. Nothing in this subsection shall be construed to limit the authority of the Commissioner

to regulate health insurance under existing state law.

 

     27-20-60. Coverage for individuals participating in approved clinical trials. – (a) As

used in this section,

     (1) “Approved clinical trial” means a phase I, phase II, phase III or phase IV clinical trial

that is conducted in relation to the prevention, detection or treatment of cancer or a life-

threatening disease or condition and is described in any of the following:

     (A) The study or investigation is approved or funded, which may include funding through

in-kind contributions, by one or more of the following:

     (i) The federal National Institutes of Health;

     (ii) The federal Centers for Disease Control and Prevention;

     (iii) The federal Agency for Health Care Research and Quality;

     (iv) The federal Centers for Medicare & Medicaid Services;

     (v) A cooperative group or center of any of the entities described in items (i) through (iv)

or the U.S. Department of Defense or the U.S. Department of Veteran Affairs;

     (vi) A qualified non-governmental research entity identified in the guidelines issued by

the federal National Institutes of Health for center support grants; or

     (vii) A study or investigation conducted by the U.S. Department of Veteran Affairs, the

U.S. Department of Defense, or the U.S. Department of Energy, if the study or investigation has

been reviewed and approved through a system of peer review that the Secretary of U.S.

Department of Health and Human Services determines:

     (I) Is comparable to the system of peer review of studies and investigations used by the

federal National Institutes of Health; and

     (II) Assures unbiased review of the highest scientific standards by qualified individuals

who have no interest in the outcome of the review.

     (B) The study or investigation is conducted under an investigational new drug application

reviewed by the U.S. Food and Drug Administration; or

     (C) The study or investigation is a drug trial that is exempt from having such an

investigational new drug application.

     (2) “Participant” has the meaning stated in section 3(7) of federal ERISA.

     (3) “Participating provider” means a health care provider that, under a contract with the

health carrier or with its contractor or subcontractor, has agreed to provide health care services to

covered persons with an expectation of receiving payment, other than coinsurance, copayments or

deductibles, directly or indirectly from the health carrier.

     (4) “Qualified individual” means a participant or beneficiary who meets the following

conditions:

     (A) The individual is eligible to participate in an approved clinical trial according to the

trial protocol with respect to the treatment of cancer or other life-threatening disease or condition;

and

     (B)(i) The referring health care professional is a participating provider and has concluded

that the individual’s participation in such trial would be appropriate based on the individual

meeting the conditions described in subdivision (A) of this subdivision (3); or

     (ii) The participant or beneficiary provides medical and scientific information

establishing the individual’s participation in such trial would be appropriate based on the

individual meeting the conditions described in subdivision (A) of this subdivision (3).

     (5) “Life-threatening condition” means any disease or condition from which the

likelihood of death is probable unless the course of the disease or condition is interrupted.

     (b)(1) If a health insurance carrier offering group or individual health insurance coverage

provides coverage to a qualified individual, the health carrier:

     (A) Shall not deny the individual participation in an approved clinical trial.

     (B) Subject to subdivision (3) of this subsection, shall not deny or limit or impose

additional conditions on the coverage of routine patient costs for items and services furnished in

connection with participation in the approved clinical trial; and

     (C) Shall not discriminate against the individual on the basis of the individual’s

participation in the approved clinical trial.

     (2)(A) Subject to subdivision (B) of this subdivision (2), routine patient costs include all

items and services consistent with the coverage typically covered for a qualified individual who is

not enrolled in an approved clinical trial.

     (B) For purposes of subdivision (B) of this subdivision (2), routine patient costs do not

include:

     (i) The investigational item, device or service itself;

     (ii) Items and services that are provided solely to satisfy data collection and analysis

needs and that are not used in the direct clinical management of the patient; or

     (iii) A service that is clearly inconsistent with widely accepted and established standards

of care for a particular diagnosis.

     (3) If one or more participating providers is participating in a clinical trial, nothing in

subdivision (1) of this subsection shall be construed as preventing a health carrier from requiring

that a qualified individual participate in the trial through such a participating provider if the

provider will accept the individual as a participant in the trial.

     (4) Notwithstanding subdivision (3) of this subsection, subdivision (1) of this subsection

shall apply to a qualified individual participating in an approved clinical trial that is conducted

outside this state.

     (5) This section shall not be construed to require a nonprofit medical service corporation

offering group or individual health insurance coverage to provide benefits for routine patient care

services provided outside of the coverage’s health care provider network unless out-of-network

benefits are otherwise provided under the coverage.

     (6) Nothing in this section shall be construed to limit a health insurance carrier’s

coverage with respect to clinical trials.

     (c) The requirements of this section shall be in addition to the requirements of Rhode

Island general laws sections 27-18-36 through 27-18-36.3.

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

to insurance coverage providing benefits for: (1) Hospital confinement indemnity; (2) Disability

income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6) Limited benefit

health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by accident or

both; and (9) Other limited benefit policies.

     (e) This section shall be effective for plan years beginning on or after January 1, 2014.

 

     27-20-61. Medical loss ratio reporting and rebates. – (a) A nonprofit medical service

corporation offering group or individual health insurance coverage of a health benefit plan,

including a grandfathered health plan, shall comply with the provisions of Section 2718 of the

Public Health Services Act as amended by the federal Affordable Care Act, in accordance with

regulations adopted thereunder.

     (b) Nonprofit medical service corporations required to report medical loss ratio and

rebate calculations and any other medical loss ratio and rebate information to the U.S.

Department of Health and Human Services shall concurrently file such information with the

commissioner.

 

     27-20-62. Emergency services -- (a) As used in this section:

     (1) “Emergency medical condition” means a medical condition manifesting itself by

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

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

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

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

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

part.

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

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

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

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

such emergency medical condition, and

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

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

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

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

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

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

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

emergency services consistent with the rules of this section.

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

services in the following manner:

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

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

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

is a participating network provider with respect to the services;

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

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

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

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

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

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

     (A) The exclusion of or coordination of benefits;

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

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

     (C) Applicable cost-sharing.

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

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

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

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

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

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

subdivision (1) of this subsection. A group health plan or health insurance carrier complies with

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

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

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

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

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

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

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

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

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

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

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

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

amount under this subdivision (A) is disregarded.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

apply to out-of-network emergency services.

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

shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity;

(2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6)

Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by

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

 

     27-20-63. Internal and external appeal of adverse benefit determinations. -- (a) The

commissioner shall adopt regulations to implement standards and procedures with respect to

internal claims and appeals of adverse benefit determinations, and with respect to external appeals

of adverse benefit determinations.

     (b) The regulations adopted by the commissioner shall apply only to those adverse

benefit determinations which are not subject to the jurisdiction of the department of health

pursuant to R.I. Gen. Laws § 23-17.12 et seq. (Utilization Review Act).

     (c) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5)

Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or

bodily injury or death by accident or both; and (9) Other limited benefit policies. This section also

shall not apply to grandfathered health plans.

 

     SECTION 9. Sections 27-41-2 and 27-41-61 of the General laws in Chapter 27-41

entitled "Health Maintenance Organizations” are hereby amended to read as follows:

 

     27-41-2. Definitions. – As used in this chapter:

     (a) "Adverse benefit determination" means any of the following: a denial, reduction, or

termination of, or a failure to provide or make payment (in whole or in part) for, a benefit,

including any such denial, reduction, termination, or failure to provide or make payment that is

based on a determination of a an individual’s eligibility to participate in a plan or to receive

coverage under a plan, and including, with respect to group health plans, a denial, reduction, or

termination of, or a failure to provide or make payment (in whole or in part) for, a benefit

resulting from the application of any utilization review, as well as a failure to cover an item or

service for which benefits are otherwise provided because it is determined to be experimental or

investigational or not medically necessary or appropriate. The term also includes a rescission of

coverage determination.

     (b) "Affordable Care Act" means the federal Patient Protection and Affordable Care act

of 2010, as amended by the federal Health Care and Education Reconciliation Act of 2010, and

federal regulations adopted thereunder;

     (c) “Commissioner” or “health insurance commissioner” means that individual appointed

pursuant to section 42-14.5-1 of the general laws.

     (d) "Covered health services" means the services that a health maintenance organization

contracts with enrollees and enrolled groups to provide or make available to an enrolled

participant.

     (e) "Director" means the director of the department of business regulation or his or her

duly appointed agents.

     (f) "Employee" means any person who has entered into the employment of or works

under a contract of service or apprenticeship with any employer. It shall not include a person who

has been employed for less than thirty (30) days by his or her employer, nor shall it include a

person who works less than an average of thirty (30) hours per week. For the purposes of this

chapter, the term "employee" means a person employed by an "employer" as defined in

subsection (d) of this section. Except as otherwise provided in this chapter the terms "employee"

and "employer" are to be defined according to the rules and regulations of the department of labor

and training.

     (g) "Employer" means any person, partnership, association, trust, estate, or corporation,

whether foreign or domestic, or the legal representative, trustee in bankruptcy, receiver, or trustee

of a receiver, or the legal representative of a deceased person, including the state of Rhode Island

and each city and town in the state, which has in its employ one or more individuals during any

calendar year. For the purposes of this section, the term "employer" refers only to an employer

with persons employed within the state of Rhode Island.

     (h) "Enrollee" means an individual who has been enrolled in a health maintenance

organization.

     (i) "Essential health benefits" shall have the meaning set forth in section 1302(b) of the

federal Affordable Care Act.

     (j) "Evidence of coverage" means any certificate, agreement, or contract issued to an

enrollee setting out the coverage to which the enrollee is entitled.

     (k) “Grandfathered health plan” means any group health plan or health insurance

coverage subject to 42 USC section 18011.

     (l) “Group health insurance coverage” means, in connection with a group health plan,

health insurance coverage offered in connection with such plan.

     (m) “Group health plan” means an employee welfare benefit plan as defined in 29 USC

section 1002(1), to the extent that the plan provides health benefits to employees or their

dependents directly or through insurance, reimbursement, or otherwise.

     (n) “Health benefits” or “covered benefits” means coverage or benefits for the diagnosis,

cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting

any structure or function of the body including coverage or benefits for transportation primarily

for and essential thereto, and including medical services as defined in R.I. Gen. Laws § 27-19-17;

     (o) “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

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

laboratory and imaging centers, and rehabilitation and other therapeutic health settings.

     (p) "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.

     (q) "Health care provider" or "provider" means a health care professional or a health care

facility.

     (r) "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.

     (s) “Health insurance carrier” means a person, firm, corporation or other entity subject to

the jurisdiction of the commissioner under this chapter, and includes a health maintenance

organization. Such term does not include a group health plan.

