2021 -- S 0233
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LC000594
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STATE OF RHODE ISLAND
IN GENERAL ASSEMBLY
JANUARY SESSION, A.D. 2021
____________
AN ACT
RELATING TO HEALTH AND SAFETY -- COMPREHENSIVE HEALTH INSURANCE
PROGRAM
Introduced By: Senators Bell, Calkin, Mack, Anderson, Goldin, Quezada, Lawson,
Mendes, Acosta, and DiMario
Date Introduced: February 10, 2021
Referred To: Senate Health & Human Services
It is enacted by the General Assembly as follows:
1 SECTION 1. Chapter 42-14.5 of the General Laws entitled "The Rhode Island Health Care
2 Reform Act of 2004 - Health Insurance Oversight" is hereby repealed in its entirety.
3 CHAPTER 42-14.5
4 The Rhode Island Health Care Reform Act of 2004 - Health Insurance Oversight
5 42-14.5-1. Health insurance commissioner.
6 There is hereby established, within the department of business regulation, an office of the
7 health insurance commissioner. The health insurance commissioner shall be appointed by the
8 governor, with the advice and consent of the senate. The director of business regulation shall grant
9 to the health insurance commissioner reasonable access to appropriate expert staff.
10 42-14.5-1.1. Legislative findings.
11 The general assembly hereby finds and declares as follows:
12 (1) A substantial amount of health care services in this state are purchased for the benefit
13 of patients by health care insurers engaged in the provision of health care financing services or is
14 otherwise delivered subject to the terms of agreements between health care insurers and providers
15 of the services.
16 (2) Health care insurers are able to control the flow of patients to providers of health care
17 services through compelling financial incentives for patients in their plans to utilize only the
18 services of providers with whom the insurers have contracted.
 1 (3) Health care insurers also control the health care services rendered to patients through
2 utilization review programs and other managed care tools and associated coverage and payment
3 policies.
4 (4) By incorporation or merger the power of health care insurers in markets of this state for
5 health care services has become great enough to create a competitive imbalance, reducing levels of
6 competition and threatening the availability of high quality, cost-effective health care.
7 (5) The power of health care insurers to unilaterally impose provider contract terms may
8 jeopardize the ability of physicians and other health care providers to deliver the superior quality
9 health care services that have been traditionally available in this state.
10 (6) It is the intention of the general assembly to authorize health care providers to jointly
11 discuss with health care insurers topics of concern regarding the provision of quality health care
12 through a committee established by an advisory to the health insurance commissioner.
13 42-14.5-2. Purpose.
14 With respect to health insurance as defined in § 42-14-5, the health insurance commissioner
15 shall discharge the powers and duties of office to:
16 (1) Guard the solvency of health insurers;
17 (2) Protect the interests of consumers;
18 (3) Encourage fair treatment of health care providers;
19 (4) Encourage policies and developments that improve the quality and efficiency of health
20 care service delivery and outcomes; and
21 (5) View the health care system as a comprehensive entity and encourage and direct
22 insurers towards policies that advance the welfare of the public through overall efficiency,
23 improved health care quality, and appropriate access.
24 42-14.5-3. Powers and duties.
25 The health insurance commissioner shall have the following powers and duties:
26 (a) To conduct quarterly public meetings throughout the state, separate and distinct from
27 rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers
28 licensed to provide health insurance in the state; the effects of such rates, services, and operations
29 on consumers, medical care providers, patients, and the market environment in which the insurers
30 operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less
31 than ten (10) days of the hearing(s) shall go to the general assembly, the governor, the Rhode Island
32 Medical Society, the Hospital Association of Rhode Island, the director of health, the attorney
33 general, and the chambers of commerce. Public notice shall be posted on the department's website
34 and given in the newspaper of general circulation, and to any entity in writing requesting notice.
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 1 (b) To make recommendations to the governor and the house of representatives and senate
2 finance committees regarding healthcare insurance and the regulations, rates, services,
3 administrative expenses, reserve requirements, and operations of insurers providing health
4 insurance in the state, and to prepare or comment on, upon the request of the governor or
5 chairpersons of the house or senate finance committees, draft legislation to improve the regulation
6 of health insurance. In making the recommendations, the commissioner shall recognize that it is
7 the intent of the legislature that the maximum disclosure be provided regarding the reasonableness
8 of individual administrative expenditures as well as total administrative costs. The commissioner
9 shall make recommendations on the levels of reserves, including consideration of: targeted reserve
10 levels; trends in the increase or decrease of reserve levels; and insurer plans for distributing excess
11 reserves.
