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Rhode Island Senate Bill S0290

Rhode Island 2023 Regular Session

Rhode Island Senate Bill S0290 Compare Versions

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99 S T A T E O F R H O D E I S L A N D
1010 IN GENERAL ASSEMBLY
1111 JANUARY SESSION, A.D. 2023
1212 ____________
1313
1414 A N A C T
1515 RELATING TO STATE AFFAIRS AND GOVERNME NT -- THE RHODE ISLAND HEALTH
1616 CARE REFORM ACT OF 2004 -- HEALTH INSURANCE OVE RSIGHT
1717 Introduced By: Senators DiMario, Pearson, LaMountain, Miller, Valverde, Lauria,
1818 Lawson, Murray, Euer, and Ujifusa
1919 Date Introduced: February 16, 2023
2020 Referred To: Senate Health & Human Services
2121
2222
2323 It is enacted by the General Assembly as follows:
2424 SECTION 1. Section 42-14.5-3 of the General Laws in Chapter 42-14.5 entitled "The 1
2525 Rhode Island Health Care Reform Act of 2004 — Health Insurance Oversight" is hereby amended 2
2626 to read as follows: 3
2727 42-14.5-3. Powers and duties. 4
2828 The health insurance commissioner shall have the following powers and duties: 5
2929 (a) To conduct quarterly public meetings throughout the state, separate and distinct from 6
3030 rate hearings pursuant to § 42-62-13, regarding the rates, services, and operations of insurers 7
3131 licensed to provide health insurance in the state; the effects of such rates, services, and operations 8
3232 on consumers, medical care providers, patients, and the market environment in which the insurers 9
3333 operate; and efforts to bring new health insurers into the Rhode Island market. Notice of not less 10
3434 than ten (10) days of the hearing(s) shall go to the general assembly, the governor, the Rhode Island 11
3535 Medical Society, the Hospital Association of Rhode Island, the director of health, the attorney 12
3636 general, and the chambers of commerce. Public notice shall be posted on the department’s website 13
3737 and given in the newspaper of general circulation, and to any entity in writing requesting notice. 14
3838 (b) To make recommendations to the governor and the house of representatives and senate 15
3939 finance committees regarding healthcare insurance and the regulations, rates, services, 16
4040 administrative expenses, reserve requirements, and operations of insurers providing health 17
4141 insurance in the state, and to prepare or comment on, upon the request of the governor or 18
4242
4343
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4545 chairpersons of the house or senate finance committees, draft legislation to improve the regulation 1
4646 of health insurance. In making the recommendations, the commissioner shall recognize that it is 2
4747 the intent of the legislature that the maximum disclosure be provided regarding the reasonableness 3
4848 of individual administrative expenditures as well as total administrative costs. The commissioner 4
4949 shall make recommendations on the levels of reserves, including consideration of: targeted reserve 5
5050 levels; trends in the increase or decrease of reserve levels; and insurer plans for distributing excess 6
5151 reserves. 7
5252 (c) To establish a consumer/business/labor/medical advisory council to obtain information 8
5353 and present concerns of consumers, business, and medical providers affected by health insurance 9
5454 decisions. The council shall develop proposals to allow the market for small business health 10
5555 insurance to be affordable and fairer. The council shall be involved in the planning and conduct of 11
5656 the quarterly public meetings in accordance with subsection (a). The advisory council shall develop 12
5757 measures to inform small businesses of an insurance complaint process to ensure that small 13
5858 businesses that experience rate increases in a given year may request and receive a formal review 14
5959 by the department. The advisory council shall assess views of the health provider community 15
6060 relative to insurance rates of reimbursement, billing, and reimbursement procedures, and the 16
6161 insurers’ role in promoting efficient and high-quality health care. The advisory council shall issue 17
6262 an annual report of findings and recommendations to the governor and the general assembly and 18
6363 present its findings at hearings before the house and senate finance committees. The advisory 19
6464 council is to be diverse in interests and shall include representatives of community consumer 20
6565 organizations; small businesses, other than those involved in the sale of insurance products; and 21
6666 hospital, medical, and other health provider organizations. Such representatives shall be nominated 22
6767 by their respective organizations. The advisory council shall be co-chaired by the health insurance 23
6868 commissioner and a community consumer organization or small business member to be elected by 24
6969 the full advisory council. 25
7070 (d) To establish and provide guidance and assistance to a subcommittee (“the professional-26
7171 provider-health-plan work group”) of the advisory council created pursuant to subsection (c), 27
7272 composed of healthcare providers and Rhode Island licensed health plans. This subcommittee shall 28
7373 include in its annual report and presentation before the house and senate finance committees the 29
7474 following information: 30
7575 (1) A method whereby health plans shall disclose to contracted providers the fee schedules 31
7676 used to provide payment to those providers for services rendered to covered patients; 32
7777 (2) A standardized provider application and credentials verification process, for the 33
7878 purpose of verifying professional qualifications of participating healthcare providers; 34
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8282 (3) The uniform health plan claim form utilized by participating providers; 1
8383 (4) Methods for health maintenance organizations, as defined by § 27-41-2, and nonprofit 2
8484 hospital or medical-service corporations, as defined by chapters 19 and 20 of title 27, to make 3
8585 facility-specific data and other medical service-specific data available in reasonably consistent 4
8686 formats to patients regarding quality and costs. This information would help consumers make 5
8787 informed choices regarding the facilities and clinicians or physician practices at which to seek care. 6
8888 Among the items considered would be the unique health services and other public goods provided 7
8989 by facilities and clinicians or physician practices in establishing the most appropriate cost 8
9090 comparisons; 9
9191 (5) All activities related to contractual disclosure to participating providers of the 10
9292 mechanisms for resolving health plan/provider disputes; 11
9393 (6) The uniform process being utilized for confirming, in real time, patient insurance 12