     (t) "Health maintenance organization" means a single public or private organization

which:

     (1) Provides or makes available to enrolled participants health care services, including at

least the following basic health care services: usual physician services, hospitalization, laboratory,

x-ray, emergency, and preventive services, and out of area coverage, and the services of licensed

midwives;

     (2) Is compensated, except for copayments, for the provision of the basic health care

services listed in subdivision (1) of this subsection to enrolled participants on a predetermined

periodic rate basis; and

     (3) Provides physicians' services primarily:

     (A) Directly through physicians who are either employees or partners of the organization;

or

     (B) Through arrangements with individual physicians or one or more groups of

physicians organized on a group practice or individual practice basis;

     (ii) "Health maintenance organization" does not include prepaid plans offered by entities

regulated under chapter 1, 2, 19, or 20 of this title that do not meet the criteria above and do not

purport to be health maintenance organizations;

     (4) Provides the services of licensed midwives primarily:

     (i) Directly through licensed midwives who are either employees or partners of the

organization; or

     (ii) Through arrangements with individual licensed midwives or one or more groups of

licensed midwives organized on a group practice or individual practice basis.

     (u) "Licensed midwife" means any midwife licensed pursuant to section 23-13-9.

     (v) "Material modification" means only systemic changes to the information filed under

section 27-41-3.

     (w) "Net worth", for the purposes of this chapter, means the excess of total admitted

assets over total liabilities.

     (x) "Office of the health insurance commissioner" means the agency established under

section 42-14.5-1 of the general laws.

     (y) "Physician" includes podiatrist as defined in chapter 29 of title 5.

     (z) "Private organization" means a legal corporation with a policy making and governing

body.

     (aa) "Provider" means any physician, hospital, licensed midwife, or other person who is

licensed or authorized in this state to furnish health care services.

     (bb) "Public organization" means an instrumentality of government.

     (cc) “Rescission" means a cancellation or discontinuance of coverage that has retroactive

effect for reasons unrelated to timely payment of required premiums or contribution to costs of

coverage.

     (dd) "Risk based capital ("RBC") instructions" means the risk based capital report

including risk based capital instructions adopted by the National Association of Insurance

Commissioners ("NAIC"), as these risk based capital instructions are amended by the NAIC in

accordance with the procedures adopted by the NAIC.

     (ee) "Total adjusted capital" means the sum of:

     (1) A health maintenance organization's statutory capital and surplus (i.e. net worth) as

determined in accordance with the statutory accounting applicable to the annual financial

statements required to be filed under section 27-41-9; and

     (2) Any other items, if any, that the RBC instructions provide.

     (ff) "Uncovered expenditures" means the costs of health care services that are covered by

a health maintenance organization, but that are not guaranteed, insured, or assumed by a person or

organization other than the health maintenance organization. Expenditures to a provider that

agrees not to bill enrollees under any circumstances are excluded from this definition.

 

     27-41-61. Termination of children's benefits Eligibility for children’s benefits --

(a)(1) Every individual health insurance contract, plan, or policy health benefit plan delivered,

issued for delivery, or renewed in this state which provides medical health benefits coverage for

dependent children that includes coverage for physician services in a physician’s office, and

every policy which provides major medical or similar comprehensive type coverage dependents,

except for supplemental policies which only provide coverage for specified diseases and other

supplemental policies, shall provide make coverage available of an unmarried child under the age

of nineteen (19) years, an unmarried child who is a student under the age of twenty-five (25)

years and who is financially dependent upon the parent and an unmarried child of any age who is

financially dependent upon the parent and medically determined to have a physical or mental

impairment which can be expected to result in death or which has lasted or can be expected to last

for a continuous period of not less than twelve (12) months for children until attainment of

twenty-six (26) years of age, and an unmarried child of any age who is financially dependent

upon the parent and medically determined to have a physical or mental impairment which can be

expected to result in death or which has lasted or can be expected to last for a continuous period

of not less than twelve (12) months. Such contract, plan or policy shall also include a provision

that policyholders shall receive no less than thirty (30) days notice from the accident and sickness

insurer that a child covered as a dependent by the policy holder is about to lose his or her

coverage as a result of reaching the maximum age for a dependent child, and that the child will

only continue to be covered upon documentation being provided of current full or part-time

enrollment in a post-secondary educational institution or that the child may purchase a conversion

policy if he or she is not an eligible student. Nothing in this section prohibits an accident and

sickness insurer from requiring a policy holder to annually provide proof of a child’s current full

or part-time enrollment in a post-secondary educational institution in order to maintain the child’s

coverage. Provided, nothing in this section requires coverage inconsistent with the membership

criteria in effect under the policyholder’s health benefits coverage.

     (2) With respect to a child who has not attained twenty-six (26) years of age, a health

maintenance organization shall not define “dependent” for purposes of eligibility for dependent

coverage of children other than the terms of a relationship between a child and the plan

participant, or subscriber.

     (3) A health maintenance organization shall not deny or restrict coverage for a child who

has not attained twenty-six (26) years of age based on the presence or absence of the child’s

financial dependency upon the participant, primary subscriber or any other person, residency with

the participant and in the individual market the primary subscriber, or with any other person,

marital status, student status, employment or any combination of those factors. A health carrier

shall not deny or restrict coverage of a child based on eligibility for other coverage, except as

provided in (b) (1) of this section.

     (4) Nothing in this section shall be construed to require a health maintenance

organization to make coverage available for the child of a child receiving dependent coverage,

unless the grandparent becomes the legal guardian or adoptive parent of that grandchild.

     (5) The terms of coverage in a health benefit plan offered by a health maintenance

organization providing dependent coverage of children cannot vary based on age except for

children who are twenty-six (26) years of age or older.

     (b)(1) For plan years beginning before January 1, 2014, a group health plan providing

group health insurance coverage that is a grandfathered health plan and makes available

dependent coverage of children may exclude an adult child who has not attained twenty-six (26)

years of age from coverage only if the adult child is eligible to enroll in an eligible employer-

sponsored health benefit plan, as defined in section 5000A(f)(2) of the federal Internal Revenue

Code, other than the group health plan of a parent.

     (2) For plan years, beginning on or after January 1, 2014, a group health plan providing

group health insurance coverage that is a grandfathered health plan shall comply with the

requirements of this section

     (c) This section does not apply to insurance coverage providing benefits for: (1) hospital

confinement indemnity; (2) disability income; (3) accident only; (4) long term care; (5) Medicare

supplement; (6) limited benefit health; (7) specified diseased indemnity; or (8) other limited

benefit policies.

 

     SECTION 10. Chapter 27-41 of the General laws entitled "Health Maintenance

Organizations" is hereby amended by adding thereto the following sections:

 

     27-41-29.1. Uniform explanation of benefits and coverage. -- (a) A health maintenance

organization shall provide a summary of benefits and coverage explanation and definitions to

policyholders and others required by, and at the times and in the format required, by the federal

regulations adopted under section 2715 of the Public Health Service Act, as amended by the

federal Affordable Care Act. The forms required by this section shall be made available to the

commissioner on request. Nothing in this section shall be construed to limit the authority of the

commissioner under existing state law.

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

shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity;

(2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6)

Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by

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

     (c) If the commissioner of the office of the health insurance commissioner determines

that the corresponding provision of the federal Patient Protection and Affordable Care Act has

been declared invalid by a final judgment of the federal judicial branch or has been repealed by

an act of Congress, on the date of the commissioner’s determination this section shall have its

effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this

section. Nothing in this section shall be construed to limit the authority of the commissioner

under existing state law.

 

     27-41-29.2. Filing of policy forms. – (a) A health maintenance organization shall file all

policy forms and rates used by it in the state with the commissioner, including the forms of any

rider, endorsement, application blank, and other matter generally used or incorporated by

reference in its policies or contracts of insurance. No such form shall be used if disapproved by

the commissioner under this section, or if the commissioner’s approval has been withdrawn after

notice and an opportunity to be heard, or until the expiration of sixty (60) days following the

filing of the form. Such a company shall comply with its filed and approved forms. . If the

commissioner finds from an examination of any form that it is contrary to the public interest or

the requirements of this code or duly promulgated regulations, he or she shall forbid its use, and

shall notify the corporation in writing.

     (b) Each rate filing shall include a certification by a qualified actuary that to the best of

the actuary's knowledge and judgment, the entire rate filing is in compliance with applicable laws

and that the benefits offered or proposed to be offered are reasonable in relation to the premium

to be charged. A health insurance carrier shall comply with its filed and approved rates and

forms.

 

     27-41-75. Prohibition on rescission of coverage. -- (a)(1) Coverage under a health plan

subject to the jurisdiction of the commissioner under this chapter with respect to an individual,

including a group to which the individual belongs or family coverage in which the individual is

included, shall not be rescinded after the individual is covered under the plan, unless:

     (A) The individual or a person seeking coverage on behalf of the individual, performs an

act, practice or omission that constitutes fraud; or

     (B) The individual makes an intentional misrepresentation of material fact, as prohibited

by the terms of the plan or coverage.

     (2) For purposes of paragraph (1)(A), a person seeking coverage on behalf of an

individual does not include an insurance producer or employee or authorized representative of the

health maintenance organization.

     (b) At least thirty (30) days advance written notice shall be provided to each plan enrollee

or, for individual health insurance coverage, primary subscriber, who would be affected by the

proposed rescission of coverage before coverage under the plan may be rescinded in accordance

with subsection (a) regardless of, in the case of group health insurance coverage, whether the

rescission applies to the entire group or only to an individual within the group.

     (c) For purposes of this section, “to rescind” means to cancel or to discontinue coverage

with retroactive effect for reasons unrelated to timely payment of required premiums or

contribution to costs of coverage.

     (d) This section applies to grandfathered health plans.

 

     27-41-76. Prohibition on annual and lifetime limits. -- (a) Annual limits.

     (1) For plan or policy years beginning prior to January 1, 2014, for any individual, a

health maintenance organization subject to the jurisdiction of the commissioner under this chapter

may establish an annual limit on the dollar amount of benefits that are essential health benefits

provided the restricted annual limit is not less than the following:

     (A) For a plan or policy year beginning after September 22, 2011, but before September

23, 2012 – one million two hundred fifty thousand dollars ($1,250,000); and

     (B) For a plan or policy year beginning after September 22, 2012, but before January 1,

2014 – two million dollars ($2,000,000).

     (2 ) For plan or policy years beginning on or after January 1, 2014, a health maintenance

organization shall not establish any annual limit on the dollar amount of essential health benefits

for any individual, except:

     (A) A health flexible spending arrangement, as defined in section 106(c)(2)(i) of the

federal Internal Revenue Code, a medical savings account, as defined in section 220 of the federal

Internal Revenue Code, and a health savings account, as defined in section 223 of the federal

Internal Revenue Code are not subject to the requirements of subdivisions (1) and (2) of this

subsection .

     (B) The provisions of this subsection shall not prevent a health maintenance organization

from placing annual dollar limits for any individual on specific covered benefits that are not

essential health benefits to the extent that such limits are otherwise permitted under applicable

federal law or the laws and regulations of this state.

     (3) In determining whether an individual has received benefits that meet or exceed the

allowable limits, as provided in subdivision (1) of this subsection, a health maintenance

organization shall take into account only essential health benefits.

