230-RICR-20-30-4
230-RICR-20-30-4. Powers and Duties of the Office of the Health Insurance Commissioner (version Amendment, 12/04/2018 to 06/25/2020)
4.1 Authority
This regulation is
promulgated pursuant to R.I. Gen. Laws §§ 42-14.5-1 et
seq ., 42-14-5, and 42-14-17.
4.2 Purpose and Scope
A. When creating the Office of
the Health Insurance Commissioner (OHIC or Office), the General
Assembly created a list of statutory purposes for the OHIC at R.I.
Gen. Laws § 42-14.5-2 (the OHIC Purposes Statute). In order to
meet the requirements established by the OHIC Purposes Statute, the
OHIC has developed this regulation, which is designed to:
1. Ensure effective regulatory
oversight by the OHIC;
2. Provide guidance to the
state’s health insurers, health care providers, consumers of
health insurance, consumers of health care services and the general
public as to how the OHIC will interpret and implement its statutory
obligations; and
3. Implement the intent of the
General Assembly as expressed in the OHIC Purposes Statute.
4.3 Definitions
A. As used in this regulation:
1. “Affiliate” has
the same meaning as set out in the first sentence of R.I. Gen. Laws §
27-35-1(a). An “affiliate” of, or an entity or person
“affiliated” with, a specific entity or person, is an
entity or person who directly or indirectly through one or more
intermediaries controls, or is controlled by, or is under common
control with, the entity or person specified.
2. "Aligned measure sets”
means any set of quality measures adopted by the Commissioner
pursuant to § 4.10(D)(3) of this Part. An Aligned Measure Set
shall consist of measures designated as ‘Core Measures’
and/or ‘Menu Measures.’ Aligned Measure Sets are
developed for specific provider contract types (e.g. primary care
provider contracts, hospital contracts, Accountable Care Organization
(ACO, or Integrated System of Care) contracts.
3. "Commissioner"
means the Health Insurance Commissioner
4. "Core measures"
means quality measures in an Aligned Measure Set that have been
designated for mandatory inclusion in applicable health care provider
contracts that incorporate quality measures into the payment terms
(e.g., primary care measures for primary care provider contracts).
5. "Direct primary care
expenses" means payments by the Health Insurer directly to a
primary care practice for:
a. Providing health care
services, including fee-for service payments, capitation payments,
and payments under other alternative, non-fee-for-service
methodologies designed to provide incentives for the efficient use of
health services;
b. Achieving quality or cost
performance goals, including pay-for-performance payments and shared
savings distributions;
c. Infrastructure development
payments within the primary care practice, which the practice cannot
reasonably fund independently, in accordance with parameters and
criteria issued by order of the Commissioner, or upon request by a
Health Insurer and approval by the Commissioner:
(1) That are designed to
transform the practice into, and maintain the practice as a Patient
Centered Medical Home, and to prepare a practice to function within
an Integrated System of Care. Examples of acceptable spending under
this category include:
(AA) Making supplemental
payments to fund a practice-based and practice-paid care manager;
(BB) Funding the provision of
care management resources embedded in, but not paid for by, the
primary care practice;
(CC) Funding the purchase by
the practice of analytic software that enables primary care practices
to analyze patient quality and/or costs, such as software that tracks
patient costs in near-to-real time;
(DD) Training of members of
the primary care team in motivational interviewing or other patient
activation techniques; and
(EE) Funding the cost of the
practice to link to the health information exchange established by
R.I. Gen. Laws Chapter 5-37.7;
(2) That promote the
appropriate integration of primary care and behavioral health care;
for example, funding behavioral health services not traditionally
covered with a discrete payment when provided in a primary care
setting, such as substance abuse or depression screening;
(3) For shared services among
small and independent primary care practices to enable the practices
to function as Patient-Centered Medical Homes Acceptable spending
under this category:
(AA) must directly enhance a
Primary Care Practice’s ability to support its patient
population, and
(BB) must provide, reinforce
or promote specific skills that Patient-Centered Medical Homes must
have to effectively operate using Patient-Centered Medical Home
principles and standards, or to participate in an Integrated System
of Care that successfully manages risk-bearing contracts. Examples of
acceptable spending under this category include:
(i) Funding the cost of a
clinical care manager who rotates through the practices;
(ii) Funding the cost of a
practice data analyst to provide data support and reports to the
participating practices, and
(iii) Funding the costs of a
pharmacist to help practices with medication reconciliation for
poly-pharmacy patients;
(4) That promote
community-based services to enable practices to function as Patient
Centered Medical Homes. Acceptable spending under this category:
(AA) must directly enhance a
Primary Care Practice’s ability to support its patient
population, and
(BB) must provide, reinforce
or promote specific skills that the Patient-Centered Medical Homes
must have to effectively operate using Patient-Centered Medical Home
principles and standards, or to participate in an Integrated System
of Care that successfully manages risk-bearing contracts. Acceptable
spending under this category includes funding multi-disciplinary care
management teams to support Primary Care Practice sites within a
geographic region;
(5) Designed to increase the
number of primary care physicians practicing in RI, and approved by
the Commissioner, such as a medical school loan forgiveness program;
and
(6) Any other direct primary
care expense that meets the parameters and criteria established in a
bulletin issued by the Commissioner, or that is requested by a Health
Insurer and approved by the Commissioner.
6. "Examination”
has the same meaning as set out in R.I. Gen. Laws § 27-13.1-1 et
seq .
7. “Health insurance”
means “health insurance coverage,” as defined in R.I.
Gen. Laws §§ 27-18.5-2 and 27-18.6-2, “health benefit
plan,” as defined in R.I. Gen. Laws § 27-50-3 and a
“medical supplement policy,” as defined in R.I. Gen. Laws
§ 27-18.2-1 or coverage similar to a Medicare supplement policy
that is issued to an employer to cover retirees.
8. “Global capitation
contract” means a Population-Based Contract with an Integrated
System of Care that:
a. holds the Integrated System
of Care responsible for providing or arranging for all, or
substantially all of the covered services provided to the Health
Insurer’s defined group of members in return for a monthly
payment that is inclusive of the total, or near total costs of such
covered services based on a negotiated percentage of the Health
Insurer’s premium or based on a negotiated fixed per member per
month payment, and
b. incorporates incentives
and/or penalties for performance relative to quality targets.
9. “Health insurer”
means any entity subject to the insurance laws and regulations of
this state, or subject to the jurisdiction of the Commissioner, that
contracts or offers to contract to provide, deliver, arrange for, pay
for, or reimburse any of the costs of health care services,
including, without limitation, an insurance company offering accident
and sickness insurance, a health maintenance organization, a
non-profit hospital service corporation, a non-profit medical service
corporation, a non-profit dental service corporation, a non-profit
optometric service corporation, a domestic insurance company subject
R.I. Gen. Laws Chapter 27-1 that offers or provides health insurance
coverage in the state and a foreign insurance company subject to R.I.
Gen. Laws Chapter 27-2 that offers or provides health insurance
coverage in the state.
10. “Holding company
system” has the same meaning as set out in R.I. Gen. Laws §
27-35-1 et seq .
11. “Indirect primary
care expenses” means payments by the Health Insurer to support
and strengthen the capacity of a primary care practice to function as
a medical home, and to successfully manage risk-bearing contracts,
but which do not qualify as Direct Primary Care Expenses. Indirect
Primary Care Expenses may include a proper allocation, proportionate
to the benefit accruing to the Primary Care Practice, of Health
Insurer investments in data, analytics, and population-health and
disease registries for Primary Care Practices without the foreseeable
ability to make and manage such infrastructure investments, but which
do not qualify as acceptable Direct Primary Care Spending, in
accordance with parameters and criteria issued in a bulletin issued
by the Commissioner, or upon request by a Health Insurer and approved
by the Commissioner. Such payments shall include financial support,
in an amount approved by the Commissioner, for the administrative
expenses of the medical home initiative endorsed by R.I. Gen. Laws
Chapter 42-14.6, and for the health information exchange established
by R.I. Gen. Laws Chapter 5-37.7. By May 1, 2016 the Commissioner
shall reassess this obligation by Health Insurers to provide
financial support for the health information exchange.