9494 enrollment status, benefits coverage, including co-pays and deductibles; 13
9595 (7) Information related to temporary credentialing of providers seeking to participate in the 14
9696 plan’s network and the impact of the activity on health plan accreditation; 15
9797 (8) The feasibility of regular contract renegotiations between plans and the providers in 16
9898 their networks; and 17
9999 (9) Efforts conducted related to reviewing impact of silent PPOs on physician practices. 18
100100 (e) To enforce the provisions of title 27 and title 42 as set forth in § 42-14-5(d). 19
101101 (f) To provide analysis of the Rhode Island affordable health plan reinsurance fund. The 20
102102 fund shall be used to effectuate the provisions of §§ 27-18.5-9 and 27-50-17. 21
103103 (g) To analyze the impact of changing the rating guidelines and/or merging the individual 22
104104 health insurance market, as defined in chapter 18.5 of title 27, and the small-employer health 23
105105 insurance market, as defined in chapter 50 of title 27, in accordance with the following: 24
106106 (1) The analysis shall forecast the likely rate increases required to effect the changes 25
107107 recommended pursuant to the preceding subsection (g) in the direct-pay market and small-employer 26
108108 health insurance market over the next five (5) years, based on the current rating structure and 27
109109 current products. 28
110110 (2) The analysis shall include examining the impact of merging the individual and small-29
111111 employer markets on premiums charged to individuals and small-employer groups. 30
112112 (3) The analysis shall include examining the impact on rates in each of the individual and 31
113113 small-employer health insurance markets and the number of insureds in the context of possible 32
114114 changes to the rating guidelines used for small-employer groups, including: community rating 33
115115 principles; expanding small-employer rate bonds beyond the current range; increasing the employer 34
116116
117117
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119119 group size in the small-group market; and/or adding rating factors for broker and/or tobacco use. 1
120120 (4) The analysis shall include examining the adequacy of current statutory and regulatory 2
121121 oversight of the rating process and factors employed by the participants in the proposed, new 3
122122 merged market. 4
123123 (5) The analysis shall include assessment of possible reinsurance mechanisms and/or 5
124124 federal high-risk pool structures and funding to support the health insurance market in Rhode Island 6
125125 by reducing the risk of adverse selection and the incremental insurance premiums charged for this 7
126126 risk, and/or by making health insurance affordable for a selected at-risk population. 8
127127 (6) The health insurance commissioner shall work with an insurance market merger task 9
128128 force to assist with the analysis. The task force shall be chaired by the health insurance 10
129129 commissioner and shall include, but not be limited to, representatives of the general assembly, the 11
130130 business community, small-employer carriers as defined in § 27-50-3, carriers offering coverage in 12
131131 the individual market in Rhode Island, health insurance brokers, and members of the general public. 13
132132 (7) For the purposes of conducting this analysis, the commissioner may contract with an 14
133133 outside organization with expertise in fiscal analysis of the private insurance market. In conducting 15
134134 its study, the organization shall, to the extent possible, obtain and use actual health plan data. Said 16
135135 data shall be subject to state and federal laws and regulations governing confidentiality of health 17
136136 care and proprietary information. 18
137137 (8) The task force shall meet as necessary and include its findings in the annual report, and 19
138138 the commissioner shall include the information in the annual presentation before the house and 20
139139 senate finance committees. 21
140140 (h) To establish and convene a workgroup representing healthcare providers and health 22
141141 insurers for the purpose of coordinating the development of processes, guidelines, and standards to 23
142142 streamline healthcare administration that are to be adopted by payors and providers of healthcare 24
143143 services operating in the state. This workgroup shall include representatives with expertise who 25
144144 would contribute to the streamlining of healthcare administration and who are selected from 26
145145 hospitals, physician practices, community behavioral health organizations, each health insurer, and 27
146146 other affected entities. The workgroup shall also include at least one designee each from the Rhode 28
147147 Island Medical Society, Rhode Island Council of Community Mental Health Organizations, the 29
148148 Rhode Island Health Center Association, and the Hospital Association of Rhode Island. In any year 30
149149 that the workgroup meets and submits recommendations to the office of the health insurance 31
150150 commissioner, the office of the health insurance commissioner shall submit such recommendations 32
151-to the health and human services committees of the Rhode Island house of representatives and the 33
152-Rhode Island senate prior to the implementation of any such recommendations and subsequently 34
151+in a report to the general assembly by January 1. The report shall include the recommendations the 33
152+commissioner intends to implement, with supporting rationale. The workgroup shall consider and 34
153153
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156-shall submit a report to the general assembly by June 30, 2024. The report shall include the 1
157-recommendations the commissioner may implement, with supporting rationale. The workgroup 2
158-shall consider and make recommendations for: 3
159-(1) Establishing a consistent standard for electronic eligibility and coverage verification. 4
160-Such standard shall: 5
161-(i) Include standards for eligibility inquiry and response and, wherever possible, be 6
162-consistent with the standards adopted by nationally recognized organizations, such as the Centers 7
163-for Medicare and Medicaid Services; 8
164-(ii) Enable providers and payors to exchange eligibility requests and responses on a system-9
165-to-system basis or using a payor-supported web browser; 10
166-(iii) Provide reasonably detailed information on a consumer’s eligibility for healthcare 11
167-coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing 12
168-requirements for specific services at the specific time of the inquiry; current deductible amounts; 13
169-accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and 14
170-other information required for the provider to collect the patient’s portion of the bill; 15