     (b) Lifetime limits.

     (1) A health insurance carrier and health benefit plan offering group or individual health

insurance coverage shall not establish a lifetime limit on the dollar value of essential health

benefits for any individual.

     (2) Notwithstanding subdivision (1) above, a health insurance carrier and health benefit

plan is not prohibited from placing lifetime dollar limits for any individual on specific covered

benefits that are not essential health benefits in accordance with federal laws and regulations.

     (c)(1) The provisions of this section relating to lifetime limits apply to any health

maintenance organization or health insurance carrier providing coverage under an individual or

group health plan, including grandfathered health plans.

     (2) The provisions of this section relating to annual limits apply to any health

maintenance organization or health insurance carrier providing coverage under a group health

plan, including grandfathered health plans, but the prohibition and limits on annual limits do not

apply to grandfathered health plans providing individual health insurance coverage.

     (d) This section shall not apply to a plan or to policy years prior to January 1, 2014 for

which the Secretary of the U.S. Department of Health and Human Services issued a waiver

pursuant to 45 C.F.R. § 147.126(d)(3). This section also shall not apply to insurance coverage

providing benefits for: (1) Hospital confinement indemnity; (2) Disability income; (3) Accident

only; (4) Long-term care; (5) Medicare supplement; (6) Limited benefit health; (7) Specified

disease indemnity; (8) Sickness or bodily injury or death by accident or both; and (9) Other

limited benefit policies.

     (e) If the commissioner of the office of the health insurance commissioner determines

that the corresponding provision of the federal Patient Protection and Affordable Care Act has

been declared invalid by a final judgment of the federal judicial branch or has been repealed by

an act of Congress, on the date of the commissioner’s determination this section shall have its

effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this

section. Nothing in this subsection shall be construed to limit the authority of the Commissioner

to regulate health insurance under existing state law.

 

     27-41-77. Coverage for individual participating in approved clinical trials. -- (a) As

used in this section.

     (1) “Approved clinical trial” means a phase I, phase II, phase III or phase IV clinical trial

that is conducted in relation to the prevention, detection or treatment of cancer or a life-

threatening disease or condition and is described in any of the following:

     (A) The study or investigation is approved or funded, which may include funding through

in-kind contributions, by one or more of the following:

     (i) The federal National Institutes of Health;

     (ii) The federal Centers for Disease Control and Prevention;

     (iii) The federal Agency for Health Care Research and Quality;

     (iv) The federal Centers for Medicare & Medicaid Services;

     (v) A cooperative group or center of any of the entities described in items (i) through (iv)

or the U.S. Department of Defense or the U.S. Department of Veteran Affairs;

     (vi) A qualified non-governmental research entity identified in the guidelines issued by

the federal National Institutes of Health for center support grants; or

     (vii) A study or investigation conducted by the U.S. Department of Veteran Affairs, the

U.S. Department of Defense, or the U.S. Department of Energy, if the study or investigation has

been reviewed and approved through a system of peer review that the Secretary of U.S.

Department of Health and Human Services determines:

     (I) Is comparable to the system of peer review of studies and investigations used by the

federal National Institutes of Health; and

     (II) Assures unbiased review of the highest scientific standards by qualified individuals

who have no interest in the outcome of the review.

     (B) The study or investigation is conducted under an investigational new drug application

reviewed by the U.S. Food and Drug Administration; or

     (C) The study or investigation is a drug trial that is exempt from having such an

investigational new drug application.

     (2) “Participant” has the meaning stated in section 3(7) of federal ERISA.

     (3) “Participating provider” means a health care provider that, under a contract with the

health carrier or with its contractor or subcontractor, has agreed to provide health care services to

covered persons with an expectation of receiving payment, other than coinsurance, copayments or

deductibles, directly or indirectly from the health carrier.

     (4) “Qualified individual” means a participant or beneficiary who meets the following

conditions:

     (A) The individual is eligible to participate in an approved clinical trial according to the

trial protocol with respect to the treatment of cancer or other life-threatening disease or condition;

and

     (B)(i) The referring health care professional is a participating provider and has concluded

that the individual’s participation in such trial would be appropriate based on the individual

meeting the conditions described in subdivision (A) of this subdivision (3); or

     (ii) The participant or beneficiary provides medical and scientific information

establishing the individual’s participation in such trial would be appropriate based on the

individual meeting the conditions described in subdivision (A) of this subdivision (3).

     (5) “Life-threatening condition” means any disease or condition from which the

likelihood of death is probable unless the course of the disease or condition is interrupted.

     (b)(1) If a health maintenance organization offering group or individual health insurance

coverage provides coverage to a qualified individual, it:

     (A) Shall not deny the individual participation in an approved clinical trial.

     (B) Subject to subdivision (3) of this subsection, shall not deny or limit or impose

additional conditions on the coverage of routine patient costs for items and services furnished in

connection with participation in the approved clinical trial; and

     (C) Shall not discriminate against the individual on the basis of the individual’s

participation in the approved clinical trial.

     (2)(A) Subject to subdivision (B) of this subdivision (2), routine patient costs include all

items and services consistent with the coverage typically covered for a qualified individual who is

not enrolled in an approved clinical trial.

     (B) For purposes of subdivision (B) of this subdivision (2), routine patient costs do not

include:

     (i) The investigational item, device or service itself;

     (ii) Items and services that are provided solely to satisfy data collection and analysis

needs and that are not used in the direct clinical management of the patient; or

     (iii) A service that is clearly inconsistent with widely accepted and established standards

of care for a particular diagnosis.

     (3) If one or more participating providers is participating in a clinical trial, nothing in

subdivision (1) of this subsection shall be construed as preventing a health maintenance

organization from requiring that a qualified individual participate in the trial through such a

participating provider if the provider will accept the individual as a participant in the trial.

     (4) Notwithstanding subdivision (3) of this subsection, subdivision (1) of this subsection

shall apply to a qualified individual participating in an approved clinical trial that is conducted

outside this state.

     (5) This section shall not be construed to require a health maintenance organization

offering group or individual health insurance coverage to provide benefits for routine patient care

services provided outside of the coverage’s health care provider network unless out-of-network

benefits are other provided under the coverage.

     (6) Nothing in this section shall be construed to limit a health maintenance organization’s

coverage with respect to clinical trials.

     (c) The requirements of this section shall be in addition to the requirements of Rhode

Island general laws sections 27-41-41 through 27-41-41.3.

     (d) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5)

Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or

bodily injury or death by accident or both; and (9) Other limited benefit policies.

 

     27-41-78. Medical loss ratio reporting and rebates. -- (a) A health maintenance

organization offering group or individual health insurance coverage of a health benefit plan,

including a grandfathered health plan, shall comply with the provisions of Section 2718 of the

Public Health Services Act as amended by the federal Affordable Care Act, in accordance with

regulations adopted thereunder.

     (b) Health maintenance organizations required to report medical loss ratio and rebate

calculations and any other medical loss ratio or rebate information to the U.S. Department of

Health and Human Services shall concurrently file such information with the commissioner.

 

     27-41-79. Emergency services. -- (a) As used in this section:

     (1) “Emergency medical condition” means a medical condition manifesting itself by

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

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

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

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

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

part.

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

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

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

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

such emergency medical condition, and

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

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

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

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

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

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

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

cover emergency services consistent with the rules of this section.

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

the following manner:

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

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

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

is a participating network provider with respect to the services;

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

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

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

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

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

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

     (A) The exclusion of or coordination of benefits;

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

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

     (C) Applicable cost sharing.

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

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

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

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

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

network provider charges over the amount the plan or health maintenance organization is required

to pay under subdivision (1) of this subsection. A health maintenance organization complies with

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

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

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

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

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

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

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

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

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

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

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

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

amount under this subdivision (A) is disregarded.

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

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

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

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

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

coverage with respect to out-of-network services.

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

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

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

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

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

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

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

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

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

apply to out-of-network emergency services.

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

23, 2010.

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

shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity;

(2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6)

Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by

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

 

     27-41-80. Internal and external appeal of adverse benefit determinations. -- (a) The

commissioner shall adopt regulations to implement standards and procedures with respect to

internal claims and appeals of adverse benefit determinations, and with respect to external appeals

of adverse benefit determinations.

     (b) The regulations adopted by the commissioner shall apply only to those adverse

benefit determinations within the jurisdiction of the department of health pursuant to R.I. Gen.

Laws § 23-17.12 et seq. (Utilization Review Act).

     (c) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5)

Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or

bodily injury or death by accident or both; and (9) Other limited benefit policies. This section also

shall not apply to grandfathered health plans.

 

     27-41-81. Prohibition on preexisting condition exclusions. -- (a) A health insurance

policy, subscriber contract, or health plan offered, issued, issued for delivery, or issued to cover a

resident of this state by a health insurance company licensed pursuant to this title and/or chapter:

     (1) Shall not limit or exclude coverage for an individual under the age of nineteen (19) by

imposing a preexisting condition exclusion on that individual.

     (2) For plan or policy years beginning on or after January 1, 2014, shall not limit or

exclude coverage for any individual by imposing a preexisting condition exclusion on that

individual.

     (b) As used in this section:

     (1) “Preexisting condition exclusion” means a limitation or exclusion of benefits,

including a denial of coverage, based on the fact that the condition (whether physical or mental)

was present before the effective date of coverage, or if the coverage is denied, the date of denial,

under a health benefit plan whether or not any medical advice, diagnosis, care or treatment was

recommended or received before the effective date of coverage.

     (2) “Preexisting condition exclusion” means any limitation or exclusion of benefits,

including a denial of coverage, applicable to an individual as a result of information relating to an

individual’s health status before the individual’s effective date of coverage, or if the coverage is

denied, the date of denial, under the health benefit plan, such as a condition (whether physical or

mental) identified as a result of a pre-enrollment questionnaire or physical examination given to

the individual, or review of medical records relating to the pre-enrollment period.

     (c) This section shall not apply to grandfathered health plans providing individual health

insurance coverage.

     (d) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5)

Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or

bodily injury or death by accident or both; and (9) Other limited benefit policies.

 

     SECTION 11. Sections 27-50-3 and 27-50-7 of the General Laws in Chapter 27-50

entitled "Small Employer Health Insurance Availability Act" are hereby amended to read as

follows:

 

     27-50-3. Definitions. [Effective December 31, 2010.] -- (a) "Actuarial certification"

means a written statement signed by a member of the American Academy of Actuaries or other

individual acceptable to the director that a small employer carrier is in compliance with the

provisions of section 27-50-5, based upon the person's examination and including a review of the

appropriate records and the actuarial assumptions and methods used by the small employer carrier

in establishing premium rates for applicable health benefit plans.

      (b) "Adjusted community rating" means a method used to develop a carrier's premium

which spreads financial risk across the carrier's entire small group population in accordance with

the requirements in section 27-50-5.

      (c) "Affiliate" or "affiliated" means any entity or person who directly or indirectly

through one or more intermediaries controls or is controlled by, or is under common control with,

a specified entity or person.

