AN ACT RELATING TO STATE AFFAIRS AND GOVERNMENT -- THE RHODE ISLAND HEALTH CARE REFORM ACT OF 2004--HEALTH INSURANCE OVERSIGHT
This act would have the health insurance commissioner adopt a uniform set of medical criteria for prior authorization and create required forms to be used by a health insurer, including telemedicine coverage.
2020-02-25: Introduced, referred to Senate Health and Human Services
2020-03-06: Scheduled for hearing and/or consideration (03/10/2020)
2020-03-10: Committee recommended measure be held for further study
2020-05-22: Scheduled for hearing and/or consideration (05/27/2020)
2020-05-26: Proposed Substitute
2020-05-27: Committee recommends passage of Sub A
2020-06-15: Placed on Senate Calendar
2020-06-15: Placed on Senate Calendar (06/17/2020)
2020-06-17: Senate passed Sub A
2020-06-18: Referred to House Finance
Changes since original draft
2020 – S 2525
S T A T E O F R H O D E I S L A N D
IN GENERAL ASSEMBLY
JANUARY SESSION, A.D. 2020
A N A C T
RELATINGTO STATE AFFAIRSAND GOVERNMENT– THERHODEISLAND HEALTH
CARE REFORM ACT OF 2004–HEALTH INSURANCE OVERSIGHT
Introduced By: Senators Miller, Goldin, Valverde, Satchell, and Goodwin
Date Introduced: February 25, 2020
Referred To: Senate Health & Human Services
It is enacted by the GeneralAssembly as follows:
SECTION 1. Section 42-14.5-3 of the General Laws in Chapter 42-14.5 entitled "The Rhode Island Health Care Reform Act of 2004 - Health Insurance Oversight" is hereby amended to read as follows:
42-14.5-3. Powers and duties.
The health insurance commissioner shall have the following powers and duties:
(a) To conduct quarterly public meetings throughout the state, separate and distinct from rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers licensed to provide health insurance in the state;the effects of such rates,services, and operations on consumers, medical care providers, patients, and the market environment in which the insurers operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less than ten (10) days ofthe hearing(s) shallgo to the generalassembly, the governor, the Rhode Island Medical Society, the Hospital Association of Rhode Island, the director of health, the attorney general, andthe chambers of commerce. Public notice shall be posted on the department's website and given in the newspaper of generalcirculation, and to any entity in writing requesting notice.
(b) Tomake recommendations to the governor and the house of representatives and senate finance committees regarding health-care insurance and the regulations, rates, services, administrative expenses, reserve requirements, and operations of insurers providing health insurance in the state, and to prepare or comment on, upon the request of the governor or chairpersons of the house or senate finance committees, draft legislation to improve the regulation of health insurance. In making the recommendations, the commissioner shall recognize that it is the intent of the legislature thatthe maximum disclosure be provided regarding the reasonableness of individual administrative expenditures as well as total administrative costs. The commissioner shall make recommendations on the levels of reserves,including consideration of: targetedreserve levels; trends in the increase or decrease of reserve levels; and insurer plans for distributing excess reserves.
(c) Toestablish a consumer/business/labor/medical advisory council to obtain information and present concerns of consumers, business, and medical providers affectedby health-insurance decisions. The council shall develop proposals to allow the market for small business health insurance to be affordable and fairer. The council shall be involved in the planning and conduct of the quarterlypublic meetings in accordancewithsubsection (a).Theadvisorycouncil shall develop measures to inform small businesses of an insurance complaint process to ensure that small businesses that experience rate increases in a given year may requestand receive a formalreview by the department. The advisory council shall assess views of the health-provider community relative to insurance rates of reimbursement, billing, and reimbursement procedures, and the insurers' role in promoting efficient and high-quality health care. The advisory council shall issue an annual report of findings and recommendations to the governor and the general assembly and present its findings at hearings before the house and senate finance committees. The advisory council is to be diverse in interests and shall include representatives of community consumer organizations; small businesses, other than those involved in the sale of insurance products; and hospital, medical, and other health-provider organizations. Such representativesshallbe nominated by their respective organizations. The advisory council shall be co-chaired by the health insurance commissioner and a community consumer organization or small business member to be electedby the full advisory council.