171-(iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility 16
172-and benefits information; 17
173-(v) Recommend a standard or common process to protect all providers from the costs of 18
174-services to patients who are ineligible for insurance coverage in circumstances where a payor 19
175-provides eligibility verification based on best information available to the payor at the date of the 20
176-request of eligibility. 21
177-(2) Developing implementation guidelines and promoting adoption of the guidelines for: 22
178-(i) The use of the National Correct Coding Initiative code-edit policy by payors and 23
179-providers in the state; 24
180-(ii) Publishing any variations from codes and mutually exclusive codes by payors in a 25
181-manner that makes for simple retrieval and implementation by providers; 26
182-(iii) Use of Health Insurance Portability and Accountability Act standard group codes, 27
183-reason codes, and remark codes by payors in electronic remittances sent to providers; 28
184-(iv) The Uniformity in the processing of claims by payors; and the processing of 29
185-corrections to claims by providers and payors. 30
186-(v) A standard payor-denial review process for providers when they request a 31
187-reconsideration of a denial of a claim that results from differences in clinical edits where no single, 32
188-common-standards body or process exists and multiple conflicting sources are in use by payors and 33
189-providers. 34
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156+make recommendations for: 1
157+(1) Establishing a consistent standard for electronic eligibility and coverage verification. 2
158+Such standard shall: 3
159+(i) Include standards for eligibility inquiry and response and, wherever possible, be 4
160+consistent with the standards adopted by nationally recognized organizations, such as the Centers 5
161+for Medicare and Medicaid Services; 6
162+(ii) Enable providers and payors to exchange eligibility requests and responses on a system-7
163+to-system basis or using a payor-supported web browser; 8
164+(iii) Provide reasonably detailed information on a consumer’s eligibility for healthcare 9
165+coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing 10
166+requirements for specific services at the specific time of the inquiry; current deductible amounts; 11
167+accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and 12
168+other information required for the provider to collect the patient’s portion of the bill; 13
169+(iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility 14
170+and benefits information; 15
171+(v) Recommend a standard or common process to protect all providers from the costs of 16
172+services to patients who are ineligible for insurance coverage in circumstances where a payor 17
173+provides eligibility verification based on best information available to the payor at the date of the 18
174+request of eligibility. 19
175+(2) Developing implementation guidelines and promoting adoption of the guidelines for: 20
176+(i) The use of the National Correct Coding Initiative code-edit policy by payors and 21
177+providers in the state; 22
178+(ii) Publishing any variations from codes and mutually exclusive codes by payors in a 23
179+manner that makes for simple retrieval and implementation by providers; 24
180+(iii) Use of Health Insurance Portability and Accountability Act standard group codes, 25
181+reason codes, and remark codes by payors in electronic remittances sent to providers; 26
182+(iv) The Uniformity in the processing of claims by payors; and the processing of 27
183+corrections to claims by providers and payors. 28
184+(v) A standard payor-denial review process for providers when they request a 29
185+reconsideration of a denial of a claim that results from differences in clinical edits where no single, 30
186+common-standards body or process exists and multiple conflicting sources are in use by payors and 31
187+providers. 32
188+(vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual 33
189+payor’s ability to employ, and not disclose to providers, temporary code edits for the purpose of 34
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193-(vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual 1
194-payor’s ability to employ, and not disclose to providers, temporary code edits for the purpose of 2
195-detecting and deterring fraudulent billing activities. The guidelines shall require that each payor 3
196-disclose to the provider its adjudication decision on a claim that was denied or adjusted based on 4
197-the application of such edits and that the provider have access to the payor’s review and appeal 5
198-process to challenge the payor’s adjudication decision. 6
199-(vii) Nothing in this subsection shall be construed to modify the rights or obligations of 7
200-payors or providers with respect to procedures relating to the investigation, reporting, appeal, or 8
201-prosecution under applicable law of potentially fraudulent billing activities. 9
202-(3) Developing and promoting widespread adoption by payors and providers of guidelines 10
203-to: 11
204-(i) Ensure payors do not automatically deny claims for services when extenuating 12
205-circumstances make it impossible for the provider to obtain a preauthorization before services are 13
206-performed or notify a payor within an appropriate standardized timeline of a patient’s admission; 14
207-(ii) Require payors to use common and consistent processes and time frames when 15
208-responding to provider requests for medical management approvals. Whenever possible, such time 16
209-frames shall be consistent with those established by leading national organizations and be based 17
210-upon the acuity of the patient’s need for care or treatment. For the purposes of this section, medical 18
211-management includes prior authorization of services, preauthorization of services, precertification 19
212-of services, post-service review, medical-necessity review, and benefits advisory; 20
213-(iii) Develop, maintain, and promote widespread adoption of a single, common website 21
214-where providers can obtain payors’ preauthorization, benefits advisory, and preadmission 22
215-requirements; 23
216-(iv) Establish guidelines for payors to develop and maintain a website that providers can 24
217-use to request a preauthorization, including a prospective clinical necessity review; receive an 25
218-authorization number; and transmit an admission notification; 26
219-(v) Develop and implement the use of programs that implement selective prior 27
220-authorization requirements, based on stratification of health care providers’ performance and 28
221-adherence to evidence-based medicine with the input of contracted health care providers and/or 29