12 (c) To establish a consumer/business/labor/medical advisory council to obtain information
13 and present concerns of consumers, business, and medical providers affected by health insurance
14 decisions. The council shall develop proposals to allow the market for small business health
15 insurance to be affordable and fairer. The council shall be involved in the planning and conduct of
16 the quarterly public meetings in accordance with subsection (a). The advisory council shall develop
17 measures to inform small businesses of an insurance complaint process to ensure that small
18 businesses that experience rate increases in a given year may request and receive a formal review
19 by the department. The advisory council shall assess views of the health provider community
20 relative to insurance rates of reimbursement, billing, and reimbursement procedures, and the
21 insurers' role in promoting efficient and high-quality health care. The advisory council shall issue
22 an annual report of findings and recommendations to the governor and the general assembly and
23 present its findings at hearings before the house and senate finance committees. The advisory
24 council is to be diverse in interests and shall include representatives of community consumer
25 organizations; small businesses, other than those involved in the sale of insurance products; and
26 hospital, medical, and other health provider organizations. Such representatives shall be nominated
27 by their respective organizations. The advisory council shall be co-chaired by the health insurance
28 commissioner and a community consumer organization or small business member to be elected by
29 the full advisory council.
30 (d) To establish and provide guidance and assistance to a subcommittee ("the professional-
31 provider-health-plan work group") of the advisory council created pursuant to subsection (c),
32 composed of healthcare providers and Rhode Island licensed health plans. This subcommittee shall
33 include in its annual report and presentation before the house and senate finance committees the
34 following information:
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 1 (1) A method whereby health plans shall disclose to contracted providers the fee schedules
2 used to provide payment to those providers for services rendered to covered patients;
3 (2) A standardized provider application and credentials verification process, for the
4 purpose of verifying professional qualifications of participating healthcare providers;
5 (3) The uniform health plan claim form utilized by participating providers;
6 (4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit
7 hospital or medical-service corporations, as defined by chapters 19 and 20 of title 27, to make
8 facility-specific data and other medical service-specific data available in reasonably consistent
9 formats to patients regarding quality and costs. This information would help consumers make
10 informed choices regarding the facilities and clinicians or physician practices at which to seek care.
11 Among the items considered would be the unique health services and other public goods provided
12 by facilities and clinicians or physician practices in establishing the most appropriate cost
13 comparisons;
14 (5) All activities related to contractual disclosure to participating providers of the
15 mechanisms for resolving health plan/provider disputes;
16 (6) The uniform process being utilized for confirming, in real time, patient insurance
17 enrollment status, benefits coverage, including co-pays and deductibles;
18 (7) Information related to temporary credentialing of providers seeking to participate in the
19 plan's network and the impact of the activity on health plan accreditation;
20 (8) The feasibility of regular contract renegotiations between plans and the providers in
21 their networks; and
22 (9) Efforts conducted related to reviewing impact of silent PPOs on physician practices.
23 (e) To enforce the provisions of Title 27 and Title 42 as set forth in § 42-14-5(d).
24 (f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The
25 fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17.
26 (g) To analyze the impact of changing the rating guidelines and/or merging the individual
27 health insurance market, as defined in chapter 18.5 of title 27, and the small-employer health
28 insurance market, as defined in chapter 50 of title 27, in accordance with the following:
29 (1) The analysis shall forecast the likely rate increases required to effect the changes
30 recommended pursuant to the preceding subsection (g) in the direct-pay market and small-employer
31 health insurance market over the next five (5) years, based on the current rating structure and
32 current products.
33 (2) The analysis shall include examining the impact of merging the individual and small-
34 employer markets on premiums charged to individuals and small-employer groups.
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 1 (3) The analysis shall include examining the impact on rates in each of the individual and
2 small-employer health insurance markets and the number of insureds in the context of possible
3 changes to the rating guidelines used for small-employer groups, including: community rating
4 principles; expanding small-employer rate bonds beyond the current range; increasing the employer
5 group size in the small-group market; and/or adding rating factors for broker and/or tobacco use.