      (d) "Affiliation period" means a period of time that must expire before health insurance

coverage provided by a carrier becomes effective, and during which the carrier is not required to

provide benefits.

      (e) "Bona fide association" means, with respect to health benefit plans offered in this

state, an association which:

      (1) Has been actively in existence for at least five (5) years;

      (2) Has been formed and maintained in good faith for purposes other than obtaining

insurance;

      (3) Does not condition membership in the association on any health-status related factor

relating to an individual (including an employee of an employer or a dependent of an employee);

      (4) Makes health insurance coverage offered through the association available to all

members regardless of any health status-related factor relating to those members (or individuals

eligible for coverage through a member);

      (5) Does not make health insurance coverage offered through the association available

other than in connection with a member of the association;

      (6) Is composed of persons having a common interest or calling;

      (7) Has a constitution and bylaws; and

      (8) Meets any additional requirements that the director may prescribe by regulation.

      (f) "Carrier" or "small employer carrier" means all entities licensed, or required to be

licensed, in this state that offer health benefit plans covering eligible employees of one or more

small employers pursuant to this chapter. For the purposes of this chapter, carrier includes an

insurance company, a nonprofit hospital or medical service corporation, a fraternal benefit

society, a health maintenance organization as defined in chapter 41 of this title or as defined in

chapter 62 of title 42, or any other entity subject to state insurance regulation that provides

medical care as defined in subsection (y) that is paid or financed for a small employer by such

entity on the basis of a periodic premium, paid directly or through an association, trust, or other

intermediary, and issued, renewed, or delivered within or without Rhode Island to a small

employer pursuant to the laws of this or any other jurisdiction, including a certificate issued to an

eligible employee which evidences coverage under a policy or contract issued to a trust or

association.

      (g) "Church plan" has the meaning given this term under section 3(33) of the Employee

Retirement Income Security Act of 1974 [29 U.S.C. section 1002(33)_.

      (h) "Control" is defined in the same manner as in chapter 35 of this title.

      (i) (1) "Creditable coverage" means, with respect to an individual, health benefits or

coverage provided under any of the following:

      (i) A group health plan;

      (ii) A health benefit plan;

      (iii) Part A or part B of Title XVIII of the Social Security Act, 42 U.S.C. section 1395c

et seq., or 42 U.S.C. section 1395j et seq., (Medicare);

      (iv) Title XIX of the Social Security Act, 42 U.S.C. section 1396 et seq., (Medicaid),

other than coverage consisting solely of benefits under 42 U.S.C. section 1396s (the program for

distribution of pediatric vaccines);

      (v) 10 U.S.C. section 1071 et seq., (medical and dental care for members and certain

former members of the uniformed services, and for their dependents)(Civilian Health and

Medical Program of the Uniformed Services)(CHAMPUS). For purposes of 10 U.S.C. section

1071 et seq., "uniformed services" means the armed forces and the commissioned corps of the

National Oceanic and Atmospheric Administration and of the Public Health Service;

      (vi) A medical care program of the Indian Health Service or of a tribal organization;

      (vii) A state health benefits risk pool;

      (viii) A health plan offered under 5 U.S.C. section 8901 et seq., (Federal Employees

Health Benefits Program (FEHBP));

      (ix) A public health plan, which for purposes of this chapter, means a plan established or

maintained by a state, county, or other political subdivision of a state that provides health

insurance coverage to individuals enrolled in the plan; or

      (x) A health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C. section

2504(e)).

      (2) A period of creditable coverage shall not be counted, with respect to enrollment of an

individual under a group health plan, if, after the period and before the enrollment date, the

individual experiences a significant break in coverage.

      (j) "Dependent" means a spouse, an unmarried child under the age of nineteen (19)

twenty-six (26) years, an unmarried child who is a student under the age of twenty-five (25)

years, and an unmarried child of any age who is financially dependent upon, the parent and is

medically determined to have a physical or mental impairment which can be expected to result in

death or which has lasted or can be expected to last for a continuous period of not less than

twelve (12) months.

      (k) "Director" means the director of the department of business regulation.

      (l) [Deleted by P.L. 2006, ch. 258, section 2, and P.L. 2006, ch. 296, section 2.]

      (m) "Eligible employee" means an employee who works on a full-time basis with a

normal work week of thirty (30) or more hours, except that at the employer's sole discretion, the

term shall also include an employee who works on a full-time basis with a normal work week of

anywhere between at least seventeen and one-half (17.5) and thirty (30) hours, so long as this

eligibility criterion is applied uniformly among all of the employer's employees and without

regard to any health status-related factor. The term includes a self-employed individual, a sole

proprietor, a partner of a partnership, and may include an independent contractor, if the self-

employed individual, sole proprietor, partner, or independent contractor is included as an

employee under a health benefit plan of a small employer, but does not include an employee who

works on a temporary or substitute basis or who works less than seventeen and one-half (17.5)

hours per week. Any retiree under contract with any independently incorporated fire district is

also included in the definition of eligible employee, as well as any former employee of an

employer who retired before normal retirement age, as defined by 42 U.S.C. 18002(a)(2)(c) while

the employer participates in the early retiree reinsurance program defined by that chapter. Persons

covered under a health benefit plan pursuant to the Consolidated Omnibus Budget Reconciliation

Act of 1986 shall not be considered "eligible employees" for purposes of minimum participation

requirements pursuant to section 27-50-7(d)(9).

      (n) "Enrollment date" means the first day of coverage or, if there is a waiting period, the

first day of the waiting period, whichever is earlier.

      (o) "Established geographic service area" means a geographic area, as approved by the

director and based on the carrier's certificate of authority to transact insurance in this state, within

which the carrier is authorized to provide coverage.

      (p) "Family composition" means:

      (1) Enrollee;

      (2) Enrollee, spouse and children;

      (3) Enrollee and spouse; or

      (4) Enrollee and children.

      (q) "Genetic information" means information about genes, gene products, and inherited

characteristics that may derive from the individual or a family member. This includes information

regarding carrier status and information derived from laboratory tests that identify mutations in

specific genes or chromosomes, physical medical examinations, family histories, and direct

analysis of genes or chromosomes.

      (r) "Governmental plan" has the meaning given the term under section 3(32) of the

Employee Retirement Income Security Act of 1974, 29 U.S.C. section 1002(32), and any federal

governmental plan.

      (s) (1) "Group health plan" means an employee welfare benefit plan as defined in section

3(1) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. section 1002(1), to the

extent that the plan provides medical care, as defined in subsection (y) of this section, and

including items and services paid for as medical care to employees or their dependents as defined

under the terms of the plan directly or through insurance, reimbursement, or otherwise.

      (2) For purposes of this chapter:

      (i) Any plan, fund, or program that would not be, but for PHSA Section 2721(e), 42

U.S.C. section 300gg(e), as added by P.L. 104-191, an employee welfare benefit plan and that is

established or maintained by a partnership, to the extent that the plan, fund or program provides

medical care, including items and services paid for as medical care, to present or former partners

in the partnership, or to their dependents, as defined under the terms of the plan, fund or program,

directly or through insurance, reimbursement or otherwise, shall be treated, subject to paragraph

(ii) of this subdivision, as an employee welfare benefit plan that is a group health plan;

      (ii) In the case of a group health plan, the term "employer" also includes the partnership

in relation to any partner; and

      (iii) In the case of a group health plan, the term "participant" also includes an individual

who is, or may become, eligible to receive a benefit under the plan, or the individual's beneficiary

who is, or may become, eligible to receive a benefit under the plan, if:

      (A) In connection with a group health plan maintained by a partnership, the individual is

a partner in relation to the partnership; or

      (B) In connection with a group health plan maintained by a self-employed individual,

under which one or more employees are participants, the individual is the self-employed

individual.

      (t) (1) "Health benefit plan" means any hospital or medical policy or certificate, major

medical expense insurance, hospital or medical service corporation subscriber contract, or health

maintenance organization subscriber contract. Health benefit plan includes short-term and

catastrophic health insurance policies, and a policy that pays on a cost-incurred basis, except as

otherwise specifically exempted in this definition.

      (2) "Health benefit plan" does not include one or more, or any combination of, the

following:

      (i) Coverage only for accident or disability income insurance, or any combination of

those;

      (ii) Coverage issued as a supplement to liability insurance;

      (iii) Liability insurance, including general liability insurance and automobile liability

insurance;

      (iv) Workers' compensation or similar insurance;

      (v) Automobile medical payment insurance;

      (vi) Credit-only insurance;

      (vii) Coverage for on-site medical clinics; and

      (viii) Other similar insurance coverage, specified in federal regulations issued pursuant

to Pub. L. No. 104-191, under which benefits for medical care are secondary or incidental to other

insurance benefits.

      (3) "Health benefit plan" does not include the following benefits if they are provided

under a separate policy, certificate, or contract of insurance or are otherwise not an integral part

of the plan:

      (i) Limited scope dental or vision benefits;

      (ii) Benefits for long-term care, nursing home care, home health care, community-based

care, or any combination of those; or

      (iii) Other similar, limited benefits specified in federal regulations issued pursuant to

Pub. L. No. 104-191.

      (4) "Health benefit plan" does not include the following benefits if the benefits are

provided under a separate policy, certificate or contract of insurance, there is no coordination

between the provision of the benefits and any exclusion of benefits under any group health plan

maintained by the same plan sponsor, and the benefits are paid with respect to an event without

regard to whether benefits are provided with respect to such an event under any group health plan

maintained by the same plan sponsor:

      (i) Coverage only for a specified disease or illness; or

      (ii) Hospital indemnity or other fixed indemnity insurance.

      (5) "Health benefit plan" does not include the following if offered as a separate policy,

certificate, or contract of insurance:

      (i) Medicare supplemental health insurance as defined under section 1882(g)(1) of the

Social Security Act, 42 U.S.C. section 1395ss(g)(1);

      (ii) Coverage supplemental to the coverage provided under 10 U.S.C. section 1071 et

seq.; or

      (iii) Similar supplemental coverage provided to coverage under a group health plan.

      (6) A carrier offering policies or certificates of specified disease, hospital confinement

indemnity, or limited benefit health insurance shall comply with the following:

      (i) The carrier files on or before March 1 of each year a certification with the director

that contains the statement and information described in paragraph (ii) of this subdivision;

      (ii) The certification required in paragraph (i) of this subdivision shall contain the

following:

      (A) A statement from the carrier certifying that policies or certificates described in this

paragraph are being offered and marketed as supplemental health insurance and not as a substitute

for hospital or medical expense insurance or major medical expense insurance; and

      (B) A summary description of each policy or certificate described in this paragraph,

including the average annual premium rates (or range of premium rates in cases where premiums

vary by age or other factors) charged for those policies and certificates in this state; and

      (iii) In the case of a policy or certificate that is described in this paragraph and that is

offered for the first time in this state on or after July 13, 2000, the carrier shall file with the

director the information and statement required in paragraph (ii) of this subdivision at least thirty

(30) days prior to the date the policy or certificate is issued or delivered in this state.