222-provider organizations. Such criteria shall be transparent and easily accessible to contracted 30
223-providers. Such selective prior authorization programs shall when health care providers participate 31
224-directly with the insurer in risk-based payment contracts and may be available to providers who do 32
225-not participate in risk-based contracts; 33
226-(vi) Require the review of medical services, including behavioral health services, and 34
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193+detecting and deterring fraudulent billing activities. The guidelines shall require that each payor 1
194+disclose to the provider its adjudication decision on a claim that was denied or adjusted based on 2
195+the application of such edits and that the provider have access to the payor’s review and appeal 3
196+process to challenge the payor’s adjudication decision. 4
197+(vii) Nothing in this subsection shall be construed to modify the rights or obligations of 5
198+payors or providers with respect to procedures relating to the investigation, reporting, appeal, or 6
199+prosecution under applicable law of potentially fraudulent billing activities. 7
200+(3) Developing and promoting widespread adoption by payors and providers of guidelines 8
201+to: 9
202+(i) Ensure payors do not automatically deny claims for services when extenuating 10
203+circumstances make it impossible for the provider to obtain a preauthorization before services are 11
204+performed or notify a payor within an appropriate standardized timeline of a patient’s admission; 12
205+(ii) Require payors to use common and consistent processes and time frames when 13
206+responding to provider requests for medical management approvals. Whenever possible, such time 14
207+frames shall be consistent with those established by leading national organizations and be based 15
208+upon the acuity of the patient’s need for care or treatment. For the purposes of this section, medical 16
209+management includes prior authorization of services, preauthorization of services, precertification 17
210+of services, post-service review, medical-necessity review, and benefits advisory; 18
211+(iii) Develop, maintain, and promote widespread adoption of a single, common website 19
212+where providers can obtain payors’ preauthorization, benefits advisory, and preadmission 20
213+requirements; 21
214+(iv) Establish guidelines for payors to develop and maintain a website that providers can 22
215+use to request a preauthorization, including a prospective clinical necessity review; receive an 23
216+authorization number; and transmit an admission notification; 24
217+(v) Require the use of programs that implement prior authorization requirements, 25
218+uniformly across payors and utilization review agents, based on stratification of health care 26
219+providers’ performance and adherence to evidence-based medicine and develop uniform criteria to 27
220+select and maintain health care providers in such selective prior authorization programs with the 28
221+input of contracted health care providers and/or provider organizations. Such criteria shall be 29
222+transparent and easily accessible to contracted providers. Such selective prior authorization 30
223+programs shall encourage appropriate adjustments to prior authorization requirements when health 31
224+care providers participate in risk-based payment contracts; 32
225+(vi) Require the review of medical services, including behavioral health services, and 33
226+prescription drugs, subject to prior authorization on at least an annual basis, with the input of 34
227227
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230-prescription drugs, subject to prior authorization on at least an annual basis, with the input of 1
231-contracted health care providers and/or provider organizations. Any changes to the list of medical 2
232-services, including behavioral health services, and prescription drugs requiring prior authorization, 3
233-shall be shared via provider-accessible websites; 4
234-(vii) Improve communication channels between health plans, health care providers, and 5
235-patients by: 6
236-(A) Requiring transparency and easy accessibility of prior authorization requirements, 7
237-criteria, rationale, and program changes to contracted health care providers and patients/health plan 8
238-enrollees which may be satisfied by posting to provider accessible and member accessible websites; 9
239-and 10
240-(B) Supporting: 11
241-(I) Timely submission by health care providers of the complete information necessary to 12
242-make a prior authorization determination, as early in the process as possible; and 13
243-(II) Timely notification of prior authorization determinations by health plans to impacted 14
244-health plan enrollees, and health care providers, including, but not limited to, ordering providers, 15
245-and/or rendering providers, and dispensing pharmacists which may be satisfied by posting to 16
246-provider accessible websites or similar electronic portals or services; and 17
247-(viii) Increase and strengthen continuity of patient care by: 18
248-(A) Defining protections for continuity of care during a transition period for patients 19
249-undergoing an active course of treatment, when there is a formulary or treatment coverage change 20
250-or change of health plan that may disrupt their current course of treatment and when the treating 21
251-physician determines that a transition may place the patient at risk; and for prescription medication 22
252-by allowing a grace period of coverage to allow consideration of referred health plan options or 23
253-establishment of medical necessity of the current course of treatment; 24
254-(B) Requiring continuity of care for medical services, including behavioral health services, 25
255-and prescription medications for patients on appropriate, chronic, stable therapy through 26
256-minimizing repetitive prior authorization requirements; and which for prescription medication shall 27
257-be allowed only on an annual review, with exception for labeled limitation, to establish continued 28
258-benefit of treatment; and 29
259-(C) Requiring communication between health care providers, health plans, and patients to 30
260-facilitate continuity of care and minimize disruptions in needed treatment which may be satisfied 31
261-by posting to provider-accessible websites or similar electronic portals or services; 32
262-(D) Continuity of care for formulary or drug coverage shall distinguish between FDA 33
263-designated interchangeable products and proprietary or marketed versions of a medication. 34
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230+contracted health care providers and/or provider organizations. Based on this review, require the 1
231+revision of prior authorization requirements, including the list of services subject to prior 2