(d) To establish andprovide guidance and assistance toa subcommittee ("the professional- provider-health-plan work group") of the advisory council created pursuant to subsection (c), composedofhealth-careprovidersandRhodeIslandlicensedhealthplans.Thissubcommitteeshall include in its annual report and presentation before the house and senate finance committees the following information:
(1) A method wherebyhealth plans shall disclose to contractedproviders the fee schedules used to provide payment to those providers for services rendered to covered patients;
(2) A standardized provider application and credentials-verification process, for the purpose of verifying professional qualifications of participating health-care providers;
(3) The uniform health plan claim form utilized by participating providers;
(4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit hospital or medical-service corporations, as defined by chapters 19 and 20 of title 27, to make facility-specific data and other medical service-specific data available in reasonably consistent formats to patients regarding quality and costs. This information would help consumers make informed choices regarding the facilities andclinicians or physician practices atwhich to seekcare. Among the items considered would be the unique health services and other public goods provided by facilities and clinicians or physician practices in establishing the most appropriate cost comparisons;
(5) All activities related to contractual disclosure to participating providers of the mechanisms for resolving health plan/provider disputes;
(6) The uniform process being utilized for confirming, in real time, patient insurance enrollment status, benefits coverage, including co-pays and deductibles;
(7) Information related totemporary credentialing of providers seeking to participate in the plan's network and the impact of the activity on health-plan accreditation;
(8) The feasibility of regular contract renegotiations betweenplans and the providers in their networks; and
(9) Efforts conducted related to reviewing impact of silent PPOs on physician practices.
(e) To enforce the provisions of Title 27 and Title 42 as set forth in § 42-14-5(d).
(f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17.
(g) To analyze the impact of changing the rating guidelines and/or merging the individual health-insurance market, as defined in chapter 18.5 of title 27, and the small-employer-health- insurance market, as defined in chapter 50 of title 27, in accordance with the following:
(1) The analysis shall forecast the likely rate increases required to effect the changes recommended pursuant to the preceding subsection (g) in the direct-pay market and small- employer-health-insurance marketover the nextfive (5) years,basedon the currentrating structure and current products.
(2) The analysis shall include examining the impact of merging the individual and small- employer markets on premiums charged to individuals and small-employer groups.
(3) The analysis shall include examining the impact on rates in eachof the individual and small-employer health-insurance markets and the number of insureds in the context of possible changes to the rating guidelines used for small-employer groups, including: community rating principles;expandingsmall-employer ratebondsbeyondthecurrentrange;increasingtheemployer group size in the small-group market; and/or adding rating factors for broker and/or tobacco use.
(4) The analysis shall include examining the adequacy of currentstatutory and regulatory oversight of the rating process and factors employed by the participants in the proposed, new merged market.
(5) The analysis shall include assessment of possible reinsurance mechanisms and/or federalhigh-riskpoolstructuresandfundingtosupportthehealth-insurancemarketinRhodeIsland by reducing the risk of adverse selection and the incremental insurance premiums chargedfor this risk, and/or by making health insurance affordable for a selected at-risk population.
(6) The health insurance commissioner shall work with an insurance market merger task force to assist with the analysis. The task force shall be chaired by the health insurance commissioner and shall include, but not be limited to, representatives of the generalassembly, the business community, small-employer carriers as definedin § 27-50-3, carriers offering coverage in the individual market in Rhode Island, health-insurance brokers, and members of the general public.
(7) For the purposes of conducting this analysis, the commissioner may contract with an outside organization with expertise in fiscalanalysis of the private-insurance market. Inconducting its study, the organization shall, to the extentpossible, obtain and use actualhealth-plan data. Said data shall be subject to state and federallaws and regulations governing confidentiality of health care and proprietary information.
(8) The taskforce shallmeet as necessary and include its findings in the annualreport, and the commissioner shall include the information in the annual presentation before the house and senate finance committees.