      (u) "Health maintenance organization" or "HMO" means a health maintenance

organization licensed under chapter 41 of this title.

      (v) "Health status-related factor" means any of the following factors:

      (1) Health status;

      (2) Medical condition, including both physical and mental illnesses;

      (3) Claims experience;

      (4) Receipt of health care;

      (5) Medical history;

      (6) Genetic information;

      (7) Evidence of insurability, including conditions arising out of acts of domestic

violence; or

      (8) Disability.

      (w) (1) "Late enrollee" means an eligible employee or dependent who requests

enrollment in a health benefit plan of a small employer following the initial enrollment period

during which the individual is entitled to enroll under the terms of the health benefit plan,

provided that the initial enrollment period is a period of at least thirty (30) days.

      (2) "Late enrollee" does not mean an eligible employee or dependent:

      (i) Who meets each of the following provisions:

      (A) The individual was covered under creditable coverage at the time of the initial

enrollment;

      (B) The individual lost creditable coverage as a result of cessation of employer

contribution, termination of employment or eligibility, reduction in the number of hours of

employment, involuntary termination of creditable coverage, or death of a spouse, divorce or

legal separation, or the individual and/or dependents are determined to be eligible for RIteCare

under chapter 5.1 of title 40 or chapter 12.3 of title 42 or for RIteShare under chapter 8.4 of title

40; and

      (C) The individual requests enrollment within thirty (30) days after termination of the

creditable coverage or the change in conditions that gave rise to the termination of coverage;

      (ii) If, where provided for in contract or where otherwise provided in state law, the

individual enrolls during the specified bona fide open enrollment period;

      (iii) If the individual is employed by an employer which offers multiple health benefit

plans and the individual elects a different plan during an open enrollment period;

      (iv) If a court has ordered coverage be provided for a spouse or minor or dependent child

under a covered employee's health benefit plan and a request for enrollment is made within thirty

(30) days after issuance of the court order;

      (v) If the individual changes status from not being an eligible employee to becoming an

eligible employee and requests enrollment within thirty (30) days after the change in status;

      (vi) If the individual had coverage under a COBRA continuation provision and the

coverage under that provision has been exhausted; or

      (vii) Who meets the requirements for special enrollment pursuant to section 27-50-7 or

27-50-8.

      (x) "Limited benefit health insurance" means that form of coverage that pays stated

predetermined amounts for specific services or treatments or pays a stated predetermined amount

per day or confinement for one or more named conditions, named diseases or accidental injury.

      (y) "Medical care" means amounts paid for:

      (1) The diagnosis, care, mitigation, treatment, or prevention of disease, or amounts paid

for the purpose of affecting any structure or function of the body;

      (2) Transportation primarily for and essential to medical care referred to in subdivision

(1); and

      (3) Insurance covering medical care referred to in subdivisions (1) and (2) of this

subsection.

      (z) "Network plan" means a health benefit plan issued by a carrier under which the

financing and delivery of medical care, including items and services paid for as medical care, are

provided, in whole or in part, through a defined set of providers under contract with the carrier.

      (aa) "Person" means an individual, a corporation, a partnership, an association, a joint

venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any

combination of the foregoing.

      (bb) "Plan sponsor" has the meaning given this term under section 3(16)(B) of the

Employee Retirement Income Security Act of 1974, 29 U.S.C. section 1002(16)(B).

      (cc) (1) "Preexisting condition" means a condition, regardless of the cause of the

condition, for which medical advice, diagnosis, care, or treatment was recommended or received

during the six (6) months immediately preceding the enrollment date of the coverage.

      (2) "Preexisting condition" does not mean a condition for which medical advice,

diagnosis, care, or treatment was recommended or received for the first time while the covered

person held creditable coverage and that was a covered benefit under the health benefit plan,

provided that the prior creditable coverage was continuous to a date not more than ninety (90)

days prior to the enrollment date of the new coverage.

      (3) Genetic information shall not be treated as a condition under subdivision (1) of this

subsection for which a preexisting condition exclusion may be imposed in the absence of a

diagnosis of the condition related to the information.

      (dd) "Premium" means all moneys paid by a small employer and eligible employees as a

condition of receiving coverage from a small employer carrier, including any fees or other

contributions associated with the health benefit plan.

      (ee) "Producer" means any insurance producer licensed under chapter 2.4 of this title.

      (ff) "Rating period" means the calendar period for which premium rates established by a

small employer carrier are assumed to be in effect.

      (gg) "Restricted network provision" means any provision of a health benefit plan that

conditions the payment of benefits, in whole or in part, on the use of health care providers that

have entered into a contractual arrangement with the carrier pursuant to provide health care

services to covered individuals.

      (hh) "Risk adjustment mechanism" means the mechanism established pursuant to section

27-50-16.

      (ii) "Self-employed individual" means an individual or sole proprietor who derives a

substantial portion of his or her income from a trade or business through which the individual or

sole proprietor has attempted to earn taxable income and for which he or she has filed the

appropriate Internal Revenue Service Form 1040, Schedule C or F, for the previous taxable year.

      (jj) "Significant break in coverage" means a period of ninety (90) consecutive days

during all of which the individual does not have any creditable coverage, except that neither a

waiting period nor an affiliation period is taken into account in determining a significant break in

coverage.

      (kk) "Small employer" means, except for its use in section 27-50-7, any person, firm,

corporation, partnership, association, political subdivision, or self-employed individual that is

actively engaged in business including, but not limited to, a business or a corporation organized

under the Rhode Island Non-Profit Corporation Act, chapter 6 of title 7, or a similar act of

another state that, on at least fifty percent (50%) of its working days during the preceding

calendar quarter, employed no more than fifty (50) eligible employees, with a normal work week

of thirty (30) or more hours, the majority of whom were employed within this state, and is not

formed primarily for purposes of buying health insurance and in which a bona fide employer-

employee relationship exists. In determining the number of eligible employees, companies that

are affiliated companies, or that are eligible to file a combined tax return for purposes of taxation

by this state, shall be considered one employer. Subsequent to the issuance of a health benefit

plan to a small employer and for the purpose of determining continued eligibility, the size of a

small employer shall be determined annually. Except as otherwise specifically provided,

provisions of this chapter that apply to a small employer shall continue to apply at least until the

plan anniversary following the date the small employer no longer meets the requirements of this

definition. The term small employer includes a self-employed individual.

      (ll ) "Waiting period" means, with respect to a group health plan and an individual who

is a potential enrollee in the plan, the period that must pass with respect to the individual before

the individual is eligible to be covered for benefits under the terms of the plan. For purposes of

calculating periods of creditable coverage pursuant to subsection (j)(2) of this section, a waiting

period shall not be considered a gap in coverage.

      (mm) "Wellness health benefit plan" means a plan developed pursuant to section 27-50-

10.

      (nn) "Health insurance commissioner" or "commissioner" means that individual

appointed pursuant to section 42-14.5-1 of the general laws and afforded those powers and duties

as set forth in sections 42-14.5-2 and 42-14.5-3 of title 42.

      (oo) "Low-wage firm" means those with average wages that fall within the bottom

quartile of all Rhode Island employers.

      (pp) "Wellness health benefit plan" means the health benefit plan offered by each small

employer carrier pursuant to section 27-50-7.

      (qq) "Commissioner" means the health insurance commissioner.

 

     27-50-7. Availability of coverage. -- (a) Until October 1, 2004, for purposes of this

section, "small employer" includes any person, firm, corporation, partnership, association, or

political subdivision that is actively engaged in business that on at least fifty percent (50%) of its

working days during the preceding calendar quarter, employed a combination of no more than

fifty (50) and no less than two (2) eligible employees and part-time employees, the majority of

whom were employed within this state, and is not formed primarily for purposes of buying health

insurance and in which a bona fide employer-employee relationship exists. After October 1, 2004,

for the purposes of this section, "small employer" has the meaning used in section 27-50-3(kk).

      (b) (1) Every small employer carrier shall, as a condition of transacting business in this

state with small employers, actively offer to small employers all health benefit plans it actively

markets to small employers in this state including a wellness health benefit plan. A small

employer carrier shall be considered to be actively marketing a health benefit plan if it offers that

plan to any small employer not currently receiving a health benefit plan from the small employer

carrier.

      (2) Subject to subdivision (1) of this subsection, a small employer carrier shall issue any

health benefit plan to any eligible small employer that applies for that plan and agrees to make the

required premium payments and to satisfy the other reasonable provisions of the health benefit

plan not inconsistent with this chapter. However, no carrier is required to issue a health benefit

plan to any self-employed individual who is covered by, or is eligible for coverage under, a health

benefit plan offered by an employer.

      (c) (1) A small employer carrier shall file with the director, in a format and manner

prescribed by the director, the health benefit plans to be used by the carrier. A health benefit plan

filed pursuant to this subdivision may be used by a small employer carrier beginning thirty (30)

days after it is filed unless the director disapproves its use.

      (2) The director may at any time may, after providing notice and an opportunity for a

hearing to the small employer carrier, disapprove the continued use by a small employer carrier of

a health benefit plan on the grounds that the plan does not meet the requirements of this chapter.

      (d) Health benefit plans covering small employers shall comply with the following

provisions:

      (1) A health benefit plan shall not deny, exclude, or limit benefits for a covered

individual for losses incurred more than six (6) months following the enrollment date of the

individual's coverage due to a preexisting condition, or the first date of the waiting period for

enrollment if that date is earlier than the enrollment date. A health benefit plan shall not define a

preexisting condition more restrictively than as defined in section 27-50-3.

      (2) (i) Except as provided in subdivision (3) of this subsection, a small employer carrier

shall reduce the period of any preexisting condition exclusion by the aggregate of the periods of

creditable coverage without regard to the specific benefits covered during the period of creditable

coverage, provided that the last period of creditable coverage ended on a date not more than

ninety (90) days prior to the enrollment date of new coverage.

      (ii) The aggregate period of creditable coverage does not include any waiting period or

affiliation period for the effective date of the new coverage applied by the employer or the carrier,

or for the normal application and enrollment process following employment or other triggering

event for eligibility.

      (iii) A carrier that does not use preexisting condition limitations in any of its health

benefit plans may impose an affiliation period that:

      (A) Does not exceed sixty (60) days for new entrants and not to exceed ninety (90) days

for late enrollees;

      (B) During which the carrier charges no premiums and the coverage issued is not

effective; and

      (C) Is applied uniformly, without regard to any health status-related factor.

      (iv) This section does not preclude application of any waiting period applicable to all

new enrollees under the health benefit plan, provided that any carrier-imposed waiting period is

no longer than sixty (60) days.

      (3) (i) Instead of as provided in paragraph (2)(i) of this subsection, a small employer

carrier may elect to reduce the period of any preexisting condition exclusion based on coverage of

benefits within each of several classes or categories of benefits specified in federal regulations.