12. “Integrated system
of care”, sometimes referred to as an Accountable Care
Organization, means one or more business entities consisting of
physicians, other clinicians, hospitals and/or other providers that
together provide care and share accountability for the cost and
quality of care for a population of patients, and that enters into a
Population-Based Contract, such as a Shared Savings Contract or Risk
Sharing Contract or Global Capitation Contract, with one or more
Health Insurers to care for a defined group of patients.
13. "Menu measures”
means quality measures within an Aligned Measure Set that are
included in applicable health care provider contracts that
incorporate quality measures into the payment terms when such
inclusion occurs at the mutual agreement of the Health Insurer and
contracted health care provider.
14. “Patient-centered
medical home” means:
a. a Primary Care Practice
recognized by the collaborative initiative endorsed by R.I. Gen. Laws
Chapter 42-14.6, or
b. a Primary Care Practice
recognized by a national accreditation body, or
c. a Primary Care Practice
designated by contract between a Health Insurer and a primary care
practice, or between a Health Insurer and an Integrated System of
Care in which the Primary Care Practice is participating. A
contractually designated Primary Care Practice must meet
pre-determined quality and efficiency criteria practice performance
standards, which are approved by the Commissioner, for improved care
management and coordination that are at least as rigorous as those of
the collaborative initiative endorsed by R.I. Gen. Laws Chapter
42-14.6.
15. “Population-based
contract” means a provider reimbursement contract with an
Integrated System of Care that uses a reimbursement methodology that
is inclusive of the total, or near total medical costs of an
identified, covered-lives population. A Population-Based Contract may
be a Shared Savings Contract, or a Risk Sharing Contract, or a Global
Capitation Contract. A primary care or specialty service capitation
reimbursement contract shall not be considered a Population-Based
Contract for purposes of this Section. A Population-Based Contract
may not transfer insurance risk or any health insurance regulatory
obligations. A Health Insurer may request clarification from the
Commissioner as to whether its proposed contract constitutes the
transfer of insurance risk.
16. "Primary care
practice” means the practice of a physician, medical practice,
or other medical provider considered by the insured subscriber or
dependent to be his or her usual source of care. Designation of a
primary care provider shall be limited to providers within the
following practice type: Family Practice, Internal Medicine and
Pediatrics; and providers with the following professional
credentials: Doctors of Medicine and Osteopathy, Nurse Practitioners,
and Physicians’ Assistants; except that specialty medical
providers, including behavioral health providers, may be designated
as a primary care provider if the specialist is paid for primary care
services on a primary care provider fee schedule, and contractually
agrees to accept the responsibilities of a primary care provider.
17. “Risk sharing
contract” means a Population-Based Contract that:
a. holds the provider
financially responsible for a negotiated portion of costs that exceed
a predetermined population-based budget, in exchange for provider
eligibility for a portion of any savings generated below the
predetermined budget, and
b. incorporates incentives
and/or penalties for performance relative to quality targets.
18. “Shared savings
contract” means a Population-Based Contract that:
a. allows the provider to
share in a portion of any savings generated below a predetermined
population-based budget, and
b. incorporates incentives
and/or penalties for performance relative to quality targets.
4.4 Discharging Duties and Powers
A. The Commissioner shall
discharge the powers and duties of the Office to:
1. Guard the solvency of
health insurers;
2. Protect the interests of
the consumers of health insurance;
3. Encourage fair treatment of
health care providers by health insurers;
4. Encourage policies and
developments that improve the quality and efficiency of health care
service delivery and outcomes; and
5. View the health care system
as a comprehensive entity and encourage and direct health insurers
towards policies that advance the welfare of the public through
overall efficiency, improved health care quality, and appropriate
access.
4.5 Guarding the Solvency and
Financial Condition of Health Insurers
A. The solvency of health
insurers must be guarded to protect the interests of insureds, health
care providers, and the public generally.
B. Whenever the Commissioner
determines that one of the circumstances in § 4.5(B)(1) through
(4) of this Part exist, the Commissioner shall, in addition to
exercising any duty or power authorized or required by R.I. Gen. Laws
Titles 27 or 42 related specifically to the solvency or financial
health of a health insurer, act to guard the solvency and financial
condition of a health insurer when exercising any other power or duty
of the Office, including, but not limited to, approving or denying
any request or application; approving, denying or modifying any
requested rate; approving or rejecting any forms, trend factors, or
other filings; issuing any order, decision or ruling; initiating any
proceeding, hearing, examination, or inquiry; or taking any other
action authorized or required by statute or regulation.
1. The solvency or financial
condition of any health insurer is in jeopardy or is likely to be in
jeopardy;
2. Any action or inaction by a
health insurer could adversely affect the solvency or financial
condition of that health insurer;
3. The approval or denial of
any regulatory request, application or filing by a health insurer
could adversely affect the solvency or financial condition of that
health insurer; or
4. Any other circumstances
exist such that the solvency or financial condition of a health
insurer may be at risk.
C. When making a determination
as described in § 4.5(B) of this Part or when acting to guard
the solvency of a health insurer, the Commissioner may consider
and/or act upon the following solvency and financial factors, either
singly or in combination of two or more:
1. Any appropriate financial
and solvency standards for the health insurer, including those set
out in R.I. Gen. Laws Title 27 and implementing regulations;
2. The investments, reserves,
surplus and other assets and liabilities of a health insurer;
3. A health insurer’s
use of reinsurance, and the insurer’s standards for ceding,
reporting on, and allowing credit for such reinsurance;
4. A health insurer’s
transactions with affiliates, agents, vendors, and other third
parties to the extent that such transactions adversely affect the
financial condition of the health insurer;
5. Any audits of a health
insurer by independent accountants, consultants or other experts;
6. The annual financial
statement and any other report prepared by or on behalf of a health
insurer related to its financial position or financial activities;
7. A health insurer’s
transactions within an insurance holding company system;
8. Whether the management of a
health insurer, including its officers, directors, or any other
person who directly or indirectly controls the operation of the
health insurer, fails to possess and demonstrate the competence,
fitness, and reputation deemed necessary to serve the insurer in the
position;
9. The findings reported in
any financial condition or market conduct examination report and
financial analysis procedures;
10. The ratios of commission
expense, general insurance expense, policy benefits and reserve
increases as to annual premium and net investment income, which could
lead to an impairment of capital and surplus;
11. Concerns that a health
insurer’s asset portfolio, when viewed in light of current
economic conditions, is not of sufficient value, liquidity, or
diversity to ensure the health insurer’s ability to meet its
outstanding obligations as such obligations mature;
12. The ability of an assuming
reinsurer to perform and whether the health insurer’s
reinsurance program provides sufficient protection for the health
insurer’s remaining surplus after taking into account the
health insurer’s cash flow and the classes of business written
and the financial condition of the assuming reinsurer;
13. The health insurer’s
operating loss in the last twelve month period or any shorter period
of time, including but not limited to net capital gain or loss,
change in non-admitted assets, and cash dividends paid to
shareholders, is greater than fifty percent of the health insurer’s
remaining surplus as regards policyholders in excess of the minimum
required;
14. Whether any affiliate,
subsidiary, or reinsurer of a health insurer is insolvent, threatened
with insolvency, or delinquent in the payment of its monetary or
other obligations;
15. Any contingent
liabilities, pledges, or guaranties of a health insurer that either
individually or collectively involve a total amount which in the
opinion of the Commissioner may affect the solvency of the health
insurer;
16. Whether any person, firm,
association, or corporation who directly or indirectly has the power
to direct or cause to be directed, the management, control, or
activities of a health insurer, is delinquent in the transmitting to,
or payment of, net premiums to the insurer;
17. The age and collectability
of a health insurer's receivables;
18. Whether the management of
a health insurer has
a. Failed to respond to
inquiries by the Commissioner, the Department of Business Regulation,
the Department of Health, the Department of the Attorney General, any
other state or federal agency relative to the financial condition of
the health insurer;
b. Furnished false and
misleading information concerning an inquiry by the Commissioner, the
Department of Business Regulation, the Department of Health, the
Department of the Attorney General, any other state or federal agency
regarding the financial condition of the health insurer; or
c. Failed to make appropriate
disclosures of financial information to the Commissioner, the
Department of Business Regulation, the Department of Health, the
Department of the Attorney General, any other state or federal
agency, or the public.
