2014 -- S 2359 SUBSTITUTE B
Enacted 06/24/14
A N A C T
RELATING TO HEALTH AND SAFETY - HEALTH CARE SERVICES - UTILIZATION REVIEW ACT
Introduced By: Senators Miller, Cool Rumsey, Ottiano, Sosnowski, and Goldin
Date Introduced: February 12, 2014
It is enacted by the General Assembly as follows:
SECTION
1. Sections 23-17.12-12 and 23-17.12-14
of the General Laws in Chapter 23-17.12 entitled "Health Care Services -
Utilization Review Act" are is hereby amended to read as
follows:
23-17.12-12. Reporting requirements. -- (a) The department shall establish reporting requirements to determine if the utilization review programs are in compliance with the provisions of this chapter and applicable regulations.
(b) By November 14, 2014, the department shall report to the general assembly regarding hospital admission practices and procedures and the effects of such practices and procedures on the care and wellbeing of patients who present behavioral healthcare conditions on an emergency basis. The report shall be developed with the cooperation of the department of behavioral healthcare, developmental disabilities, and hospitals and of the department of children, youth, and families, and shall recommend changes to state law and regulation to address any necessary and appropriate revisions to the department's regulations related to utilization review based on the Federal Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and the Patient Protection and Affordable Care Act, Pub. L.111-148, and the state's regulatory interpretation of parity in insurance coverage of behavioral healthcare. These recommended or adopted revisions to the department's regulations shall include, but not be limited to:
(1) Adverse determination and internal appeals, with particular regard to the time necessary to complete a review of urgent and/or emergent services for patients with behavioral health needs;
(2) External appeal requirements;
(3) The
process for investigating whether insurers and agents are complying with the
provisions of § 23-17.12 chapter 17.12 of title 23 in light of parity in
insurance coverage for behavioral healthcare, with particular regard to
emergency admissions; and
(4)
Enforcement of the provisions of § 23-17.12 chapter 17.12 of title 23 in
light of insurance parity for behavioral healthcare.
SECTION 2. Section 42-14.5-3 of the General Laws in Chapter 42-14.5 entitled "The Rhode Island Health Care Reform Act of 2004 - Health Insurance Oversight" is hereby amended to read as follows:
42-14.5-3. Powers and duties [Contingent effective date; see effective dates under this section.] -- The health insurance commissioner shall have the following powers and duties:
(a) To conduct quarterly public
meetings throughout the state, separate and distinct from rate hearings
pursuant to section §42-62-13, regarding the rates, services,
and operations of insurers licensed to provide health insurance in the state,
the effects of such rates, services, and operations on consumers,
medical care providers, patients, and the market environment in which such
insurers operate, and efforts to bring new health insurers into the
Rhode Island market. Notice of not less than ten (10) days of said hearing(s)
shall go to the general assembly, the governor, the Rhode Island Medical
Society, the Hospital Association of Rhode Island, the director of health, the
attorney general and the chambers of commerce. Public notice shall be posted on
the department's web site and given in the newspaper of general circulation,
and to any entity in writing requesting notice.
(b) To make recommendations to the
governor and the house of representatives and senate finance committees
regarding health care insurance and the regulations, rates, services,
administrative expenses, reserve requirements, and operations of insurers
providing health insurance in the state, and to prepare or comment on, upon the
request of the governor, or chairpersons of the house or senate finance
committees, draft legislation to improve the regulation of health insurance. In
making such recommendations, the commissioner shall recognize that it is the
intent of the legislature that the maximum disclosure be provided regarding the
reasonableness of individual administrative expenditures as well as total
administrative costs. The commissioner shall make recommendations on the levels
of reserves including consideration of: targeted reserve levels; trends in the
increase or decrease of reserve levels; and insurer plans for distributing
excess reserves.
(c) To establish a
consumer/business/labor/medical advisory council to obtain information and
present concerns of consumers, business, and medical providers affected
by health insurance decisions. The council shall develop proposals to allow the
market for small business health insurance to be affordable and fairer. The
council shall be involved in the planning and conduct of the quarterly public
meetings in accordance with subsection (a) above. The advisory council shall
develop measures to inform small businesses of an insurance complaint process
to ensure that small businesses that experience rate increases in a given year
may request and receive a formal review by the department. The advisory council
shall assess views of the health provider community relative to insurance rates
of reimbursement, billing, and reimbursement procedures, and the
insurers' role in promoting efficient and high-quality health care. The
advisory council shall issue an annual report of findings and recommendations
to the governor and the general assembly and present their its findings
at hearings before the house and senate finance committees. The advisory
council is to be diverse in interests and shall include representatives of
community consumer organizations; small businesses, other than those involved
in the sale of insurance products; and hospital, medical, and other health
provider organizations. Such representatives shall be nominated by their
respective organizations. The advisory council shall be co-chaired by the
health insurance commissioner and a community consumer organization or small
business member to be elected by the full advisory council.