      (ii) A small employer electing to reduce the period of any preexisting condition

exclusion using the alternative method described in paragraph (i) of this subdivision shall:

      (A) Make the election on a uniform basis for all enrollees; and

      (B) Count a period of creditable coverage with respect to any class or category of

benefits if any level of benefits is covered within the class or category.

      (iii) A small employer carrier electing to reduce the period of any preexisting condition

exclusion using the alternative method described under paragraph (i) of this subdivision shall:

      (A) Prominently state that the election has been made in any disclosure statements

concerning coverage under the health benefit plan to each enrollee at the time of enrollment under

the plan and to each small employer at the time of the offer or sale of the coverage; and

      (B) Include in the disclosure statements the effect of the election.

      (4) (i) A health benefit plan shall accept late enrollees, but may exclude coverage for late

enrollees for preexisting conditions for a period not to exceed twelve (12) months.

      (ii) A small employer carrier shall reduce the period of any preexisting condition

exclusion pursuant to subdivision (2) or (3) of this subsection.

      (5) A small employer carrier shall not impose a preexisting condition exclusion:

      (i) Relating to pregnancy as a preexisting condition; or

      (ii) With regard to a child who is covered under any creditable coverage within thirty

(30) days of birth, adoption, or placement for adoption, provided that the child does not

experience a significant break in coverage, and provided that the child was adopted or placed for

adoption before attaining eighteen (18) years of age.

      (6) A small employer carrier shall not impose a preexisting condition exclusion in the

case of a condition for which medical advice, diagnosis, care or treatment was recommended or

received for the first time while the covered person held creditable coverage, and the medical

advice, diagnosis, care or treatment was a covered benefit under the plan, provided that the

creditable coverage was continuous to a date not more than ninety (90) days prior to the

enrollment date of the new coverage.

      (7) (i) A small employer carrier shall permit an employee or a dependent of the

employee, who is eligible, but not enrolled, to enroll for coverage under the terms of the group

health plan of the small employer during a special enrollment period if:

      (A) The employee or dependent was covered under a group health plan or had coverage

under a health benefit plan at the time coverage was previously offered to the employee or

dependent;

      (B) The employee stated in writing at the time coverage was previously offered that

coverage under a group health plan or other health benefit plan was the reason for declining

enrollment, but only if the plan sponsor or carrier, if applicable, required that statement at the

time coverage was previously offered and provided notice to the employee of the requirement and

the consequences of the requirement at that time;

      (C) The employee's or dependent's coverage described under subparagraph (A) of this

paragraph:

      (I) Was under a COBRA continuation provision and the coverage under this provision

has been exhausted; or

      (II) Was not under a COBRA continuation provision and that other coverage has been

terminated as a result of loss of eligibility for coverage, including as a result of a legal separation,

divorce, death, termination of employment, or reduction in the number of hours of employment or

employer contributions towards that other coverage have been terminated; and

      (D) Under terms of the group health plan, the employee requests enrollment not later

than thirty (30) days after the date of exhaustion of coverage described in item (C)(I) of this

paragraph or termination of coverage or employer contribution described in item (C)(II) of this

paragraph.

      (ii) If an employee requests enrollment pursuant to subparagraph (i)(D) of this

subdivision, the enrollment is effective not later than the first day of the first calendar month

beginning after the date the completed request for enrollment is received.

      (8) (i) A small employer carrier that makes coverage available under a group health plan

with respect to a dependent of an individual shall provide for a dependent special enrollment

period described in paragraph (ii) of this subdivision during which the person or, if not enrolled,

the individual may be enrolled under the group health plan as a dependent of the individual and,

in the case of the birth or adoption of a child, the spouse of the individual may be enrolled as a

dependent of the individual if the spouse is eligible for coverage if:

      (A) The individual is a participant under the health benefit plan or has met any waiting

period applicable to becoming a participant under the plan and is eligible to be enrolled under the

plan, but for a failure to enroll during a previous enrollment period; and

      (B) A person becomes a dependent of the individual through marriage, birth, or adoption

or placement for adoption.

      (ii) The special enrollment period for individuals that meet the provisions of paragraph

(i) of this subdivision is a period of not less than thirty (30) days and begins on the later of:

      (A) The date dependent coverage is made available; or

      (B) The date of the marriage, birth, or adoption or placement for adoption described in

subparagraph (i)(B) of this subdivision.

      (iii) If an individual seeks to enroll a dependent during the first thirty (30) days of the

dependent special enrollment period described under paragraph (ii) of this subdivision, the

coverage of the dependent is effective:

      (A) In the case of marriage, not later than the first day of the first month beginning after

the date the completed request for enrollment is received;

      (B) In the case of a dependent's birth, as of the date of birth; and

      (C) In the case of a dependent's adoption or placement for adoption, the date of the

adoption or placement for adoption.

      (9) (i) Except as provided in this subdivision, requirements used by a small employer

carrier in determining whether to provide coverage to a small employer, including requirements

for minimum participation of eligible employees and minimum employer contributions, shall be

applied uniformly among all small employers applying for coverage or receiving coverage from

the small employer carrier.

      (ii) For health benefit plans issued or renewed on or after October 1, 2000, a small

employer carrier shall not require a minimum participation level greater than seventy-five percent

(75%) of eligible employees.

      (iii) In applying minimum participation requirements with respect to a small employer, a

small employer carrier shall not consider employees or dependents who have creditable coverage

in determining whether the applicable percentage of participation is met.

      (iv) A small employer carrier shall not increase any requirement for minimum employee

participation or modify any requirement for minimum employer contribution applicable to a small

employer at any time after the small employer has been accepted for coverage.

      (10) (i) If a small employer carrier offers coverage to a small employer, the small

employer carrier shall offer coverage to all of the eligible employees of a small employer and

their dependents who apply for enrollment during the period in which the employee first becomes

eligible to enroll under the terms of the plan. A small employer carrier shall not offer coverage to

only certain individuals or dependents in a small employer group or to only part of the group.

      (ii) A small employer carrier shall not place any restriction in regard to any health status-

related factor on an eligible employee or dependent with respect to enrollment or plan

participation.

      (iii) Except as permitted under subdivisions (1) and (4) of this subsection, a small

employer carrier shall not modify a health benefit plan with respect to a small employer or any

eligible employee or dependent, through riders, endorsements, or otherwise, to restrict or exclude

coverage or benefits for specific diseases, medical conditions, or services covered by the plan.

      (e) (1) Subject to subdivision (3) of this subsection, a small employer carrier is not

required to offer coverage or accept applications pursuant to subsection (b) of this section in the

case of the following:

      (i) To a small employer, where the small employer does not have eligible individuals

who live, work, or reside in the established geographic service area for the network plan;

      (ii) To an employee, when the employee does not live, work, or reside within the

carrier's established geographic service area; or

      (iii) Within an area where the small employer carrier reasonably anticipates, and

demonstrates to the satisfaction of the director, that it will not have the capacity within its

established geographic service area to deliver services adequately to enrollees of any additional

groups because of its obligations to existing group policyholders and enrollees.

      (2) A small employer carrier that cannot offer coverage pursuant to paragraph (1)(iii) of

this subsection may not offer coverage in the applicable area to new cases of employer groups

until the later of one hundred and eighty (180) days following each refusal or the date on which

the carrier notifies the director that it has regained capacity to deliver services to new employer

groups.

      (3) A small employer carrier shall apply the provisions of this subsection uniformly to all

small employers without regard to the claims experience of a small employer and its employees

and their dependents or any health status-related factor relating to the employees and their

dependents.

      (f) (1) A small employer carrier is not required to provide coverage to small employers

pursuant to subsection (b) of this section if:

      (i) For any period of time the director determines the small employer carrier does not

have the financial reserves necessary to underwrite additional coverage; and

      (ii) The small employer carrier is applying this subsection uniformly to all small

employers in the small group market in this state consistent with applicable state law and without

regard to the claims experience of a small employer and its employees and their dependents or

any health status-related factor relating to the employees and their dependents.

      (2) A small employer carrier that denies coverage in accordance with subdivision (1) of

this subsection may not offer coverage in the small group market for the later of:

      (i) A period of one hundred and eighty (180) days after the date the coverage is denied;

or

      (ii) Until the small employer has demonstrated to the director that it has sufficient

financial reserves to underwrite additional coverage.

      (g) (1) A small employer carrier is not required to provide coverage to small employers

pursuant to subsection (b) of this section if the small employer carrier elects not to offer new

coverage to small employers in this state.

      (2) A small employer carrier that elects not to offer new coverage to small employers

under this subsection may be allowed, as determined by the director, to maintain its existing

policies in this state.

      (3) A small employer carrier that elects not to offer new coverage to small employers

under subdivision (g)(1) shall provide at least one hundred and twenty (120) days notice of its

election to the director and is prohibited from writing new business in the small employer market

in this state for a period of five (5) years beginning on the date the carrier ceased offering new

coverage in this state.

     (h) No small group carrier may impose a pre-existing condition exclusion pursuant to the

provisions of subdivisions 27-50-7(d)(1), 27-50-7(d)(2), 27-50-7(d)(3), 27-50-7(d)(4), 27-50-

7(d)(5) and 27-50-7(d)(6) with regard to an individual that is less than nineteen (19) years of age.

With respect to health benefit plans issued on and after January 1, 2014 a small employer carrier

shall offer and issue coverage to small employers and eligible individuals notwithstanding any

pre-existing condition of an employee, member, or individual, or their dependents.

 

     SECTION 12. Section 27-18.6-3 of the General laws in Chapter 27-18.6 entitled "Large

Group Health Insurance Coverage" is hereby amended to read as follows:

 

     27-18.6-3. Limitation on preexisting condition exclusion. -- (a) (1) Notwithstanding

any of the provisions of this title to the contrary, a group health plan and a health insurance

carrier offering group health insurance coverage shall not deny, exclude, or limit benefits with

respect to a participant or beneficiary because of a preexisting condition exclusion except if:

     (i) The exclusion relates to a condition (whether physical or mental), regardless of the

cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended

or received within the six (6) month period ending on the enrollment date;

     (ii) The exclusion extends for a period of not more than twelve (12) months (or eighteen

(18) months in the case of a late enrollee) after the enrollment date; and

     (iii) The period of the preexisting condition exclusion is reduced by the aggregate of the

periods of creditable coverage, if any, applicable to the participant or the beneficiary as of the

enrollment date.

     (2) For purposes of this section, genetic information shall not be treated as a preexisting

condition in the absence of a diagnosis of the condition related to that information.

     (b) With respect to paragraph (a)(1)(iii) of this section, a period of creditable coverage

shall not be counted, with respect to enrollment of an individual under a group health plan, if,

after that period and before the enrollment date, there was a sixty-three (63) day period during

which the individual was not covered under any creditable coverage.

     (c) Any period that an individual is in a waiting period for any coverage under a group

health plan or for group health insurance or is in an affiliation period shall not be taken into

account in determining the continuous period under subsection (b) of this section.