19. Whether the management of
a health insurer either has filed any false or misleading sworn
financial statement, or has released a false or misleading financial
statement to lending institutions or to the general public, or has
made a false or misleading entry, or has omitted an entry of material
amount in the books of the health insurer;
20. Whether a health insurer
has grown so rapidly and to such an extent that it lacks adequate
financial and administrative capacity to meet its obligations in a
timely manner; and
21. Whether a health insurer
has experienced or will experience in the foreseeable future cash
flow and/or liquidity problems.
D. The factors enumerated in §
4.5(C) of this Part shall not be construed as limiting the
Commissioner from making a finding that other factors not
specifically enumerated in § 4.5(C) of this Part are necessary
or desirable factors for the evaluation and maintenance of the sound
financial condition and solvency of a health insurer.
4.6 Protecting the Interests of
Consumers
A. The interests of the
consumers of health insurance, including individuals, groups and
employers, must be protected.
B. The provisions of this
regulation do not require the Commissioner to act as an advocate on
behalf of a particular health insurance consumer. Instead, while the
Commissioner will endeavor to address individual consumer complaints
as they arise, the OHIC Purposes Statute requires the OHIC to protect
the interests of health insurance consumers, including individuals,
groups and employers, on a system-wide basis.
C. Whenever the Commissioner
determines that one of the circumstances in § 4.6(C)(1) through
(3) of this Part exist, the Commissioner shall, in addition to
exercising any duty or power authorized or required by R.I. Gen. Laws
Titles 27 or 42 related specifically to the protection of the
interests of the consumers of health insurance, act to protect the
interests of consumers of health insurance when exercising any other
power or duty of the Office, including, but not limited to, approving
or denying any request or application; approving, denying or
modifying any requested rate; approving or rejecting any forms, trend
factors, or other filings; issuing any order, decision or ruling;
initiating any proceeding, hearing, examination, or inquiry; or
taking any other action authorized or required by statute or
regulation.
1. The interests of the
state’s health insurance consumers are, or are likely to be,
adversely affected by any policy, practice, action or inaction of a
health insurer;
2. The approval or denial by
the Commissioner of any regulatory request, application or filing
made by a health insurer could adversely affect the interests of the
state’s health insurance consumers; or
3. Any other circumstances
exist such that the interests of the state’s health insurance
consumers may be adversely affected.
D. When making a determination
as described in § 4.6(C) of this Part or when acting to protect
the interests of the state’s health insurance consumers, the
Commissioner may consider and/or act upon the following consumer
interest issues, either singly or in combination of two or more:
1. The privacy and security of
consumer health information;
2. The efforts by a health
insurer to ensure that consumers are able to
a. Read and understand the
terms and scope of the health insurance coverage documents issued or
provided by the health insurer and
b. Make fully informed choices
about the health insurance coverage provided by the health insurer;
3. The effectiveness of a
health insurer’s consumer appeal and complaint procedures for
matters other than medical necessity and utilization review, which
are within jurisdiction of the Department of Health;
4. The efforts by a health
insurer to ensure that consumers have ready access to claims
information;
5. The efforts by a health
insurer to increase the effectiveness of its communications with its
insureds, including, but not limited to, communications related to
the insureds’ financial responsibilities;
6. That the benefits in health
insurance coverage documents issued or provided by a health insurer
are consistent with state laws;
7. That the benefits delivered
by a health insurer are consistent with those guaranteed by the
health insurance coverage documents issued or provided by the health
insurer; and
8. The steps taken by a health
insurer to enhance the affordability of its products, as described in
§ 4.9 of this Part.
E. The factors enumerated in §
4.6(D) of this Part shall not be construed as limiting the
Commissioner from making a finding that other consumer protection
issues not specifically enumerated in § 4.6(D) of this Part are
necessary or desirable factors upon which the Commissioner may act to
protect the interests of consumers of health insurance.
4.7 Encouraging Fair Treatment of
Health Care Providers
A. The Commissioner will act
to encourage the fair treatment of health care providers by health
insurers.
B. The provisions of this
regulation do not require the Commissioner to act as an advocate for
a particular health care provider or for a particular group of health
care providers. Instead, while the Commissioner will endeavor to
address individual health care provider complaints as they arise, the
OHIC Purposes Statute requires the OHIC to act to enhance system-wide
treatment of providers.
C. Whenever the Commissioner
determines that any of the circumstances in § 4.7(C)(1) through
(4) of this Part exist, the Commissioner shall, in addition to
exercising any duty or power authorized or required by R.I. Gen. Laws
Titles 27 or 42 related specifically to the fair treatment of health
care providers, take the treatment of health care providers by a
health insurer into consideration when exercising any other power or
duty of the Office, including, but not limited to, approving or
denying any request or application; approving, denying or modifying
any requested rate; approving or rejecting any forms, trend factors,
or other filings; issuing any order, decision or ruling; initiating
any proceeding, hearing, examination, or inquiry; or taking any other
action authorized or required by statute or regulation.
1. Health care providers are
being treated unfairly by a health insurer;
2. The policies or procedures
of a health insurer place an undue, inconsistent or disproportionate
burden upon a class or providers;
3. The approval or denial by
the Commissioner of any regulatory request, application or filing
made by a health insurer will result in unfair treatment of a health
care providers by a health insurer; or
4. Any other circumstances
exist such that Commissioner is concerned that health care providers
will be treated unfairly by a health insurer.
D. When making a determination
as described in § 4.7(C) of this Part or when acting to
encourage the fair treatment of providers, the Commissioner may
consider and/or act upon the following issues, either singly or in
combination of two or more:
1. The policies, procedures
and practices employed by health insurers with respect to provider
reimbursement, claims processing, dispute resolution and contracting
processes;
2. A health insurer’s
provider rate schedules; and
3. The efforts undertaken by
the health insurers to enhance communications with providers.
E. The factors enumerated in §
4.7(D) of this Part shall not be construed as limiting the
Commissioner from making a finding that other factors related to the
treatment of health care providers by a health insurer not
specifically enumerated are necessary or desirable factors for the
evaluation of whether health care providers are being treated fairly
by a health insurer. The factors that may be considered by the
Commissioner will not typically include those matters over which
other agencies, such as the Department of Health, have jurisdiction.
4.8 Improving the Efficiency and
Quality of Health Care Delivery and Increasing Access to Health Care
Services
A. Consumers, providers,
health insurers and the public generally have an interest in:
1. Improving the quality and
efficiency of health care service delivery and outcomes in Rhode
Island;
2. Viewing the health care
system as a comprehensive entity; and
3. Encouraging and directing
insurers towards policies that advance the welfare of the public
through overall efficiency, improved health care quality, and
appropriate access.
B. The government, consumers,
employers, providers and health insurers all have a role to play in
increasing access to health care services and improving the quality
and efficiency of health care service delivery and outcomes in Rhode
Island. Nevertheless, the state’s health insurers, because of
their prominent role in the financing of health care services, bear a
greater burden with respect to improving the quality and efficiency
of health care service delivery and outcomes in Rhode Island,
treating the health care system as a comprehensive entity, and
advancing the welfare of the public through overall efficiency,
improved health care quality, and appropriate access. Furthermore, a
balance must be struck between competition among the health plans,
which can result in benefits such as innovation, and collaboration,
which can promote consumer benefits such as standardization and
simplification.