232+authorization, based on the prior year’s data analytics and up-to-date clinical criteria provided to 3
233+the office of the health insurance commissioner by insurers. Any changes to the list of medical 4
234+services, including behavioral health services, and prescription drugs requiring prior authorization, 5
235+shall be shared via provider-accessible websites, and communicated at least annually to health care 6
236+providers; 7
237+(vii) Improve communication channels between health plans, health care providers, and 8
238+patients by: 9
239+(A) Requiring transparency and easy accessibility of prior authorization requirements, 10
240+criteria, rationale, and program changes to contracted health care providers and patients/health plan 11
241+enrollees; and 12
242+(B) Supporting: 13
243+(I) Timely submission by health care providers of the complete information necessary to 14
244+make a prior authorization determination, as early in the process as possible; and 15
245+(II) Timely notification of prior authorization determinations by health plans to impacted 16
246+patients, health plan enrollees, and health care providers, including, but not limited to, ordering 17
247+providers, rendering providers, and dispensing pharmacists; and 18
248+(viii) Increase and strengthen continuity of patient care by: 19
249+(A) Defining protections for continuity of care during a transition period for patients 20
250+undergoing an active course of treatment, when there is a formulary or treatment coverage change 21
251+or change of health plan that may disrupt their current course of treatment; 22
252+(B) Requiring continuity of care for medical services, including behavioral health services, 23
253+and prescription medications for patients on appropriate, chronic, stable therapy through 24
254+minimizing repetitive prior authorization requirements; and 25
255+(C) Requiring communication between health care providers, health plans, and patients to 26
256+facilitate continuity of care and minimize disruptions in needed treatment. 27
257+(4) To provide a report to the house and senate, on or before January 1, 2017, with 28
258+recommendations for establishing guidelines and regulations for systems that give patients 29
259+electronic access to their claims information, particularly to information regarding their obligations 30
260+to pay for received medical services, pursuant to 45 C.F.R. § 164.524. 31
261+(i) To issue an anti-cancer medication report. Not later than June 30, 2014, and annually 32
262+thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate 33
263+committee on health and human services, and the house committee on corporations, with: (1) 34
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267-(ix) Encourage health care providers and/or provider organizations and health plans to 1
268-accelerate use of electronic prior authorization technology, including adoption of national standards 2
269-where applicable; 3
270-(x) For the purposes of subsections (h)(3)(v) through (h)(3)(x) of this section, the 4
271-workgroup meeting may be conducted in part or whole through electronic methods.. 5
272-(4) To provide a report to the house and senate, on or before January 1, 2017, with 6
273-recommendations for establishing guidelines and regulations for systems that give patients 7
274-electronic access to their claims information, particularly to information regarding their obligations 8
275-to pay for received medical services, pursuant to 45 C.F.R. § 164.524. 9
276-(5) No provision of § 42-14.5-3(h) shall preclude the ongoing work of the office of health 10
277-insurance commissioner's administrative simplification task force, which includes meetings with 11
278-key stakeholders in order to improve, and provide recommendations regarding, the prior 12
279-authorization process. 13
280-(i) To issue an anti-cancer medication report. Not later than June 30, 2014, and annually 14
281-thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate 15
282-committee on health and human services, and the house committee on corporations, with: (1) 16
283-Information on the availability in the commercial market of coverage for anti-cancer medication 17
284-options; (2) For the state employee’s health benefit plan, the costs of various cancer-treatment 18
285-options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member 19
286-utilization and cost-sharing expense. 20
287-(j) To monitor the adequacy of each health plan’s compliance with the provisions of the 21
288-federal Mental Health Parity Act, including a review of related claims processing and 22
289-reimbursement procedures. Findings, recommendations, and assessments shall be made available 23
290-to the public. 24
291-(k) To monitor the transition from fee-for-service and toward global and other alternative 25
292-payment methodologies for the payment for healthcare services. Alternative payment 26
293-methodologies should be assessed for their likelihood to promote access to affordable health 27
294-insurance, health outcomes, and performance. 28
295-(l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital 29
296-payment variation, including findings and recommendations, subject to available resources. 30
297-(m) Notwithstanding any provision of the general or public laws or regulation to the 31
298-contrary, provide a report with findings and recommendations to the president of the senate and the 32
299-speaker of the house, on or before April 1, 2014, including, but not limited to, the following 33
300-information: 34
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267+Information on the availability in the commercial market of coverage for anti-cancer medication 1
268+options; (2) For the state employee’s health benefit plan, the costs of various cancer-treatment 2
269+options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member 3
270+utilization and cost-sharing expense. 4
271+(j) To monitor the adequacy of each health plan’s compliance with the provisions of the 5
272+federal Mental Health Parity Act, including a review of related claims processing and 6
273+reimbursement procedures. Findings, recommendations, and assessments shall be made available 7
274+to the public. 8
275+(k) To monitor the transition from fee-for-service and toward global and other alternative 9
276+payment methodologies for the payment for healthcare services. Alternative payment 10
277+methodologies should be assessed for their likelihood to promote access to affordable health 11
278+insurance, health outcomes, and performance. 12
279+(l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital 13
280+payment variation, including findings and recommendations, subject to available resources. 14
281+(m) Notwithstanding any provision of the general or public laws or regulation to the 15