     (d) Except as otherwise provided in subsection (e) of this section, for purposes of

applying paragraph (a)(1)(iii) of this section, a group health plan and a health insurance carrier

offering group health insurance coverage shall count a period of creditable coverage without

regard to the specific benefits covered during the period.

     (e) (1) A group health plan or a health insurance carrier offering group health insurance

may elect to apply paragraph (a)(1)(iii) of this section based on coverage of benefits within each

of several classes or categories of benefits. Those classes or categories of benefits are to be

determined by the secretary of the United States Department of Health and Human Services

pursuant to regulation. The election shall be made on a uniform basis for all participants and

beneficiaries. Under the election, a group health plan or carrier shall count a period of creditable

coverage with respect to any class or category of benefits if any level of benefits is covered

within the class or category.

     (2) In the case of an election under this subsection with respect to a group health plan

(whether or not health insurance coverage is provided in connection with that plan), the plan

shall:

     (i) Prominently state in any disclosure statements concerning the plan, and state to each

enrollee under the plan, that the plan has made the election; and

     (ii) Include in the statements a description of the effect of this election.

     (3) In the case of an election under this subsection with respect to health insurance

coverage offered by a carrier in the large group market, the carrier shall:

     (i) Prominently state in any disclosure statements concerning the coverage, and to each

employer at the time of the offer or sale of the coverage, that the carrier has made the election;

and

     (ii) Include in the statements a description of the effect of the election.

     (f) (1) A group health plan and a health insurance carrier offering group health insurance

coverage may not impose any preexisting condition exclusion in the case of an individual who, as

of the last day of the thirty (30) day period beginning with the date of birth, is covered under

creditable coverage.

     (2) Subdivision (1) of this subsection shall no longer apply to an individual after the end

of the first sixty-three (63) day period during all of which the individual was not covered under

any creditable coverage. Moreover, any period that an individual is in a waiting period for any

coverage under a group health plan (or for group health insurance coverage) or is in an affiliation

period shall not be taken into account in determining the continuous period for purposes of

determining creditable coverage.

     (g) (1) A group health plan and a health insurance carrier offering group health insurance

coverage may not impose any preexisting condition exclusion in the case of a child who is

adopted or placed for adoption before attaining eighteen (18) years of age and who, as of the last

day of the thirty (30) day period beginning on the date of the adoption or placement for adoption,

is covered under creditable coverage. The previous sentence does not apply to coverage before

the date of the adoption or placement for adoption.

     (2) Subdivision (1) of this subsection shall no longer apply to an individual after the end

of the first sixty-three (63) day period during all of which the individual was not covered under

any creditable coverage. Any period that an individual is in a waiting period for any coverage

under a group health plan (or for group health insurance coverage) or is in an affiliation period

shall not be taken into account in determining the continuous period for purposes of determining

creditable coverage.

     (h) A group health plan and a health insurance carrier offering group health insurance

coverage may not impose any preexisting condition exclusion relating to pregnancy as a

preexisting condition or with regard to an individual who is under nineteen (19) years of age.

     (i) (1) Periods of creditable coverage with respect to an individual shall be established

through presentation of certifications. A group health plan and a health insurance carrier offering

group health insurance coverage shall provide certifications:

     (i) At the time an individual ceases to be covered under the plan or becomes covered

under a COBRA continuation provision;

     (ii) In the case of an individual becoming covered under a continuation provision, at the

time the individual ceases to be covered under that provision; and

     (iii) On the request of an individual made not later than twenty-four (24) months after the

date of cessation of the coverage described in paragraph (i) or (ii) of this subdivision, whichever

is later.

     (2) The certification under this subsection may be provided, to the extent practicable, at a

time consistent with notices required under any applicable COBRA continuation provision.

     (3) The certification described in this subsection is a written certification of:

     (i) The period of creditable coverage of the individual under the plan and the coverage (if

any) under the COBRA continuation provision; and

     (ii) The waiting period (if any) (and affiliation period, if applicable) imposed with respect

to the individual for any coverage under the plan.

     (4) To the extent that medical care under a group health plan consists of group health

insurance coverage, the plan is deemed to have satisfied the certification requirement under this

subsection if the health insurance carrier offering the coverage provides for the certification in

accordance with this subsection.

     (5) In the case of an election taken pursuant to subsection (e) of this section by a group

health plan or a health insurance carrier, if the plan or carrier enrolls an individual for coverage

under the plan and the individual provides a certification of creditable coverage, upon request of

the plan or carrier, the entity which issued the certification shall promptly disclose to the

requisition plan or carrier information on coverage of classes and categories of health benefits

available under that entity's plan or coverage, and the entity may charge the requesting plan or

carrier for the reasonable cost of disclosing the information.

     (6) Failure of an entity to provide information under this subsection with respect to

previous coverage of an individual so as to adversely affect any subsequent coverage of the

individual under another group health plan or health insurance coverage, as determined in

accordance with rules and regulations established by the secretary of the United States

Department of Health and Human Services, is a violation of this chapter.

     (j) A group health plan and a health insurance carrier offering group health insurance

coverage in connection with a group health plan shall permit an employee who is eligible, but not

enrolled, for coverage under the terms of the plan (or a dependent of an employee if the

dependent is eligible, but not enrolled, for coverage under the terms) to enroll for coverage under

the terms of the plan if each of the following conditions are met:

     (1) The employee or dependent was covered under a group health plan or had health

insurance coverage at the time coverage was previously offered to the employee or dependent;

     (2) The employee stated in writing at the time that coverage under a group health plan or

health insurance coverage was the reason for declining enrollment, but only if the plan sponsor or

carrier (if applicable) required a statement at the time and provided the employee with notice of

that requirement (and the consequences of the requirement) at the time;

     (3) The employee's or dependent's coverage described in subsection (j)(1):

     (i) Was under a COBRA continuation provision and the coverage under that provision

was exhausted; or

     (ii) Was not under a continuation provision and either the coverage was terminated as a

result of loss of eligibility for the coverage (including as a result of legal separation, divorce,

death, termination of employment, or reduction in the number of hours of employment) or

employer contributions towards the coverage were terminated; and

     (4) Under the terms of the plan, the employee requests enrollment not later than thirty

(30) days after the date of exhaustion of coverage described in paragraph (3)(i) of this subsection

or termination of coverage or employer contribution described in paragraph (3)(ii) of this

subsection.

     (k) (1) If a group health plan makes coverage available with respect to a dependent of an

individual, the individual is a participant under the plan (or has met any waiting period applicable

to becoming a participant under the plan and is eligible to be enrolled under the plan but for a

failure to enroll during a previous enrollment period), and a person becomes a dependent of the

individual through marriage, birth, or adoption or placement through adoption, the group health

plan shall provide for a dependent special enrollment period during which the person (or, if not

enrolled, the individual) may be enrolled under the plan as a dependent of the individual, and in

the case of the birth or adoption of a child, the spouse of the individual may be enrolled as a

dependent of the individual if the spouse is eligible for coverage.

     (2) A dependent special enrollment period shall be a period of not less than thirty (30)

days and shall begin on the later of:

     (i) The date dependent coverage is made available; or

     (ii) The date of the marriage, birth, or adoption or placement for adoption (as the case

may be).

     (3) If an individual seeks to enroll a dependent during the first thirty (30) days of a

dependent special enrollment period, the coverage of the dependent shall become effective:

     (i) In the case of marriage, not later than the first day of the first month beginning after

the date the completed request for enrollment is received;

     (ii) In the case of a dependent's birth, as of the date of the birth; or

     (iii) In the case of a dependent's adoption or placement for adoption, the date of the

adoption or placement for adoption.

     (l) (1) A health maintenance organization which offers health insurance coverage in

connection with a group health plan and which does not impose any preexisting condition

exclusion allowed under subsection (a) of this section with respect to any particular coverage

option may impose an affiliation period for the coverage option, but only if that period is applied

uniformly without regard to any health status-related factors, and the period does not exceed two

(2) months (or three (3) months in the case of a late enrollee).

     (2) For the purposes of this subsection, an affiliation shall begin on the enrollment date.

     (3) An affiliation period under a plan shall run concurrently with any waiting period

under the plan.

     (4) The director may approve alternative methods from those described under this

subsection to address adverse selection.

     (m) For the purpose of determining creditable coverage pursuant to this chapter, no

period before July 1, 1996, shall be taken into account. Individuals who need to establish

creditable coverage for periods before July 1, 1996, and who would have the coverage credited

but for the prohibition in the preceding sentence may be given credit for creditable coverage for

those periods through the presentation of documents or other means in accordance with any rule

or regulation that may be established by the secretary of the United States Department of Health

and Human Services.

     (n) In the case of an individual who seeks to establish creditable coverage for any period

for which certification is not required because it relates to an event occurring before June 30,

1996, the individual may present other credible evidence of coverage in order to establish the

period of creditable coverage. The group health plan and a health insurance carrier shall not be

subject to any penalty or enforcement action with respect to the plan's or carrier's crediting (or not

crediting) the coverage if the plan or carrier has sought to comply in good faith with the

applicable requirements of this section.

     (o) Notwithstanding the provisions of any general or public law to the contrary, for plan

or policy years beginning on and after January 1, 2014, a group health plan and a health insurance

carrier offering group health insurance coverage shall not deny, exclude, or limit benefits with

respect to a participant or beneficiary because of a preexisting condition exclusion.

 

     SECTION. 13 Applicability and Construction.

     (a) This act shall apply only to health insurance policies, subscriber contracts, and any

other health benefit contract issued on and after July 1, 2012 notwithstanding any other provision

of this act.

     (b) In its construction and enforcement of the provisions of this act, and in the interests of

promoting uniform national rules for health insurance carriers, the office of the health insurance

commissioner shall give due deference to the construction, enforcement policies, and guidance of

the federal government with respect to federal law substantially similar to the provisions of this

act.

 

     SECTION 14. Sections 27-18-36, 27-18-36.1, 27-18-36.2 and 27-18-36.3 of the General

Laws in Chapter 27-18 entitled "Accident and Sickness Insurance Policies" are hereby repealed

on the effective date of RI General Law 27-18-80.

 

     27-18-36. New cancer therapies -- Under investigation. -- Every individual or group

hospital or medical expense insurance policy or individual or group hospital or medical service

plan contract delivered, issued for delivery or renewed in this state, except policies which only

provide coverage for specified diseases other than cancer, fixed indemnity, disability income,

accident only, long-term care Medicare supplement limited benefit health, sickness or bodily

injury or death by accident or both, or other limited benefit policies, shall provide coverage for

new cancer therapies still under investigation as outlined in this chapter.

 

     27-18-36.1. "Reliable evidence" defined. -- "Reliable evidence" means:

      (1) Evidence including published reports and articles in authoritative, peer reviewed

medical and scientific literature;

      (2) A written informed consent used by the treating facility or by another facility

studying substantially the same service; or

      (3) A written protocol or protocols used by the treating facility or protocols of another

facility studying substantially the same service.