(d) To establish and provide guidance
and assistance to a subcommittee ("Tthe Pprofessional
Pprovider-Hhealth Pplan Wwork
Ggroup") of the advisory council created pursuant to subsection
(c) above, composed of health care providers and Rhode Island licensed health
plans. This subcommittee shall include in its annual report and presentation
before the house and senate finance committees the following information:
(1) A method whereby health plans shall disclose to contracted providers the fee schedules used to provide payment to those providers for services rendered to covered patients;
(2) A standardized provider application and credentials verification process, for the purpose of verifying professional qualifications of participating health care providers;
(3) The uniform health plan claim form utilized by participating providers;
(4) Methods for health maintenance
organizations as defined by section §27-41-1, and nonprofit
hospital or medical service corporations as defined by chapters 27-19 and
27-20 of title 27, to make facility-specific data and other
medical service-specific data available in reasonably consistent formats to
patients regarding quality and costs. This information would help consumers
make informed choices regarding the facilities and/or clinicians or physician
practices at which to seek care. Among the items considered would be the unique
health services and other public goods provided by facilities and/or clinicians
or physician practices in establishing the most appropriate cost comparisons;
(5) All activities related to contractual disclosure to participating providers of the mechanisms for resolving health plan/provider disputes;
(6) The uniform process being utilized for confirming, in real time, patient insurance enrollment status, benefits coverage, including co-pays and deductibles;
(7) Information related to temporary credentialing of providers seeking to participate in the plan's network and the impact of said activity on health plan accreditation;
(8) The feasibility of regular contract renegotiations between plans and the providers in their networks; and
(9) Efforts conducted related to reviewing impact of silent PPOs on physician practices.
(e) To enforce the provisions of Title
27 and Title 42 as set forth in section §42-14-5(d).
(f) To provide analysis of the Rhode
Island Affordable Health Plan Reinsurance Fund. The fund shall be used to
effectuate the provisions of sections §§27-18.5-8 and 27-50-17.
(g) To analyze the impact of changing
the rating guidelines and/or merging the individual health insurance market as
defined in chapter 27-18.5 of title 27 and the small employer
health insurance market as defined in chapter 27-50 of title 27
in accordance with the following:
(1) The analysis shall forecast the
likely rate increases required to effect the changes recommended pursuant to
the preceding subsection (g) in the direct-pay market and small employer
health insurance market over the next five (5) years, based on the current
rating structure, and current products.
(2) The analysis shall include examining the impact of merging the individual and small employer markets on premiums charged to individuals and small employer groups.
(3) The analysis shall include examining the impact on rates in each of the individual and small employer health insurance markets and the number of insureds in the context of possible changes to the rating guidelines used for small employer groups, including: community rating principles; expanding small employer rate bonds beyond the current range; increasing the employer group size in the small group market; and/or adding rating factors for broker and/or tobacco use.
(4) The analysis shall include examining the adequacy of current statutory and regulatory oversight of the rating process and factors employed by the participants in the proposed new merged market.
(5) The analysis shall include assessment of possible reinsurance mechanisms and/or federal high-risk pool structures and funding to support the health insurance market in Rhode Island by reducing the risk of adverse selection and the incremental insurance premiums charged for this risk, and/or by making health insurance affordable for a selected at-risk population.
(6) The health insurance commissioner
shall work with an insurance market merger task force to assist with the
analysis. The task force shall be chaired by the health insurance commissioner
and shall include, but not be limited to, representatives of the general
assembly, the business community, small employer carriers as defined in section
§27-50-3, carriers offering coverage in the individual market in Rhode
Island, health insurance brokers, and members of the general public.
(7) For the purposes of conducting this analysis, the commissioner may contract with an outside organization with expertise in fiscal analysis of the private insurance market. In conducting its study, the organization shall, to the extent possible, obtain and use actual health plan data. Said data shall be subject to state and federal laws and regulations governing confidentiality of health care and proprietary information.
(8) The task force shall meet as
necessary and include their its findings in the annual report and
the commissioner shall include the information in the annual presentation
before the house and senate finance committees.
(h) To establish and convene a
workgroup representing health care providers and health insurers for the
purpose of coordinating the development of processes, guidelines, and standards
to streamline health care administration that are to be adopted by payors and
providers of health care services operating in the state. This workgroup shall
include representatives with expertise that who would contribute
to the streamlining of health care administration and that who are
selected from hospitals, physician practices, community behavioral health
organizations, each health insurer, and other affected entities. The
workgroup shall also include at least one designee each from the Rhode Island
Medical Society, Rhode Island Council of Community Mental Health Organizations,
the Rhode Island Health Center Association, and the Hospital Association of
Rhode Island. The workgroup shall consider and make recommendations for:
(1) Establishing a consistent standard for electronic eligibility and coverage verification. Such standard shall:
(i) Include standards for eligibility
inquiry and response and, wherever possible, be consistent with the standards
adopted by nationally recognized organizations, such as the cCenters
for Medicare and Medicaid sServices;
(ii) Enable providers and payors to exchange eligibility requests and responses on a system-to-system basis or using a payor-supported web browser;
(iii) Provide reasonably detailed
information on a consumer's eligibility for health care coverage,;
scope of benefits,; limitations and exclusions provided under
that coverage,; cost-sharing requirements for specific services
at the specific time of the inquiry,; current deductible amounts,;
accumulated or limited benefits,; out-of-pocket maximums,;
any maximum policy amounts,; and other information required for
the provider to collect the patient's portion of the bill;
(iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility and benefits information;
(v) Recommend a standard or common process to protect all providers from the costs of services to patients who are ineligible for insurance coverage in circumstances where a payor provides eligibility verification based on best information available to the payor at the date of the request of eligibility.