C. Whenever the Commissioner
determines that any of the circumstances listed in § 4.8(C)(1)
or (2) of this Part exist, the Commissioner shall, in addition to
exercising any duty or power authorized or required by R.I. Gen. Laws
Titles 27 or 42 related specifically to improving the efficiency and
quality of health care delivery and increasing access to healthcare
services, act to further the interests set out in § 4.8(C)(1)(a)
of this Part when exercising any other power or duty of the Office,
including, but not limited to, approving or denying any request or
application; approving, denying or modifying any requested rate;
approving or rejecting any forms, trend factors, or other filings;
issuing any order, decision or ruling; initiating any proceeding,
hearing, examination, or inquiry; or taking any other action
authorized or required by statute or regulation.
1. The decision to approve or
deny any regulatory request, application or filing made by a health
insurer
a. Can be made in a manner
that will
(1) Improve the quality and
efficiency of health care service delivery and outcomes in Rhode
Island;
(2) View the health care
system as a comprehensive entity; or
(3) Encourage and direct
insurers towards policies that advance the welfare of the public
through overall efficiency, improved health care quality, and
appropriate access; or
b. Should include conditions
when feasible that will
(1) Promote increased quality
and efficiency of health care service delivery and outcomes in Rhode
Island;
(2) Incent health insurers to
view the health care system as a comprehensive entity; or
(3) Encourage and direct
insurers towards policies that advance the welfare of the public
through overall efficiency, improved health care quality, and
appropriate access; or
2. Any other circumstances
exist such that regulatory action by the Commissioner with respect to
a health insurer will likely improve the efficiency and quality of
health care delivery and increase access to health care services.
D. When making a determination
as described in § 4.8(C) of this Part or when acting to further
the interests set out in § 4.8(A) of this Part, the Commissioner
may consider and/or act upon the following, either singly or in
combination of two or more:
1. Efforts by health insurers
to develop benefit design and payment policies that:
a. Enhance the affordability
of their products, as described in § 4.9 of this Part;
b. Encourage more efficient
use of the state’s existing health care resources;
c. Promote appropriate and
cost effective acquisition of new health care technology and
expansion of the existing health care infrastructure;
d. Advance the development and
use of high quality health care services (e.g., centers of
excellence); and
e. Prioritize the use of
limited resources
2. Efforts by health insurers
to promote the dissemination of information, increase consumer access
to health care information, and encourage public policy dialog about
increasing health care costs and solutions by:
a. Providing consumers' timely
and user-friendly access to health care information related to the
quality and cost of providers and health care services so that
consumers can make well informed-decisions;
b. Encouraging public
understanding, participation and dialog with respect to the rising
costs of health care services, technologies, and pharmaceuticals; the
role played by health insurance as both a financing mechanism for
health care and as a hedge against financial risk for the consumers
of health care; and potential solutions to the problems inherent in
the health insurance market (e.g., market concentration, increasing
costs, the growing population of uninsureds, market-driven changes to
insurance products (such as the growth of high deductible plans) and
segmentation of the insurance market due to state and federal laws);
and
c. Providing consumers timely
and user friendly access to administrative information, including
information related to benefits; eligibility; claim processing and
payment; financial responsibility, including deductible, coinsurance
and copayment information; and complaint and appeal procedures;
3. Efforts by health insurers
to promote collaboration among the state’s health insurers to
promote standardization of administrative practices and policy
priorities, including
a. Participation in
administrative standardization activities to increase efficiency and
simplify practices; and
b. Efforts to develop
standardized measurement and provider payment processes to promote
the goals set out in this regulation;
4. Directing resources,
including financial contributions, toward system-wide improvements in
the state’s health care system related to quality, access and
efficiency, including providing support to local collaboratives,
organizations and initiatives that promote quality, access and
efficiency;
5. Participating in the
development and implementation of public policy issues related to
health, including
a. Collaborating with state
and local health planning officials;
b. Participating in the
legislative and regulatory processes; and
c. Engaging the public in
policy debates and discussions
E. The factors enumerated in §
4.8(D) of this Part shall not be construed as limiting the
Commissioner from making a finding that other factors may be
considered when acting to further the interests set out in §
4.8(A) of this Part.
4.9 Affordable Health Insurance -
General
A. Consumers of health
insurance have an interest in stable, predictable, affordable rates
for high quality, cost efficient health insurance products. Achieving
an economic environment in which health insurance is affordable will
depend in part on improving the performance of the Rhode Island
health care system as a whole, including but not limited to the
following areas:
1. Improved primary care
supply, measured by the total number of primary care providers, and
by the percentage of physicians identified as primary care providers.
2. Reduced incidence of
hospitalizations for ambulatory care-sensitive conditions, and of
re-hospitalizations.
3. Reduced incidence of
emergency room visits for ambulatory care-sensitive conditions.
4. Reduced rates of premium
increase for fully insured, commercial health insurance.
B. In discharging the duties
of the Office, including but not limited to the Commissioner’s
decisions to approve, disapprove, modify or take any other action
authorized by law with respect to a health insurer’s filing of
health insurance rates or rate formulas under the provisions of R.I.
Gen. Laws Titles 27 or 42, the Commissioner may consider whether the
health insurer’s products are affordable, and whether the
carrier has implemented effective strategies to enhance the
affordability of its products.
C. In determining whether a
carrier’s health insurance products are affordable, the
Commissioner may consider the following factors:
1. Trends, including:
a. Historical rates of trend
for existing products;
b. National medical and health
insurance trends (including Medicare trends);
c. Regional medical and health
insurance trends; and
d. Inflation indices, such as
the Consumer Price Index and the medical care component of the
Consumer Price Index.
2. Price comparison to other
market rates for similar products (including consideration of rate
differentials, if any, between not-for-profit and for-profit insurers
in other markets);
3. The ability of lower-income
individuals to pay for health insurance;
4. Efforts of the health
insurer to maintain close control over its administrative costs;
5. Implementation of effective
strategies by the health insurer to enhance the affordability of its
products; and
6. Any other relevant
affordability factor, measurement or analysis determined by the
Commissioner to be necessary or desirable to carry out the purposes
of this Regulation.
D. In determining whether a
health insurance carrier has implemented effective strategies to
enhance the affordability of its products, the Commissioner may
consider the following factors:
1. Whether the health insurer
offers a spectrum of product choices to meet consumer needs.
2. Whether the health insurer
offers products that address the underlying cost of health care by
creating appropriate and effective incentives for consumers,
employers, providers and the insurer itself. Such incentives shall be
designed to promote efficiency in the following areas:
a. Creating a focus on primary
care, prevention and wellness.
b. Establishing active
management procedures for the chronically ill population.
c. Encouraging use of the
least cost, most appropriate settings; this goal is meant to apply in
the aggregate. Use of some higher cost providers and settings do
result in better outcomes and should not be discourage; and
d. Promoting use of evidence
based, quality care.
3. Whether the insurer employs
delivery system reform and payment reform strategies to enhance cost
effective utilization of appropriate services. Such delivery system
reform and payment reform strategies for insurers with greater than
10,000 covered lives shall include, but not be limited to complying
with the requirements of § 4.10 of this Part. Consideration may
also be given to:
a. whether the insurer
supports product offerings with simple and cost effective
administrative processes for providers and consumers;
b. whether the insurer
addresses consumer need for cost information through increasing the
availability of provider cost information and promoting public
conversation on trade-offs and cost effects of medical choices; and
c. whether the insurer allows
for an appropriate contribution to surplus.
E. The following constraints
on affordability efforts will be considered:
1. State and federal
requirements (e.g., state mandates, federal laws).
2. Costs of medical services
over which plans have limited control.
3. Health plan solvency
requirements.
4. The prevailing financing
system in United States (i.e., the third-party payor system) and the
resulting decrease in consumer price sensitivity.
4.10 Affordable Health Insurance –
Affordability Standards
A. Health Insurers with at
least 10,000 covered lives under a Health Insurance plan issued,
delivered, or renewed in Rhode Island shall comply with the delivery
system and payment reform strategy requirements set forth in this §
4.10 of this Part. For purposes of this § 4.10 of this Part
only, a Health Insurer shall not include a non-profit dental service
corporation, or a non-profit optometric service corporation.