 

     27-18-36.2. Conditions of coverage. -- As provided in section 27-18-36, coverage shall

be extended to new cancer therapies still under investigation when the following circumstances

are present:

      (1) Treatment is being provided pursuant to a phase II, III or IV clinical trial which has

been approved by the National Institutes of Health (NIH) in cooperation with the National Cancer

Institute (NCI), Community clinical oncology programs; the Food and Drug Administration in the

form of an Investigational New Drug (IND) exemption; the Department of Veterans' Affairs; or a

qualified nongovernmental research entity as identified in the guidelines for NCI cancer center

support grants;

      (2) The proposed therapy has been reviewed and approved by a qualified institutional

review board (IRB);

      (3) The facility and personnel providing the treatment are capable of doing so by virtue

of their experience, training, and volume of patients treated to maintain expertise;

      (4) The patients receiving the investigational treatment meet all protocol requirements;

      (5) There is no clearly superior, noninvestigational alternative to the protocol treatment;

      (6) The available clinical or preclinical data provide a reasonable expectation that the

protocol treatment will be at least as efficacious as the noninvestigational alternative; and

      (7) The coverage of new cancer therapy treatment provided pursuant to a Phase II

clinical trial shall not be required for only that portion of that treatment provided as part of the

phase II clinical trial and is otherwise funded by a national agency, such as the National Cancer

Institute, the Veteran's Administration, the Department of Defense, or funded by commercial

organizations such as the biotechnical and/or pharmaceutical industry or manufacturers of

medical devices. Any portions of a Phase II trial which are customarily funded by government,

biotechnical and/or pharmaceutical and/or medical device industry sources in Rhode Island or in

other states shall continue to be so funded in Rhode Island and coverage pursuant to this section

shall supplement, not supplant, customary funding.

 

     27-18-36.3. Managed care. -- Nothing in this chapter shall preclude the conducting of

managed care reviews and medical necessity reviews by an insurer, hospital or medical service

corporation, or health maintenance organization.

 

     SECTION 15. Sections 27-19-32, 27-19-32.1, 27-19-32.2 and 27-19-32.3 of the General

Laws in Chapter 27-19 entitled "Nonprofit Hospital Service Corporations" are hereby repealed on

the effective date of RI General Law 27-19-64.

 

     27-19-32. New cancer therapies -- Under investigation. -- Every individual or group

hospital or medical expense insurance policy or individual or group hospital or medical service

plan contract delivered, issued for delivery or renewed in this state shall provide coverage for new

cancer therapies still under investigation as outlined in this chapter.

 

     27-19-32.1. "Reliable evidence" defined. -- "Reliable evidence" means:

      (1) Evidence including published reports and articles in authoritative, peer reviewed

medical and scientific literature;

      (2) A written informed consent used by the treating facility or by another facility

studying substantially the same service; or

      (3) A written protocol or protocols used by the treating facility or protocols of another

facility studying substantially the same service.

 

     27-19-32.2. Conditions of coverage. -- As provided in section 27-19-32, coverage shall

be extended to new cancer therapies still under investigation when the following circumstances

are present:

      (1) Treatment is being provided pursuant to a phase II, III or IV clinical trial which has

been approved by the National Institutes of Health (NIH) in cooperation with the National Cancer

Institute (NCI), community clinical oncology programs; the Food and Drug Administration in the

form of an investigation new drug (IND) exemption; the Department of Veterans' Affairs; or a

qualified nongovernmental research entity as identified in the guidelines for NCI cancer center

support grants;

      (2) The proposed therapy has been reviewed and approved by a qualified institutional

review board (IRB);

      (3) The facility and personnel providing the treatment are capable of doing so by virtue

of their experience, training, and volume of patients treated to maintain expertise;

      (4) The patients receiving the investigational treatment meet all protocol requirements;

      (5) There is no clearly superior, noninvestigational alternative to the protocol treatment;

      (6) The available clinical or preclinical data provide a reasonable expectation that the

protocol treatment will be at least as efficacious as the noninvestigational alternative; and

      (7) The coverage of new cancer therapy treatment provided pursuant to a phase II

clinical trial shall not be required for that portion of that treatment that is provided as part of the

phase II clinical trial and is funded by a national agency, such as the National Cancer Institute,

the Veteran's Administration, the Department of Defense, or funded by commercial organizations

such as the biotechnical and/or pharmaceutical industry or manufacturers of medical devices. Any

portions of a phase II trial which are customarily funded by government, biotechnical and/or

pharmaceutical and/or medical device industry sources in Rhode Island or in other states shall

continue to be funded in Rhode Island and coverage pursuant to this section shall supplement, not

supplant, customary funding.

 

     27-19-32.3. Managed care. -- Nothing in this chapter shall preclude the conducting of

managed care reviews and medical necessity reviews by an insurer, hospital or medical service

corporation, or health maintenance corporation.

 

     SECTION 16. Sections 27-20-27, 27-20-27.1, 27-20-27.2 and 27-20-27.3 of the General

Laws in Chapter 27-20 entitled "Nonprofit Medical Service Corporations" are hereby repealed on

the effective date of RI General Law 27-20-64.

 

     27-20-27. New cancer therapies -- Under investigation. -- Every individual or group

hospital or medical expense insurance policy or individual or group hospital or medical service

plan contract delivered, issued for delivery or renewed in this state shall provide coverage for new

cancer therapies still under investigation as outlined in this chapter.

 

     27-20-27.1. "Reliable evidence" defined. -- "Reliable evidence" means:

      (1) Evidence including published reports and articles in authoritative, peer reviewed

medical and scientific literature;

      (2) A written informed consent used by the treating facility or by another facility

studying substantially the same service; or

      (3) A written protocol or protocols used by the treating facility or protocols of another

facility studying substantially the same service.

 

     27-20-27.2. Conditions of coverage. -- As provided in section 27-20-27, coverage shall

be extended to new cancer therapies still under investigation when the following circumstances

are present:

      (1) Treatment is being provided pursuant to a phase II, III or IV clinical trial which has

been approved by the National Institutes of Health (NIH) in cooperation with the National Cancer

Institute (NCI), community clinical oncology programs; the Food and Drug Administration in the

form of an investigational new drug (IND) exemption; the Department of Veterans' Affairs; or a

qualified nongovernmental research entity as identified in the guidelines for NCI cancer center

support grants;

      (2) The proposed therapy has been reviewed and approved by a qualified institutional

review board (IRB);

      (3) The facility and personnel providing the treatment are capable of doing so by virtue

of their experience, training, and volume of patients treated to maintain expertise;

      (4) The patients receiving the investigational treatment meet all protocol requirements;

      (5) There is no clearly superior, noninvestigational alternative to the protocol treatment;

      (6) The available clinical or preclinical data provide a reasonable expectation that the

protocol treatment will be at least as efficacious as the noninvestigational alternative; and

      (7) The coverage of new cancer therapy treatment provided pursuant to a phase II

clinical trial is not required for only that portion of that treatment that is provided as part of the

phase II clinical trial and is funded by a national agency, such as the National Cancer Institute,

the Veteran's Administration, the Department of Defense, or funded by commercial organizations

such as the biotechnical and/or pharmaceutical industry or manufacturers of medical devices. Any

portions of a phase II trial which are customarily funded by government, biotechnical and/or

pharmaceutical and/or medical device industry sources in Rhode Island or in other states shall

continue to be funded in Rhode Island and coverage pursuant to this section supplements, does

not supplant customary funding.

 

     27-20-27.3. Managed care. -- Nothing in this chapter shall preclude the conducting of

managed care reviews and medical necessity reviews by an insurer, hospital or medical service

corporation, or health maintenance organization. A nonprofit medical service corporation may, as

a condition of coverage, require its members to obtain new cancer therapies still under

investigation as outlined in this chapter from providers and facilities designated by the nonprofit

medical service corporation to render these new cancer therapies.

 

     SECTION 17. Sections 27-41-41, 27-41-41.1, 27-41-41.2 and 27-41-41.3 of the General

Laws in Chapter 27-41 entitled "Health Maintenance Organizations" are hereby repealed on the

effective date of RI General Law 27-41-77.

 

     27-41-41. New cancer therapies -- Under investigation. -- Every individual or group

hospital or medical expense insurance policy or individual or group hospital or medical service

plan contract delivered, issued for delivery or renewed in this state shall provide coverage for new

cancer therapies still under investigation as outlined in this chapter.

 

     27-41-41.1. "Reliable evidence" defined. -- "Reliable evidence" means:

      (1) Evidence including published reports and articles in authoritative, peer reviewed

medical and scientific literature;

      (2) A written informed consent used by the treating facility or by another facility

studying substantially the same service; or

      (3) A written protocol or protocols used by the treating facility or protocols of another

facility studying substantially the same service.

 

     27-41-41.2. Conditions of coverage. -- As provided in section 27-41-41, coverage shall

be extended to new cancer therapies still under investigation when the following circumstances

are present:

      (1) Treatment is being provided pursuant to a phase II, III or IV clinical trial which has

been approved by the National Institutes of Health (NIH) in cooperation with the National Cancer

Institute (NCI), community clinical oncology programs; the food and drug administration in the

form of an investigational new drug (IND) exemption; the Department of Veterans' Affairs; or a

qualified nongovernmental research entity as identified in the guidelines for NCI cancer center

support grants;

      (2) The proposed therapy has been reviewed and approved by a qualified institutional

review board (IRB);

      (3) The facility and personnel providing the treatment are capable of doing so by virtue

of their experience, training, and volume of patients treated to maintain expertise;

      (4) The patients receiving the investigational treatment meet all protocol requirements;

      (5) There are no clearly superior, noninvestigational alternatives to the protocol

treatment;

      (6) The available clinical or preclinical data provide a reasonable expectation that the

protocol treatment will be at least as efficacious as the noninvestigational alternative; and

      (7) The coverage of new cancer therapy treatment provided pursuant to a phase II

clinical trial is not required for only the portion of that treatment that is provided as part of the

phase II clinical trial and is funded by a national agency, such as the National Cancer Institute,

the Veteran's Administration, the Department of Defense, or funded by commercial organizations

such as the biotechnical and/or pharmaceutical industry or manufacturers of medical devices. Any

portions of a phase II trial which are customarily funded by government, biotechnical and/or

pharmaceutical and/or medical device industry sources in Rhode Island or in other states shall

continue to be funded in Rhode Island and coverage pursuant to this section supplements, but

does not supplant, that customary funding.

 

     27-41-41.3. Managed care. -- Nothing in this chapter shall preclude the conducting of

managed care reviews and medical necessity reviews by an insurer, hospital or medical service

corporation, or health maintenance organization. A health maintenance organization may as a

condition of coverage require its members to obtain these new cancer therapies still under

investigation from providers and facilities designated by the health maintenance organization to

render these new cancer therapies.

 

     SECTION18. This act shall take effect upon passage.

     

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LC02074/SUB A/4

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