(h) To establish and convene a workgroup representing health-care providers and health insurers for the purpose of coordinating the development of processes,guidelines, and standards to streamline health-care administration thatare to be adopted by payors andproviders of health-care services operating in the state. This workgroup shall include representatives with expertise who would contribute to the streamlining of health-care administration and who are selected from hospitals, physician practices,communitybehavioral-health organizations, eachhealth insurer, and other affectedentities. The workgroup shall also include atleastone designee eachfromthe Rhode Island Medical Society, Rhode Island Council of Community Mental Health Organizations, the Rhode Island Health Center Association, and the Hospital Association of Rhode Island. The workgroup shall consider and make recommendations for:
(1) Establishing a consistent standard for electronic eligibility and coverage verification. Such standard shall:
(i) Include standards for eligibility inquiry and response and, wherever possible, be consistent with the standards adopted by nationally recognized organizations, such as the Centers for Medicare and Medicaid Services;
(ii)Enableprovidersandpayorstoexchangeeligibilityrequestsandresponsesonasystem- to-system basis or using a payor-supported web browser;
(iii) Provide reasonably detailed information on a consumer's eligibility for health-care coverage;scope of benefits; limitations andexclusions provided under that coverage;cost-sharing requirements for specific services at the specific time of the inquiry; current deductible amounts; accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and other information required for the provider to collect the patient's portion of the bill;
(iv) Reflectthe necessarylimitations imposed on payors by the originator of the eligibility and benefits information;
(v) Recommend a standard or common process to protect all providers from the costs of services to patients who are ineligible for insurance coverage in circumstances where a payor provides eligibility verification based on bestinformation available to the payor at the date of the request of eligibility.
(2) Developing implementation guidelines and promoting adoption of the guidelines for:
(i) The use of the National Correct Coding Initiative code-edit policy by payors and providers in the state;
(ii) Publishing any variations from codes and mutually exclusive codes by payors in a manner that makes for simple retrieval and implementation by providers;
(iii) Use of Health Insurance Portability and Accountability Act standard group codes, reason codes, and remark codes by payors in electronic remittances sent to providers;
(iv) The processing of corrections to claims by providers and payors.
(v) A standard payor-denial review process for providers when they request a reconsideration of a denial of a claim that results from differences in clinical edits where no single, common-standards body or processexists and multipleconflicting sources are in use by payors and providers.
(vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual payor's ability to employ, and not disclose to providers, temporary code edits for the purpose of detecting and deterring fraudulent billing activities. The guidelines shall require that each payor disclose to the provider its adjudication decision on a claim that was denied or adjusted based on the application of such edits and that the provider have access to the payor's review and appeal process to challenge the payor's adjudication decision.
(vii) Nothing in this subsection shall be construed to modify the rights or obligations of payors or providers with respectto procedures relating to the investigation, reporting, appeal, or prosecution under applicable law of potentially fraudulent billing activities.
(3) Developing andpromoting widespread adoption by payors and providers of guidelines to:
(i) Ensure payors do not automatically deny claims for services when extenuating circumstances make it impossible for the provider to obtain a preauthorization before services are performed or notify a payor within an appropriate standardized timeline of a patient's admission;
(ii) Require payors to use common and consistent processes and time frames when responding toprovider requests for medicalmanagement approvals. Whenever possible, suchtime frames shall be consistent with those established by leading national organizations and be based upon the acuity of the patient's needfor care or treatment. For the purposes of this section, medical management includes prior authorization of services, preauthorization of services, precertification of services, post-service review, medical-necessity review, and benefits advisory;
(iii) Develop, maintain, and promote widespread adoption of a single, common website where providers can obtain payors' preauthorization, benefits advisory, and preadmission requirements;
(iv) Establish guidelines for payors to develop and maintain a website that providers can use to request a preauthorization, including a prospective clinical necessity review; receive an authorization number; and transmit an admission notification.