6 (4) The analysis shall include examining the adequacy of current statutory and regulatory
7 oversight of the rating process and factors employed by the participants in the proposed, new
8 merged market.
9 (5) The analysis shall include assessment of possible reinsurance mechanisms and/or
10 federal high-risk pool structures and funding to support the health insurance market in Rhode Island
11 by reducing the risk of adverse selection and the incremental insurance premiums charged for this
12 risk, and/or by making health insurance affordable for a selected at-risk population.
13 (6) The health insurance commissioner shall work with an insurance market merger task
14 force to assist with the analysis. The task force shall be chaired by the health insurance
15 commissioner and shall include, but not be limited to, representatives of the general assembly, the
16 business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage in
17 the individual market in Rhode Island, health insurance brokers, and members of the general public.
18 (7) For the purposes of conducting this analysis, the commissioner may contract with an
19 outside organization with expertise in fiscal analysis of the private insurance market. In conducting
20 its study, the organization shall, to the extent possible, obtain and use actual health plan data. Said
21 data shall be subject to state and federal laws and regulations governing confidentiality of health
22 care and proprietary information.
23 (8) The task force shall meet as necessary and include its findings in the annual report, and
24 the commissioner shall include the information in the annual presentation before the house and
25 senate finance committees.
26 (h) To establish and convene a workgroup representing healthcare providers and health
27 insurers for the purpose of coordinating the development of processes, guidelines, and standards to
28 streamline healthcare administration that are to be adopted by payors and providers of healthcare
29 services operating in the state. This workgroup shall include representatives with expertise who
30 would contribute to the streamlining of healthcare administration and who are selected from
31 hospitals, physician practices, community behavioral health organizations, each health insurer, and
32 other affected entities. The workgroup shall also include at least one designee each from the Rhode
33 Island Medical Society, Rhode Island Council of Community Mental Health Organizations, the
34 Rhode Island Health Center Association, and the Hospital Association of Rhode Island. The
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 1 workgroup shall consider and make recommendations for:
2 (1) Establishing a consistent standard for electronic eligibility and coverage verification.
3 Such standard shall:
4 (i) Include standards for eligibility inquiry and response and, wherever possible, be
5 consistent with the standards adopted by nationally recognized organizations, such as the Centers
6 for Medicare and Medicaid Services;
7 (ii) Enable providers and payors to exchange eligibility requests and responses on a system-
8 to-system basis or using a payor-supported web browser;
9 (iii) Provide reasonably detailed information on a consumer's eligibility for healthcare
10 coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing
11 requirements for specific services at the specific time of the inquiry; current deductible amounts;
12 accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and
13 other information required for the provider to collect the patient's portion of the bill;
14 (iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility
15 and benefits information;
16 (v) Recommend a standard or common process to protect all providers from the costs of
17 services to patients who are ineligible for insurance coverage in circumstances where a payor
18 provides eligibility verification based on best information available to the payor at the date of the
19 request of eligibility.
20 (2) Developing implementation guidelines and promoting adoption of the guidelines for:
21 (i) The use of the National Correct Coding Initiative code-edit policy by payors and
22 providers in the state;
23 (ii) Publishing any variations from codes and mutually exclusive codes by payors in a
24 manner that makes for simple retrieval and implementation by providers;
25 (iii) Use of Health Insurance Portability and Accountability Act standard group codes,
26 reason codes, and remark codes by payors in electronic remittances sent to providers;
27 (iv) The processing of corrections to claims by providers and payors.
28 (v) A standard payor-denial review process for providers when they request a
29 reconsideration of a denial of a claim that results from differences in clinical edits where no single,
30 common-standards body or process exists and multiple conflicting sources are in use by payors and
31 providers.
32 (vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual
33 payor's ability to employ, and not disclose to providers, temporary code edits for the purpose of
34 detecting and deterring fraudulent billing activities. The guidelines shall require that each payor
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 1 disclose to the provider its adjudication decision on a claim that was denied or adjusted based on
2 the application of such edits and that the provider have access to the payor's review and appeal
3 process to challenge the payor's adjudication decision.
4 (vii) Nothing in this subsection shall be construed to modify the rights or obligations of
5 payors or providers with respect to procedures relating to the investigation, reporting, appeal, or
6 prosecution under applicable law of potentially fraudulent billing activities.
7 (3) Developing and promoting widespread adoption by p