B. Primary care spend
obligation. The purpose of this § 4.10(B) of this Part is to
ensure financial support for primary care providers in Rhode Island
that will assist in achieving the goals of these Affordability
Standards.
1. Each Health Insurer’s
annual, actual Primary Care Expenses, including both Direct and
Indirect Primary Care Expenses, shall be at least an amount
calculated as 10.7 percent of its annual medical expenses for all
insured lines of business. Of the Health Insurer’s annual
Primary Care Expense financial obligation, at least 9.7 percent of
the calculated amount shall be for Direct Primary Care Expenses. Each
Health Insurer’s Indirect Primary Care Expenses shall include
at least its proportionate share for the administrative expenses of
the medical home initiative endorsed by R.I. Gen. Laws Chapter
42-14.6, and for its proportionate share of the expenses of the
health information exchange established by R.I. Gen Laws Chapter
5-37.7.
a. The Commissioner may
reassess the primary care spending obligations set forth in §
4.10(B)(1)(A) of this Part in order to determine whether any
adjustments would better achieve the purposes of supporting primary
care as an affordability strategy. The reassessment may include a
determination of whether the Health Insurer's obligation to provide
financial support for the health information exchange established by
R.I. Gen. Laws Chapter 5-37.7 should continue. Any adjustments
proposed by the Commissioner shall be considered after soliciting
comments from stakeholders, and in connection with the annual rate
review process conducted by the Office. The reassessment may include
a national survey of health care systems with a reputation for high
performance and a commitment to primary care for the purposes of
quantifying primary care spending in those systems
2. Direct Primary Care
Expenses shall be accounted for as medical expenses on the Health
Insurer’s annual financial statements, and on its RI annual
health supplemental statement. Indirect Primary Care Expenses shall
be accounted for as administrative costs on the Health Insurer’s
annual financial statements, and on its RI annual health supplemental
statement. Indirect Primary Care Expenses may be deducted from each
statement’s administrative cost category as cost containment
expenses, in accordance with federal Medical Loss Ratio calculation
rules.
3. In meeting its annual
primary care spend obligations, a Health Insurer’s insured
covered lives shall not bear a financial burden greater than their
fair share of expenses that benefit both insured covered lives, and
non-insured covered lives whose health plans are administered by the
Health Insurer.
C. Primary care practice
transformation. The purpose of this § 4.10(C) of this Part is to
transform how primary care is delivered in Rhode Island, in order
that the goals of these Affordability Standards can be achieved.
While primary care practice transformation should not be considered
an ultimate goal in itself, the Commissioner finds that it produces
higher quality and potentially lower cost care and is a necessary
foundation for the effective transition of practices into Integrated
Systems of Care.
1. Each Health Insurer shall
take such actions as are necessary so that, no later than December
31, 2019, 80 percent of the Primary Care Practices contracting with
the Health Insurer are functioning as a Patient-Centered Medical
Home, as defined in § 4.3(A)(14) of this Part. Such actions
shall include but not be limited to contractual incentives for
practices participating in a Patient-Centered Medical Home, and
contractual disincentives for practices that are not participating in
such care transformation practices.
2. Care Transformation
Advisory Committee
a. The Commissioner shall
convene a Care Transformation Advisory Committee by February 28,
2015, by October 1, 2015, and by October 1 of each year thereafter.
The Committee shall be charged with developing an annual care
transformation plan designed to achieve the 80 percent requirement
established in § 4.10(C)(1) of this Part.
b. The Commissioner shall
designate as members of the Committee individuals or organizations
that can bring value to the work of the Committee representing:
(1) Relevant state agencies
and programs, such as the Office of the Health Insurance
Commissioner, the Medicaid program, and the state employees’
health benefit plan;
(2) Health Insurers;
(3) Hospital systems;
(4) Health care providers;
(5) Consumers;
(6) Businesses; and
(7) Any other individual or
organization that the Commissioner determines can bring value to work
of the Committee.
c. The care transformation
plan shall recommend, subject to approval by the Commissioner:
(1) annual care transformation
targets prior to 2019,
(2) the specific Health
Insurer activities, resources and financial supports needed by
providers to achieve the targets, and
(3) common standards and
procedures governing Health Insurer-primary care provider contractual
agreements, such as, for alignment of performance measures and Health
Insurer provision of information to practice. Such activities,
resources, and financial support may include: the creation of
community health teams to support small, independent practices with
care management resources, and the deployment of practice coaches to
provide technical assistance for primary care practices. The plan,
together with any stakeholder comments, shall be submitted to the
Commissioner on or before May 1, 2015 and before January 1 of each
year thereafter. Health Insurers shall comply with the requirements
of the plan approved by the Commissioner.
d. In the event that the
Committee’s stakeholders are unable to reach agreement on the
plan, or in the event that the plan is inadequate for achieving the
80 percent requirement established in § 4.10(C)(1) of this Part,
the Commissioner may adopt, and may require compliance by Health
Insurers with a suitable plan as a condition of approval of Health
Insurers’ rates.
3. Health Insurers shall fund
the care transformation plan approved by the Commissioner in
accordance with a formula established by the Commissioner that is
based upon the Health Insurer’s market share and other relevant
considerations. In meeting its annual financial obligation, the
Health Insurer’s insured covered lives shall not bear a
financial burden greater than their fair share of expenses that
benefit both insured covered lives, and other covered lives whose
health plans are administered by the Health Insurer. The Health
Insurer’s expenses in connection with the budget shall be
accounted for as Direct or Indirect Primary Care Expenses, as
applicable.
D. Payment reform
1. Population-based
contracting. Health Insurers shall take such actions as are necessary
to achieve the following population-based contracting targets:
a. By the end of calendar year
2015, at least 30 percent of insured covered lives shall be
attributed to a Population-Based Contract that is a Shared Savings
Contract, a Risk Sharing Contract, or a Global Capitation Contract.
b. By the end of calendar year
2016, at least 45 percent of insured covered lives shall be subject
to a Population-Based Contract with at least 10 percent of insured
covered lives attributed to a Population-Based Contract that is a
Risk Sharing Contract, or a Global Capitation Contract.
c. A Health Insurer shall not
enter into a Risk Sharing Contract or a Global Capitation contract
unless the Health Insurer has determined, in accordance with standard
operating procedures filed and approved by the Commissioner, that the
provider organization entering into the contract has the operational
and financial capacity and resources needed to assume clinical and
financial responsibility for the provision of covered services to
members attributable to the provider organization. At the reasonable
request of the provider organization, the Health Insurer shall
maintain the confidentiality of information which the Health Insurer
requests to make its determination. The Health Insurer shall
periodically review the provider organization's continuing ability to
assume such responsibilities. The Health Insurer shall maintain
contingency plans in the event the provider organization is unable to
sustain its ability to manage its responsibilities. The foregoing
shall not be construed to permit the transfer of insurance risk or
the transfer of delegation of the Health Insurer’s regulatory
obligations.