282+contrary, provide a report with findings and recommendations to the president of the senate and the 16
283+speaker of the house, on or before April 1, 2014, including, but not limited to, the following 17
284+information: 18
285+(1) The impact of the current, mandated healthcare benefits as defined in §§ 27-18-48.1, 19
286+27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41 of title 27, and §§ 27-20
287+18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health 21
288+insurance for fully insured employers, subject to available resources; 22
289+(2) Current provider and insurer mandates that are unnecessary and/or duplicative due to 23
290+the existing standards of care and/or delivery of services in the healthcare system; 24
291+(3) A state-by-state comparison of health insurance mandates and the extent to which 25
292+Rhode Island mandates exceed other states benefits; and 26
293+(4) Recommendations for amendments to existing mandated benefits based on the findings 27
294+in (m)(1), (m)(2), and (m)(3) above. 28
295+(n) On or before July 1, 2014, the office of the health insurance commissioner, in 29
296+collaboration with the director of health and lieutenant governor’s office, shall submit a report to 30
297+the general assembly and the governor to inform the design of accountable care organizations 31
298+(ACOs) in Rhode Island as unique structures for comprehensive healthcare delivery and value-32
299+based payment arrangements, that shall include, but not be limited to: 33
300+(1) Utilization review; 34
301301
302302
303-LC001062/SUB A - Page 9 of 13
304-(1) The impact of the current, mandated healthcare benefits as defined in §§ 27-18-48.1, 1
305-27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41 of title 27, and §§ 27-2
306-18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health 3
307-insurance for fully insured employers, subject to available resources; 4
308-(2) Current provider and insurer mandates that are unnecessary and/or duplicative due to 5
309-the existing standards of care and/or delivery of services in the healthcare system; 6
310-(3) A state-by-state comparison of health insurance mandates and the extent to which 7
311-Rhode Island mandates exceed other states benefits; and 8
312-(4) Recommendations for amendments to existing mandated benefits based on the findings 9
313-in (m)(1), (m)(2), and (m)(3) above. 10
314-(n) On or before July 1, 2014, the office of the health insurance commissioner, in 11
315-collaboration with the director of health and lieutenant governor’s office, shall submit a report to 12
316-the general assembly and the governor to inform the design of accountable care organizations 13
317-(ACOs) in Rhode Island as unique structures for comprehensive healthcare delivery and value-14
318-based payment arrangements, that shall include, but not be limited to: 15
319-(1) Utilization review; 16
320-(2) Contracting; and 17
321-(3) Licensing and regulation. 18
322-(o) On or before February 3, 2015, the office of the health insurance commissioner shall 19
323-submit a report to the general assembly and the governor that describes, analyzes, and proposes 20
324-recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard 21
325-to patients with mental health and substance use disorders. 22
326-(p) To work to ensure the health insurance coverage of behavioral health care under the 23
327-same terms and conditions as other health care, and to integrate behavioral health parity 24
328-requirements into the office of the health insurance commissioner insurance oversight and health 25
329-care transformation efforts. 26
330-(q) To work with other state agencies to seek delivery system improvements that enhance 27
331-access to a continuum of mental health and substance use disorder treatment in the state; and 28
332-integrate that treatment with primary and other medical care to the fullest extent possible. 29
333-(r) To direct insurers toward policies and practices that address the behavioral health needs 30
334-of the public and greater integration of physical and behavioral healthcare delivery. 31
335-(s) The office of the health insurance commissioner shall conduct an analysis of the impact 32
336-of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and 33
337-submit a report of its findings to the general assembly on or before June 1, 2023. 34
303+LC001062/SUB A - Page 9 of 12
304+(2) Contracting; and 1
305+(3) Licensing and regulation. 2
306+(o) On or before February 3, 2015, the office of the health insurance commissioner shall 3
307+submit a report to the general assembly and the governor that describes, analyzes, and proposes 4
308+recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard 5
309+to patients with mental health and substance use disorders. 6
310+(p) To work to ensure the health insurance coverage of behavioral health care under the 7
311+same terms and conditions as other health care, and to integrate behavioral health parity 8
312+requirements into the office of the health insurance commissioner insurance oversight and health 9
313+care transformation efforts. 10
314+(q) To work with other state agencies to seek delivery system improvements that enhance 11
315+access to a continuum of mental health and substance use disorder treatment in the state; and 12
316+integrate that treatment with primary and other medical care to the fullest extent possible. 13
317+(r) To direct insurers toward policies and practices that address the behavioral health needs 14
318+of the public and greater integration of physical and behavioral healthcare delivery. 15
319+(s) The office of the health insurance commissioner shall conduct an analysis of the impact 16
320+of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and 17
321+submit a report of its findings to the general assembly on or before June 1, 2023. 18
322+(t) To undertake the analyses, reports, and studies contained in this section: 19
323+(1) The office shall hire the necessary staff and prepare a request for proposal for a qualified 20
324+and competent firm or firms to undertake the following analyses, reports, and studies: 21
325+(i) The firm shall undertake a comprehensive review of all social and human service 22
326+programs having a contract with or licensed by the state or any subdivision of the department of 23
327+children, youth and families (DCYF), the department of behavioral healthcare, developmental 24
328+disabilities and hospitals (BHDDH), the department of human services (DHS), the department of 25
329+health (DOH), and Medicaid for the purposes of: 26
330+(A) Establishing a baseline of the eligibility factors for receiving services; 27
331+(B) Establishing a baseline of the service offering through each agency for those 28
332+determined eligible; 29
333+(C) Establishing a baseline understanding of reimbursement rates for all social and human 30