(2) Developing implementation guidelines and promoting adoption of such guidelines for:
(i) The use of the nNational
cCorrect cCoding iInitiative code
edit policy by payors and providers in the state;
(ii) Publishing any variations from codes and mutually exclusive codes by payors in a manner that makes for simple retrieval and implementation by providers;
(iii) Use of health insurance portability and accountability act standard group codes, reason codes, and remark codes by payors in electronic remittances sent to providers;
(iv) The processing of corrections to claims by providers and payors.
(v) A standard payor-denial review process for providers when they request a reconsideration of a denial of a claim that results from differences in clinical edits where no single, common-standards body or process exists and multiple conflicting sources are in use by payors and providers.
(vi) Nothing in this section, or in the guidelines developed, shall inhibit an individual payor's ability to employ, and not disclose to providers, temporary code edits for the purpose of detecting and deterring fraudulent billing activities. The guidelines shall require that each payor disclose to the provider its adjudication decision on a claim that was denied or adjusted based on the application of such edits and that the provider have access to the payor's review and appeal process to challenge the payor's adjudication decision.
(vii) Nothing in this subsection shall be construed to modify the rights or obligations of payors or providers with respect to procedures relating to the investigation, reporting, appeal, or prosecution under applicable law of potentially fraudulent billing activities.
(3) Developing and promoting widespread adoption by payors and providers of guidelines to:
(i) Ensure payors do not automatically deny claims for services when extenuating circumstances make it impossible for the provider to obtain a preauthorization before services are performed or notify a payor within an appropriate standardized timeline of a patient's admission;
(ii) Require payors to use common and consistent processes and time frames when responding to provider requests for medical management approvals. Whenever possible, such time frames shall be consistent with those established by leading national organizations and be based upon the acuity of the patient's need for care or treatment. For the purposes of this section, medical management includes prior authorization of services, preauthorization of services, precertification of services, post-service review, medical-necessity review, and benefits advisory;
(iii) Develop, maintain, and promote widespread adoption of a single, common website where providers can obtain payors' preauthorization, benefits advisory, and preadmission requirements;
(iv) Establish guidelines for payors to develop and maintain a website that providers can use to request a preauthorization, including a prospective clinical necessity review; receive an authorization number; and transmit an admission notification.
(i) To issue an ANTI-CANCER MEDICATION REPORT. - Not later than June 30, 2014 and annually thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate committee on health and human services, and the house committee on corporations, with: (1) Information on the availability in the commercial market of coverage for anti-cancer medication options; (2) For the state employee's health benefit plan, the costs of various cancer treatment options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member utilization and cost-sharing expense.
(j) To monitor the adequacy of each health plan's compliance with the provisions of the federal mental health parity act, including a review of related claims processing and reimbursement procedures. Findings, recommendations, and assessments shall be made available to the public.
(k) To monitor the transition from fee for service and toward global and other alternative payment methodologies for the payment for health_care services. Alternative payment methodologies should be assessed for their likelihood to promote access to affordable health insurance, health outcomes, and performance.
(l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital payment variation, including findings and recommendations, subject to available resources.
(m) Notwithstanding any provision of the general or public laws or regulation to the contrary, provide a report with findings and recommendations to the president of the senate and the speaker of the house, on or before April 1, 2014, including, but not limited to, the following information:
(1) The impact of the current mandated
healthcare benefits as defined in sections §§27-18-48.1,
27-18-60, 27-18-62, 27-18-64, similar provisions in title 27, chapters
19, 20 and 41 of title 27, and subsection §§27-18-3(c),
27-38.2-1 et seq., or others as determined by the commissioner, on the cost of
health insurance for fully insured employers, subject to available resources;
(2) Current provider and insurer mandates that are unnecessary and/or duplicative due to the existing standards of care and/or delivery of services in the healthcare system;
(3) A state-by-state comparison of health insurance mandates and the extent to which Rhode Island mandates exceed other states benefits; and
(4) Recommendations for amendments to existing mandated benefits based on the findings in (1), (2) and (3) above.
(n) On or before July 1, 2014, the office of the health insurance commissioner, in collaboration with the director of health and lieutenant governor's office, shall submit a report to the general assembly and the governor to inform the design of accountable care organizations (ACOs) in Rhode Island as unique structures for comprehensive healthcare delivery and value based payment arrangements, that shall include, but not be limited to:
(1) Utilization review;
(2) Contracting; and
(3) Licensing and regulation.
(o) On or before February 3, 2015, the office of the health insurance commissioner shall submit a report to the general assembly and the governor that describes, analyzes, and proposes recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard to patients with mental health and substance-use disorders.
SECTION 3. This act shall take effect upon passage.
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LC004580/SUB B
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