2. Alternative payment
methodologies
a. The purpose of this §
4.10(D)(2) of this Part is to significantly reduce the use of
fee-for-service payment as a payment methodology, in order to
mitigate fee-for-service volume incentives which unreasonably and
unnecessarily increase the overall cost of care, and to replace
fee-for-service payment with alternative payment methodologies that
provide incentives for better quality and more efficient delivery of
health services.
b. Health Insurers shall
increase annually their use of nationally recognized, alternative
payment methodology payments for hospital services, medical and
surgical services, and primary care services in accordance with a
schedule filed by the Health Insurer and approved or approved as
modified by the Commissioner during the annual rate review process. A
Health Insurer may request the Commissioner’s approval of other
effective alternative payment methodologies which have not been
nationally recognized.
c. The Commissioner shall
convene an Alternative Payment Methodology Committee by February 28,
2015, by October 1, 2015, and by October 1 each year thereafter. The
Committee shall be charged with developing a target and a target date
for increasing the use of alternative payment methodologies submitted
for the Commissioner’s approval by May 1, 2015, and by January
1 each year thereafter, and an annual alternative payment methodology
plan for achieving the target. The Committee that convenes on October
1, 2015 shall be tasked with developing an alternative payment plan
that specifically addresses medical and surgical specialty
professional providers.
d. The Commissioner shall
designate as members of the Committee individuals or organizations
representing:
(1) Relevant state agencies
and programs, such as the Office of the Health Insurance
Commissioner, the Medicaid program, and the state employees’
health benefit plan;
(2) Health Insurers;
(3) Hospital systems;
(4) Health care providers;
(5) Consumers;
(6) Businesses; and
(7) Any other individual or
organization that the Commissioner determines can bring value to work
of the Committee.
e. The alternative payment
methodology plan shall recommend subject to approval by the
Commissioner:
(1) annual targets prior to
achieving the ultimate target, and
(2) the type of payments that
should be considered alternative methodology payments (such as
bundled payments, prospective payments, and pay-for-performance
payments). The plan, together with any stakeholder comments, shall be
submitted to the Commissioner on or before May 1st of each year.
Health Insurer shall comply with the requirements of the plan
approved by the Commissioner.
f. In the event that the
Committee’s stakeholders are unable to reach agreement on the
plan, or in the event that the plan is inadequate for implementing
the schedule approved in § 4.10(D)(2)(b) of this Part, the
Commissioner may require adoption of a suitable plan as a condition
of approval of Health Insurers’ rates.
3. Measure alignment
a. The purpose of this §
4.10(D)(3) of this Part is to ensure consistency in the use of
quality measures in contracts between Health Insurers and health care
providers in Rhode Island, to reduce the administrative burden placed
on providers by the unaligned use of quality measures across payers,
to improve the quality of care by channeling clinical focus on core
areas of health care delivery, to formally adopt Aligned Measure Sets
to be used in contracts between Health Insurers and health care
providers in Rhode Island, and to articulate a process for annually
refining and updating the Aligned Measure Sets.
b. § 4.10(D)(3) of this
Part applies to contracts between health care providers, including
primary care providers, specialists, hospitals, and Integrated
Systems of Care and a Health Insurer which incorporate quality
measures into the payment terms of the contract and which are entered
into after July 1, 2017, or expire after July 1, 2017, or which would
expire after July 1, 2017 but for the amendment or renewal of the
contract (whether the renewal is effective pursuant to the terms of
a previously executed contract, or otherwise).
c. Health Insurers shall adopt
the Aligned Measure Sets for primary care, hospitals, and Accountable
Care Organizations (ACOs, otherwise known as Integrated Systems of
Care as defined in § 4.3(A)(12) of this Part) and any other
Aligned Measure Set developed pursuant to this § 4.10(D)(3) of
this Part.
(1) Health care provider
contracts which incorporate quality measures into the payment terms
shall include all measures designated as Core Measures in an Aligned
Measure Set.
(2) Health care provider
contracts which incorporate quality measures into the payment terms
shall not include any measures beyond those designated as Core
Measures in an Aligned Measure Set, with the exception of designated
Menu Measures. Menu Measures may be incorporated into the payment
terms of the contract at the mutual agreement of the Health Insurer
and contracted health care provider.
(3) In the event than an
Aligned Measure Set does not include any Core Measures, Health
Insurers shall limit selection of measures to Menu Measures.
d. The Commissioner shall
convene a Quality Measure Alignment and Review Committee (Committee)
by August 1 each year. The Committee shall be charged with developing
a plan, for consideration by the Commissioner, that:
(1) Proposes modifications, if
necessary, to existing Aligned Measure Sets to be used in contracts
between Health Insurers and health care providers in Rhode Island.
(2) Proposes measures as Core
Measures and Menu Measures.
(3) Proposes a work plan for
the development of Aligned Measure Sets for additional professional
health care provider specialties as determined necessary by the
Commissioner.
e. The Commissioner shall
designate as members of the Committee individuals or organizations
representing:
(1) relevant state agencies
and programs, including the Office, the Medicaid program, the Rhode
Island Department of Health, and the Department of Behavioral Health,
Developmental Disabilities and Hospitals;
(2) Health Insurers;
(3) Hospital systems;
(4) Health care providers;
(5) Consumers;
(6) Quality measure experts;
and/or
(7) Any other individual or
organization that the Commissioner determines can bring value to the
work of the Committee.
f. The plan, together with any
stakeholder comments, shall be submitted to the Commissioner on or
before October 1 of each year. Health Insurers shall comply with the
requirements of the plan adopted by the Commissioner.
g. The Commissioner shall
maintain the Aligned Measure Sets and publish them, along with any
supporting documentation, on the OHIC website.
4. Hospital contracts
a. Each Health Insurer shall
include in its hospital contracts the terms required by §
4.10(D)(4) of this Part.
b. This § 4.10(D)(4) of
this Part shall apply to contracts between a Health Insurer and a
hospital licensed in Rhode Island which are entered into, or which
expire after January 1, 2017, or which would expire but for the
amendment or renewal of the contract (whether the renewal is
effective pursuant to the terms of a previously executed contract, or
otherwise). To ensure compliance with this subsection in the event of
any hospital conversions pursuant to R.I. Gen. Laws Chapter 23-17.14,
the Health Insurer shall, in terms of contracting, treat the contract
of the successor hospital or entity as a continuation of the contract
of the predecessor hospital or entity with whom the Health Insurer
had contracted.
c. Hospital contracts shall
utilize unit-of-service payment methodologies for both inpatient and
outpatient services that realign payment to provide incentives for
efficient use of health services, and are derived from nationally
utilized payment practices other than fee-for-service. Nothing in
this requirement prevents contract terms that provide additional or
stronger payment incentives toward quality and efficiency such as
performance bonuses, bundled payments, global payments, or case
rates.
d. Hospital contracts shall
include a quality incentive program.
(1) The quality incentive
program shall include payment for attaining or exceeding mutually
agreed-to, sufficiently challenging performance levels for all Core
Measures within Aligned Measure Set for hospitals. For measures
beyond the Core Measures the Health Insurer shall limit selection of
measures to those listed as Menu Measures in the Aligned Measures Set
for hospitals.
(2) The measures, performance
levels, payment levels, and payment mechanisms must be articulated in
the contract.
(3) Incentive payments will
not be due and payable until the quality incentive measure targets
have been met or otherwise achieved by the hospital. A Health Insurer
may take interim payments in the event that interim quality
performance targets have been met; provided that the interim payments
must be commensurate with the achievement of the interim targets; and
provided further that if the annual quality performance targets have
not been achieved, the hospital shall be required to remit unearned
interim payments back to the Health Insurer.
e. Hospital contracts shall
include a provision that agrees on rates, and quality incentive
payments for each contract year, such that review and prior approval
by the Office of the Health Insurance Commissioner shall be required
if either:
(1) The average rate increase,
including estimated quality incentive payments, is greater than the
US All Urban Consumer All Items Less Food and Energy CPI
(“CPI-Urban”) percentage increase (determined by the
Commissioner by October 1 each year, based on the most recently
published United States Department of Labor data). Such percentage
increase shall be plus 1%, or
(2) Less than 50% of the
average rate increase is for expected quality incentive payments.
f. Hospital contracts shall
include terms that define the parties’ mutual obligations for
greater administrative efficiencies, such as improvements in claims
and eligibility verification processes, and identify commitments on
the part of each, and that require the parties to actively
participate in the Commissioner's Administrative Simplification Work
Group.
g. Hospital contracts shall
include terms that relinquish the right of either party to contest
the public release, by state officials or the parties to the contract
of the provisions of the contract demonstrating compliance with the
requirements of this § 4.10(D)(4) of this Part; provided that
the Health Insurer or other affected party may request the
Commissioner to maintain specific contract terms or portions thereof
as confidential, if properly supported with legal and factual
analysis justifying the claim of confidentiality.