(4) To provide a report to the house and senate, on or before January 1, 2017, with recommendations for establishing guidelines and regulations for systems that give patients electronic access to their claims information, particularly toinformation regarding their obligations to pay for received medicalservices, pursuant to 45 C.F.R. 164.524.
(i) To issue an anti-cancer medication report. Not later than June 30, 2014 and annually thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate committee on health and human services, and the house committee on corporations, with: (1) Information on the availability in the commercial market of coverage for anti-cancer medication options; (2) For the state employee's health benefit plan, the costs of various cancer-treatment options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member utilization and cost-sharing expense.
(j) To monitor the adequacy of eachhealth plan's compliance with the provisions of the federal Mental Health Parity Act, including a review of related claims processing and reimbursement procedures. Findings, recommendations, and assessments shall be made available to the public.
(k) To monitor the transition from fee-for-service andtoward global and other alternative payment methodologies for the payment for health-care services. Alternative payment methodologies should be assessed for their likelihood to promote access to affordable health insurance, health outcomes, and performance.
(l) To report annually, no later than July 1, 2014, then biannually thereafter,on hospital payment variation, including findings and recommendations, subject to available resources.
(m) Notwithstanding any provision of the general or public laws or regulation to the contrary, provide a reportwith findings andrecommendations tothe president of the senate andthe speaker of the house, on or before April 1, 2014, including, but not limited to, the following information:
(1) The impact of the current, mandated health-care benefits as defined in §§ 27-18-48.1, 27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41, of title 27, and §§ 27- 18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health insurance for fully insured employers, subject to available resources;
(2) Current provider and insurer mandates that are unnecessary and/or duplicative due to the existing standards of care and/or delivery of services in the health-care system;
(3) A state-by-state comparison of health-insurance mandates and the extent to which Rhode Island mandates exceed other states benefits; and
(4) Recommendations for amendments to existing mandatedbenefits based on the findings in (m)(1), (m)(2), and (m)(3) above.
(n) On or before July 1, 2014, the office of the health insurance commissioner, in collaboration with the director of health and lieutenant governor's office, shall submit a report to the general assembly and the governor to inform the design of accountable care organizations (ACOs) in Rhode Island as unique structures for comprehensive health-care delivery and value- based payment arrangements, that shallinclude, but not be limited to:
(1) Utilization review;
(2) Contracting; and
(3) Licensing and regulation.
(o) On or before February 3, 2015, the office of the health insurance commissioner shall submit a report to the general assembly and the governor that describes, analyzes, and proposes recommendations toimprove compliance of insurers with the provisions of § 27-18-76 with regard to patients with mental-health and substance-use disorders.
(p) To work to ensure the health insurance coverage of behavioral health care under the same terms and conditions as other health care, and to integrate behavioral health parity requirements into the office of the health insurance commissioner insurance oversight and health care transformation efforts.
(q) To work with other state agencies to seekdelivery systemimprovements that enhance access to a continuum of mental-health and substance-use disorder treatment in the state; and integrate that treatment with primary and other medicalcare to the fullest extent possible.
(r) To directinsurers towardpolicies andpractices thataddress the behavioral health needs of the public and greater integration of physical and behavioral health care delivery.
(s) The office of the health insurance commissioner shall conduct ananalysis of the impact of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and submit a report of its findings to the generalassembly on or before June 1, 2023.
(t) On or before January 1, 2021, the office of the health insurance commissioner shall adopt a uniform set of medical criteria for prior authorization and create and disseminate a standardized electronic or written prior authorization form that shall be used by a health insurer whenever prior authorization is required by the health insurer.
SECTION 2. This act shall take effect upon passage.
BY THE LEGISLATIVE COUNCIL
A N A C T
RELATINGTO STATE AFFAIRSAND GOVERNMENT – THERHODEISLAND HEALTH
CARE REFORM ACT OF 2004–HEALTH INSURANCE OVERSIGHT
This act would have the health insurance commissioner adopt a uniform set of medical criteria for prior authorization and create required form to be used by a health insurer.
This act would take effect upon passage. ======== LC004557 ========
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