Title 27
Insurance

Chapter 41
Health Maintenance Organizations

§ 27-41-2. 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, Pub. L. No. 111-148, 124 Stat. 119, as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029, and federal regulations adopted thereunder.

(3) “Commissioner” or “health insurance commissioner” means that individual appointed pursuant to § 42-14.5-1.

(4) “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.

(5) “Director” means the director of the department of business regulation or his or her duly appointed agents.

(6) “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 (7) 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.

(7) “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, that 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.

(8) “Enrollee” means an individual who has been enrolled in a health maintenance organization.

(9) “Essential health benefits” shall have the meaning set forth in section 1302(b) of the Patient Protection and Affordable Care Act [42 U.S.C. § 18022(b)].

(10) “Evidence of coverage” means any certificate, agreement, or contract issued to an enrollee setting out the coverage to which the enrollee is entitled.

(11) “Grandfathered health plan” means any group health plan or health insurance coverage subject to 42 U.S.C. § 18011.

(12) “Group health insurance coverage” means, in connection with a group health plan, health insurance coverage offered in connection with that plan.

(13) “Group health plan” means an employee welfare benefit plan as defined in 29 U.S.C. § 1002(1), to the extent that the plan provides health benefits to employees or their dependents directly or through insurance, reimbursement, or otherwise.

(14) “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 § 27-19-17.

(15) “Healthcare facility” means an institution providing healthcare services or a healthcare 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.

(16) “Healthcare professional” means a physician or other healthcare practitioner licensed, accredited, or certified to perform specified healthcare services consistent with state law.

(17) “Healthcare provider” or “provider” means a healthcare professional or a healthcare facility.

(18) “Healthcare 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.

(19) “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.

(20) “Health maintenance organization” means a single public or private organization that:

(i) Provides or makes available to enrolled participants healthcare services, including at least the following basic healthcare services: usual physician services, hospitalization, laboratory, x-ray, emergency, and preventive services, and out-of-area coverage, and the services of licensed midwives;

(ii) Is compensated, except for copayments, for the provision of the basic healthcare services listed in subsection (20)(i) of this section to enrolled participants on a predetermined periodic rate basis;

(iii)(A) Provides physicians’ services primarily:

(I) Directly through physicians who are either employees or partners of the organization; or

(II) Through arrangements with individual physicians or one or more groups of physicians organized on a group practice or individual practice basis;

(B) “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; and

(iv) Provides the services of licensed midwives primarily:

(A) Directly through licensed midwives who are either employees or partners of the organization; or

(B) Through arrangements with individual licensed midwives or one or more groups of licensed midwives organized on a group practice or individual practice basis.

(21) “Licensed midwife” means any midwife licensed pursuant to § 23-13-9.

(22) “Material modification” means only systemic changes to the information filed under § 27-41-3.

(23) “Net worth,” for the purposes of this chapter, means the excess of total admitted assets over total liabilities.

(24) “Office of the health insurance commissioner” means the agency established under § 42-14.5-1.

(25) “Physician” includes a podiatrist as defined in chapter 29 of title 5.

(26) “Private organization” means a legal corporation with a policy-making and governing body.

(27) “Provider” means any physician, hospital, licensed midwife, or other person who or that is licensed or authorized in this state to furnish healthcare services.

(28) “Public organization” means an instrumentality of government.

(29) “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.

(30) “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.

(31) “Total adjusted capital” means the sum of:

(i) 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 § 27-41-9; and

(ii) Any other items, if any, that the RBC instructions provide.

(32) “Uncovered expenditures” means the costs of healthcare 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 who or that agrees not to bill enrollees under any circumstances are excluded from this definition.