5. Population-based contracts
a. This § 4.10(D)(5) of
this Part applies to Population-Based Contracts between an Integrated
System of Care and a Health Insurer which are entered into after July
1, 2015, or expire after July 1, 2015, or which would expire after
July 1, 2015 but for the amendment or renewal of the contract
(whether the renewal is effective pursuant to the terms of a
previously executed contract, or otherwise). Each Health Insurer
shall comply with the requirements of this § 4.10(D)(5) of this
Part.
b. Population-Based Contracts
shall include a provision that agrees on a budget for each contract
year, such that review and prior approval by the Office of the Health
Insurance Commissioner shall be required if any annual increase in
the total cost of care for services reimbursed under the contract,
after risk adjustment, exceeds the US All Urban Consumer All Items
Less Food and Energy CPI (“CPI-Urban”) percentage
increase (determined by the Commissioner as soon as practicable for
calendar year 2015 and by October 1 of each year, based on the most
recently published United States Department of Labor data). Such
percentage increase shall be plus 3.5% during calendar year 2015,
plus 3.0% during calendar year 2016, plus 2.5% during calendar year
2017, plus 2.0% during calendar year 2018, and plus 1.5% after
calendar year 2018.
c. Population-Based Contracts
shall include terms that relinquish the right of any party to contest
the public release, by state officials or the parties to the
contract, of the provisions of the contract demonstrating compliance
with the requirements of § 4.10(D)(5) of this Part; provided
that the Health Insurer or other affected party may request the
Commissioner to maintain specific contract terms or portions thereof
as confidential, if properly supported with legal and factual
analysis justifying the claim of confidentiality.
6. Nothing in §
4.10(D)(4) or (5) of this Part is intended to require that the Health
Insurer must contract with all hospitals and providers licensed in
Rhode Island. Consistent with statutes administered by the Department
of Health, Health Insurers must demonstrate the adequacy of their
hospital and provider network.
E. Waiver and modification
1. The Commissioner, upon
petition by a Health Insurer for good cause shown, or in his or her
discretion as necessary to carry out the purposes of the laws and
regulations administered by the Office, may modify or waive one or
more of the requirements of this Section. Any such modifications
shall be considered and made during the formal process of the
Commissioner’s review and approval of health insurance rates
filed by the Health Insurer.
2. Comment and accountability
a. On or before January 1 of
each year the Commissioner shall solicit comments from stakeholders,
and issue formal guidance concerning whether the population-based
contracting targets established in §§ 4.10(D)(1)(a) through
(c) of this Part, the population-based contract budget limits
established in § 4.10(D)(5)(b) of this Part, the care
transformation requirements established in § 4.10(C)(1) of this
Part, or the alternative payment requirements established in §
4.10(D)(2)(b) of this Part should be modified:
(1) To create or maintain an
effective incentive for hospitals and providers to participate in
care transformation, population-based contracts and alternative
payment arrangements; or
(2) To account for
unanticipated and profound macroeconomic events, or similarly
significant changes in systemic utilization or costs that are beyond
the ability of the Health Insurer to control, such that application
of the budget limit would be manifestly unfair.
b. A Health Insurer shall not
be held accountable for a violation of the population-based
contracting targets established in §§ 4.10(D)(1)(a) through
(c) of this Part, the population-based budget limit established in §
4.10(D)(5)(b) of this Part, the care transformation requirements
established in § 4.10(C)(1) of this Part, or the alternative
payment requirements established in § 4.10(D)(2)(b) of this Part
if the Health Insurer demonstrates to the satisfaction of the
Commissioner that compliance with any of these requirements was not
possible, notwithstanding the Health Insurer’s good faith and
reasonable efforts. The Health Insurer shall notify the Commissioner
and request a waiver under § 4.10(E)(1) of this Part, if
desired, as soon as any such circumstances arise.
F. Data collection and
evaluation
1. On or before 15 days
following the end of each quarter, each Health Insurer shall submit
to the Commissioner, in a format approved by the Commissioner, a
Primary Care Spend Report, a Care Transformation Report, and a
Payment Reform Report, including such data as is necessary to monitor
and evaluate the provisions of this Section. The Care Transformation
Report shall include data measuring the integration of behavioral
health care into Patient-Centered Medical Homes and other provider
practices, and measuring the impact of such integration on health
care quality and cost.
2. On or before October 1 and
annually thereafter, the Office shall present to the Health Insurance
Advisory Council a monitoring report describing the status of
progress in implementing the Affordability Standards.
3. During calendar year 2018,
the Office shall conduct a comprehensive evaluation of the
Affordability Standards, together with recommendations for achieving
the health care quality and affordability goals of the Office.
Following completion of the comprehensive evaluation, the
Commissioner shall request the Health Insurance Advisory Council to
review the evaluation and make recommendations to the Commissioner
for any revisions to the Affordability Standards.
4. Health Insurers shall
provide to the Office, in a timely manner and in the format requested
by the Commissioner, such data as the Commissioner determines is
necessary to evaluate the Affordability Standards, to monitor
compliance with the Affordability Standards established in this §
4.10 of this Part, and to evaluate and monitor the activities
necessary to implement the State Innovation Models Grant, which has
been awarded to Rhode Island by the federal Centers for Medicare and
Medicaid Services. Such data may include any hospital or provider
reimbursement contract, and any data relating to a hospital’s
attainment of quality and other performance-based measures as
specified in quality incentive programs referenced in §§
4.10(D)(4)(d) and (e) of this Part.
5. To the extent possible, the
Office shall use the All Payer Claims Database authorized by R.I.
Gen. Laws Chapter 23-17.17 to collect data required by this
subsection.
4.11 Administrative Simplification
A. Administrative
Simplification Task Force
1. An Administrative
Simplification Task Force is established to make recommendations to
the Commissioner for streamlining health care administration so as to
be more cost-effective, and less time-consuming for hospitals,
providers, consumers, and insurers, and to carry out the purposes of
R.I. Gen. Laws § 42-14.5-3(h). The Commissioner shall appoint as
members of the Task Force representatives of hospitals, physician
practices, community behavioral health organizations, each health
insurer, consumers, businesses, and other affected entities, as
necessary and relevant to the issues and work of the Task Force. The
Task force 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 Chair
or Co-Chairs of the Task Force shall be selected annually by its
members.
2. At the discretion of, and
as directed by the Commissioner, the Task Force shall convene to
consider issues of streamlining health care administration. Members
of the Task Force may propose and substantiate such issues for review
and inclusion in a work plan, together with such data and analysis
that demonstrates the need to address the issue. The Task Force will
meet during September, October and November to make its
recommendations to the Commissioner for resolving issues identified
in the work plan no later than December 31 of each year. If the Task
Force agrees on recommendations for resolving the identified issues,
those recommendations will be submitted to the Commissioner for her
or his consideration. If the Task Force cannot agree on
recommendations, a report will be submitted to the Commissioner on
the Task Force’s activities, together with comments by members
concerning the identified issues. The Commissioner shall consider the
report of the Task Force, and may adopt such regulations as are
necessary to carry out the purposes of this section, and the purposes
of R.I. Gen. Laws § 42-14.5-3(h).
B. Retroactive terminations
1. The purpose of this
Subsection is to reduce administrative burdens as well as the
associated costs in connection with the practice of retroactive
terminations, create an incentive for efficiencies among stakeholders
for timeliness of notices of termination, and establish an equitable
balance of financial liability among health insurers, employers and
enrollees in light of the unavailability of real time, accurate
eligibility information.
2. Health Insurers shall cease
the administrative process of seeking recoupment of payment from
providers in the case of retroactive terminations of an enrollee,
except when verified by the Health Insurer that the enrollee is
covered by another Health Insurer for the service provided during the
retroactivity period. For purposes of this Subsection, the term
Health Insurer includes state and federal government programs, a
self-insured benefit plan, and an entity providing COBRA coverage.