334+service programs including rates currently being paid, the date of the last increase, and a proposed 31
335+model that the state may use to conduct future studies and analyses; 32
336+(D) Ensuring accurate and adequate reimbursement to social and human service providers 33
337+that facilitate the availability of high-quality services to individuals receiving home and 34
338338
339339
340-LC001062/SUB A - Page 10 of 13
341-(t) To undertake the analyses, reports, and studies contained in this section: 1
342-(1) The office shall hire the necessary staff and prepare a request for proposal for a qualified 2
343-and competent firm or firms to undertake the following analyses, reports, and studies: 3
344-(i) The firm shall undertake a comprehensive review of all social and human service 4
345-programs having a contract with or licensed by the state or any subdivision of the department of 5
346-children, youth and families (DCYF), the department of behavioral healthcare, developmental 6
347-disabilities and hospitals (BHDDH), the department of human services (DHS), the department of 7
348-health (DOH), and Medicaid for the purposes of: 8
349-(A) Establishing a baseline of the eligibility factors for receiving services; 9
350-(B) Establishing a baseline of the service offering through each agency for those 10
351-determined eligible; 11
352-(C) Establishing a baseline understanding of reimbursement rates for all social and human 12
353-service programs including rates currently being paid, the date of the last increase, and a proposed 13
354-model that the state may use to conduct future studies and analyses; 14
355-(D) Ensuring accurate and adequate reimbursement to social and human service providers 15
356-that facilitate the availability of high-quality services to individuals receiving home and 16
357-community-based long-term services and supports provided by social and human service providers; 17
358-(E) Ensuring the general assembly is provided accurate financial projections on social and 18
359-human service program costs, demand for services, and workforce needs to ensure access to entitled 19
360-beneficiaries and services; 20
361-(F) Establishing a baseline and determining the relationship between state government and 21
362-the provider network including functions, responsibilities, and duties; 22
363-(G) Determining a set of measures and accountability standards to be used by EOHHS and 23
364-the general assembly to measure the outcomes of the provision of services including budgetary 24
365-reporting requirements, transparency portals, and other methods; and 25
366-(H) Reporting the findings of human services analyses and reports to the speaker of the 26
367-house, senate president, chairs of the house and senate finance committees, chairs of the house and 27
368-senate health and human services committees, and the governor. 28
369-(2) The analyses, reports, and studies required pursuant to this section shall be 29
370-accomplished and published as follows and shall provide: 30
371-(i) An assessment and detailed reporting on all social and human service program rates to 31
372-be completed by January 1, 2023, including rates currently being paid and the date of the last 32
373-increase; 33
374-(ii) An assessment and detailed reporting on eligibility standards and processes of all 34
340+LC001062/SUB A - Page 10 of 12
341+community-based long-term services and supports provided by social and human service providers; 1
342+(E) Ensuring the general assembly is provided accurate financial projections on social and 2
343+human service program costs, demand for services, and workforce needs to ensure access to entitled 3
344+beneficiaries and services; 4
345+(F) Establishing a baseline and determining the relationship between state government and 5
346+the provider network including functions, responsibilities, and duties; 6
347+(G) Determining a set of measures and accountability standards to be used by EOHHS and 7
348+the general assembly to measure the outcomes of the provision of services including budgetary 8
349+reporting requirements, transparency portals, and other methods; and 9
350+(H) Reporting the findings of human services analyses and reports to the speaker of the 10
351+house, senate president, chairs of the house and senate finance committees, chairs of the house and 11
352+senate health and human services committees, and the governor. 12
353+(2) The analyses, reports, and studies required pursuant to this section shall be 13
354+accomplished and published as follows and shall provide: 14
355+(i) An assessment and detailed reporting on all social and human service program rates to 15
356+be completed by January 1, 2023, including rates currently being paid and the date of the last 16
357+increase; 17
358+(ii) An assessment and detailed reporting on eligibility standards and processes of all 18
359+mandatory and discretionary social and human service programs to be completed by January 1, 19
360+2023; 20
361+(iii) An assessment and detailed reporting on utilization trends from the period of January 21
362+1, 2017, through December 31, 2021, for social and human service programs to be completed by 22
363+January 1, 2023; 23
364+(iv) An assessment and detailed reporting on the structure of the state government as it 24
365+relates to the provision of services by social and human service providers including eligibility and 25
366+functions of the provider network to be completed by January 1, 2023; 26
367+(v) An assessment and detailed reporting on accountability standards for services for social 27
368+and human service programs to be completed by January 1, 2023; 28
369+(vi) An assessment and detailed reporting by April 1, 2023, on all professional licensed 29
370+and unlicensed personnel requirements for established rates for social and human service programs 30
371+pursuant to a contract or established fee schedule; 31
372+(vii) An assessment and reporting on access to social and human service programs, to 32
373+include any wait lists and length of time on wait lists, in each service category by April 1, 2023; 33
374+(viii) An assessment and reporting of national and regional Medicaid rates in comparison 34
375375
376376
377-LC001062/SUB A - Page 11 of 13
378-mandatory and discretionary social and human service programs to be completed by January 1, 1
379-2023; 2
380-(iii) An assessment and detailed reporting on utilization trends from the period of January 3
381-1, 2017, through December 31, 2021, for social and human service programs to be completed by 4
382-January 1, 2023; 5
383-(iv) An assessment and detailed reporting on the structure of the state government as it 6
384-relates to the provision of services by social and human service providers including eligibility and 7
385-functions of the provider network to be completed by January 1, 2023; 8