3. Health insurers may include
the reasonable cost of retroactive terminations into their filed
rates. Health insurers shall establish reasonable policies and
procedures for providers to conduct eligibility checks at the time
services are provided. If the health issuer requires by
administrative policy or provider contract that the eligibility check
is a prerequisite to the application of the provisions of this
subsection, the Health Insurer must also provide an administratively
simple mechanism, approved by the Commissioner, for the provider to
document that eligibility was checked by the provider at the time of
service. In addition, Health Insurers may include reasonable
adjustments attributable to the Insurer’s financial burden with
respect to retroactive terminations with its employer groups, so long
as the process does not include recoupment of payments from providers
not permitted under this § 4.11(B) of this Part in the event of
retroactive termination.
C. Coordination of benefits
1. The purpose of this
Subsection is to improve on the accuracy and timeliness of
information when an enrollee is covered by more than one Health
Insurer, and to communicate to affected parties which Insurer’s
coverage is primary.
2. Health Insurers shall:
a. accept a common
coordination of benefits (“COB”) form approved by the
Commissioner;
b. submit to the Commissioner
for approval a procedure to inform contracted providers of a manual
and electronic use of the common COB form in provider settings;
c. not alter the common COB
form, except for use internally by the Insurer, or on the Insurer’s
website, and in these excepted instances only the Insurer’s
name and contact information may be added to the form;
d. accept the common COB form
submitted by the provider on behalf of patient; and
e. no later than January 1,
2016, include a flag within the insurance eligibility look-up section
of its website indicating the most recent information available to
the Insurer on additional coverage by another Health Insurer, the
last update of an enrollee’s COB information. Health Insurers
may continue to use their own COB form as part of an annual member
survey.
3. Health insurers shall
participate in a centralized registry for coverage information
designated by the Commissioner. If the Centers for Medicare and
Medicaid Services designates a centralized registry, Health Insurers
shall participate in the CMS-designated registry no later than one
calendar year from the date of use of the designated registry by
Medicare, unless such deadline is extended by the Commissioner.
4. Health insurers shall
establish written standards and procedures to notify providers of all
eligibility determinations electronically and telephonic at the time
eligibility determination is requested by the provider.
D. Appeals of “timely
filing” denials
1. This Subsection is intended
to permit a provider to appeal the denial of a claim for failure to
file the claim within the time period provided for in the
participation agreement when the provider exercised due diligence in
submitting the claim in a timely manner, or when the claim is filed
late due to no fault of the provider.
2. Health insurers shall
accept a provider appeal of a denial for failure to meet timely claim
filing requirements so long as the claim is submitted to the correct
Health Insurer within 180 days of the date of receipt by the provider
of a denial from the initial, incorrect Health Insurer, provided that
the initial claim was submitted to the incorrect Health Insurer
within 180 days of the date of service.
3. Health Insurers shall not
deny the appeal of a claim based on failure to meet timely filing
requirements in the event that the provider submits all of the
following documentation:
a. A copy of the timely filing
denial;
b. Written documentation that
the provider billed another Health Insurer or the patient within at
least 180 days of the date of service;
c. If the provider billed
another Health Insurer, an electronic remittance advice, explanation
of benefits or other communication from the plan confirming the claim
was denied and not paid, or inappropriate payment was returned;
d. If the provider billed the
patient, acceptable documentation may include:
(1) benefit determination
documents from another carrier,
(2) a copy of provider’s
billing system information documenting proof of an original carrier
claim submission,
(3) a patient billing
statement that includes initial claim send date and the date of
service, or
(4) documentation as to the
exact date the provider was notified of member’s correct
coverage, who notified the provider, how the provider was notified
and a brief, reasonable statement as to why the provider did not
initially know the patient was not covered by carrier. Practice
management and billing system information can be used as supportive
documentation for these purposes.
4. Health Insurers shall
notify providers that upon submission of the information required by
§ 4.11(D)(3) of this Part the Health Insurer shall not deny the
appeal of a claim due to the failure to file the claim in a timely
manner. Nothing in this Subsection precludes the denial of a claim
for other reasons unrelated to the timeliness of filing the claim.
a. Health insurers shall
utilize a standardized appeal checklist approved by the Commissioner
when informing providers of a timely filing denial and what needs to
be submitted to appeal that denial. The checklist and appeal
submissions shall be made available for both manual and electronic
processing.
b. Health Insurers may
implement the requirements of this Subsection either by amendments to
their claims processing system, or by amendments to their provider
appeal policies and procedures.
E. Medical records management
1. The purpose of this
Subsection is to maintain the confidentiality of patient information
during the process of transmittal of medical records between
providers and health insurers, and to reduce the administrative
burden of both the providers and carriers with regard to medical
record submissions.
2. Health insurers shall
comply with all state and federal laws and regulations relating to
requests for written clinical and medical record information from
patients or providers.
3. Health insurer requests
for medical records shall specify:
a. What medical record
information is being requested;
b. Why the medical record
information being requested meets ‘need to know’
requirements under The Privacy and Individually Identifiable Health
Information, 45 C.F.R. § 164.500-534 (2013); and
c. Where the medical record is
to be sent via mailing addresses, fax or electronically.
4. Health Insurers shall
establish a mechanism to provide for verification of the receipt of
the medical records when a provider requests such verification.
5. Upon a provider’s
request, the Health Insurer disclose when a medical record was
mis-sent or mis-addressed. In such events the Health Insurer shall
destroy the mis-sent of mis-addressed records.
6. Upon a provider’s
request, Health Insurers shall provide:
a. a clear listing of contact
information (including mailing address, telephone number, fax number
or email address) as to where medical records are to be sent,
b. what specific records are
to be sent, and
c. why the records are needed
and permitted to be used in accordance with 45 C.F.R. §
164.500-534.
4.12 Price Disclosure
A. The purpose of this Section
is to empower consumers who are enrollees in a health insurance plan
to make cost effective decisions concerning their health care, and to
enable providers to make cost-effective treatment decisions on behalf
of their patients who are enrollees of a health insurance plan,
including referral and care coordination decisions.
B. A Health Insurer shall not
enforce a provision in any participating provider agreement which
purports to obligate the Health Insurer or health care provider to
keep confidential price information requested by a health care
provider for the purpose of making cost-effective clinical referrals,
and for the purpose of making other care coordination or treatment
decisions on behalf of their patients who are enrollees in the health
benefit plan of the Health Insurer.
C. At the request of a health
care provider acting on behalf of an enrollee-patient, a Health
Insurer shall disclose in a timely manner to the health care provider
such price information as the provider determines is necessary to
make cost-effective treatment decisions on behalf of their patients,
including clinical referrals, care coordination, and other treatment
decisions.
D. A Health Insurer may adopt
reasonable policies and procedures designed to limit the disclosure
of price information for unauthorized purposes.
E. Each Health Insurer shall
file for the Commissioner's approval its Comprehensive Price
Transparency Plan. A Comprehensive Price Transparency Plan shall
empower consumers and health care providers to make informed and
cost-effective health care decisions with respect to the Health
Insurer’s network of participating providers, facilities and
vendors. The Plan shall:
1. Identify the health care
services, products and supplies subject to price disclosure under the
Plan, including but not limited to hospital in-patient and
out-patient services, physician services, other health care provider
services, medical imaging services, laboratory services, prescription
drug prices, durable medical equipment, and medical supplies;
2. Identify the health
services, products and supplies, if any, that are not subject to
price disclosure under the Plan, a reasonable basis for not including
those services, products and supplies within the Plan, and a time
table for including those services, products and supplies in the
Plan; and
3. Disclose price information
with respect to services reimbursed on a fee-for service basis, as
well as services reimbursed by alternative reimbursement mechanisms.
4.13 Severability
If any section, term, or
provision of this regulation is adjudged invalid for any reason, that
judgment shall not affect, impair, or invalidate any remaining
section, term, or provision, which shall remain in full force and
effect.
4.14 Construction
A. This regulation shall be
liberally construed to give full effect to the purposes stated in
R.I. Gen. Laws § 42-14.5-2.
B. This regulation shall not
be interpreted to limit the powers granted the Commissioner by other
provisions of the law.