386-(v) An assessment and detailed reporting on accountability standards for services for social 9
387-and human service programs to be completed by January 1, 2023; 10
388-(vi) An assessment and detailed reporting by April 1, 2023, on all professional licensed 11
389-and unlicensed personnel requirements for established rates for social and human service programs 12
390-pursuant to a contract or established fee schedule; 13
391-(vii) An assessment and reporting on access to social and human service programs, to 14
392-include any wait lists and length of time on wait lists, in each service category by April 1, 2023; 15
393-(viii) An assessment and reporting of national and regional Medicaid rates in comparison 16
394-to Rhode Island social and human service provider rates by April 1, 2023; 17
395-(ix) An assessment and reporting on usual and customary rates paid by private insurers and 18
396-private pay for similar social and human service providers, both nationally and regionally, by April 19
397-1, 2023; and 20
398-(x) Completion of the development of an assessment and review process that includes the 21
399-following components: eligibility; scope of services; relationship of social and human service 22
400-provider and the state; national and regional rate comparisons and accountability standards that 23
401-result in recommended rate adjustments; and this process shall be completed by September 1, 2023, 24
402-and conducted biennially hereafter. The biennial rate setting shall be consistent with payment 25
403-requirements established in § 1902(a)(30)(A) of the Social Security Act, 42 U.S.C. § 26
404-1396a(a)(30)(A), and all federal and state law, regulations, and quality and safety standards. The 27
405-results and findings of this process shall be transparent, and public meetings shall be conducted to 28
406-allow providers, recipients, and other interested parties an opportunity to ask questions and provide 29
407-comment beginning in September 2023 and biennially thereafter. 30
408-(3) In fulfillment of the responsibilities defined in subsection (t), the office of the health 31
409-insurance commissioner shall consult with the Executive Office of Health and Human Services. 32
410-(u) Annually, each department (namely, EOHHS, DCYF, DOH, DHS, and BHDDH) shall 33
411-include the corresponding components of the assessment and review (i.e., eligibility; scope of 34
412-
413-
414-LC001062/SUB A - Page 12 of 13
415-services; relationship of social and human service provider and the state; and national and regional 1
416-rate comparisons and accountability standards including any changes or substantive issues between 2
417-biennial reviews) including the recommended rates from the most recent assessment and review 3
418-with their annual budget submission to the office of management and budget and provide a detailed 4
419-explanation and impact statement if any rate variances exist between submitted recommended 5
420-budget and the corresponding recommended rate from the most recent assessment and review 6
421-process starting October 1, 2023, and biennially thereafter. 7
422-(v) The general assembly shall appropriate adequate funding as it deems necessary to 8
423-undertake the analyses, reports, and studies contained in this section relating to the powers and 9
424-duties of the office of the health insurance commissioner. 10
425-SECTION 2. This act shall take effect upon passage. 11
377+LC001062/SUB A - Page 11 of 12
378+to Rhode Island social and human service provider rates by April 1, 2023; 1
379+(ix) An assessment and reporting on usual and customary rates paid by private insurers and 2
380+private pay for similar social and human service providers, both nationally and regionally, by April 3
381+1, 2023; and 4
382+(x) Completion of the development of an assessment and review process that includes the 5
383+following components: eligibility; scope of services; relationship of social and human service 6
384+provider and the state; national and regional rate comparisons and accountability standards that 7
385+result in recommended rate adjustments; and this process shall be completed by September 1, 2023, 8
386+and conducted biennially hereafter. The biennial rate setting shall be consistent with payment 9
387+requirements established in § 1902(a)(30)(A) of the Social Security Act, 42 U.S.C. § 10
388+1396a(a)(30)(A), and all federal and state law, regulations, and quality and safety standards. The 11
389+results and findings of this process shall be transparent, and public meetings shall be conducted to 12
390+allow providers, recipients, and other interested parties an opportunity to ask questions and provide 13
391+comment beginning in September 2023 and biennially thereafter. 14
392+(3) In fulfillment of the responsibilities defined in subsection (t), the office of the health 15
393+insurance commissioner shall consult with the Executive Office of Health and Human Services. 16
394+(u) Annually, each department (namely, EOHHS, DCYF, DOH, DHS, and BHDDH) shall 17
395+include the corresponding components of the assessment and review (i.e., eligibility; scope of 18
396+services; relationship of social and human service provider and the state; and national and regional 19
397+rate comparisons and accountability standards including any changes or substantive issues between 20
398+biennial reviews) including the recommended rates from the most recent assessment and review 21
399+with their annual budget submission to the office of management and budget and provide a detailed 22
400+explanation and impact statement if any rate variances exist between submitted recommended 23
401+budget and the corresponding recommended rate from the most recent assessment and review 24
402+process starting October 1, 2023, and biennially thereafter. 25
403+(v) The general assembly shall appropriate adequate funding as it deems necessary to 26
404+undertake the analyses, reports, and studies contained in this section relating to the powers and 27
405+duties of the office of the health insurance commissioner. 28
406+SECTION 2. This act shall take effect upon passage. 29
426407 ========
427408 LC001062/SUB A
428409 ========
429410
430411
431-LC001062/SUB A - Page 13 of 13
412+LC001062/SUB A - Page 12 of 12
432413 EXPLANATION
433414 BY THE LEGISLATIVE COUNCIL
434415 OF
435416 A N A C T
436417 RELATING TO STATE AFFAIRS AND GOVERNMENT -- THE RHODE ISLAND HEALTH
437418 CARE REFORM ACT OF 2004 -- HEALTH INSURANCE OVE RSIGHT
438419 ***
439420 This act would require a workgroup of health care providers and health insurers convened 1
440421 by the office of the health commissioner, to make recommendations regarding prior authorization 2
441422 policies. 3
442423 This act would take effect upon passage. 4
443424 ========
444425 LC001062/SUB A
445426 ========
427+