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Rhode Island House Bill H6119

Rhode Island 2025 Regular Session

Rhode Island House Bill H6119 Compare Versions

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55 2025 -- H 6119
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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. 2025
1212 ____________
1313
1414 A N A C T
1515 RELATING TO STATE AFFAIRS AND GOVERNMENT -- THE RHODE ISLAND HEALTH
1616 CARE REFORM ACT OF 2004 -- HEALTH INSURANCE OVERSIGHT
1717 Introduced By: Representatives Fogarty, Spears, McEntee, Carson, Shallcross Smith,
1818 Hull, Felix, Kislak, Giraldo, and Kazarian
1919 Date Introduced: March 21, 2025
2020 Referred To: House 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
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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 copays 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
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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
151151 to the health and human services committees of the Rhode Island house of representatives and the 33
152152 Rhode Island senate prior to the implementation of any such recommendations and subsequently 34
153153
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156156 shall submit a report to the general assembly by June 30, 2024. The report shall include the 1
157157 recommendations the commissioner may implement, with supporting rationale. The workgroup 2
158158 shall consider and make recommendations for: 3
159159 (1) Establishing a consistent standard for electronic eligibility and coverage verification. 4
160160 Such standard shall: 5
161161 (i) Include standards for eligibility inquiry and response and, wherever possible, be 6
162162 consistent with the standards adopted by nationally recognized organizations, such as the Centers 7
163163 for Medicare & Medicaid Services; 8
164164 (ii) Enable providers and payors to exchange eligibility requests and responses on a system-9
165165 to-system basis or using a payor-supported web browser; 10
166166 (iii) Provide reasonably detailed information on a consumer’s eligibility for healthcare 11
167167 coverage; scope of benefits; limitations and exclusions provided under that coverage; cost-sharing 12
168168 requirements for specific services at the specific time of the inquiry; current deductible amounts; 13
169169 accumulated or limited benefits; out-of-pocket maximums; any maximum policy amounts; and 14
170170 other information required for the provider to collect the patient’s portion of the bill; 15
171171 (iv) Reflect the necessary limitations imposed on payors by the originator of the eligibility 16
172172 and benefits information; 17
173173 (v) Recommend a standard or common process to protect all providers from the costs of 18
174174 services to patients who are ineligible for insurance coverage in circumstances where a payor 19
175175 provides eligibility verification based on best information available to the payor at the date of the 20
176176 request of eligibility. 21
177177 (2) Developing implementation guidelines and promoting adoption of the guidelines for: 22
178178 (i) The use of the National Correct Coding Initiative code-edit policy by payors and 23
179179 providers in the state; 24
180180 (ii) Publishing any variations from codes and mutually exclusive codes by payors in a 25
181181 manner that makes for simple retrieval and implementation by providers; 26
182182 (iii) Use of Health Insurance Portability and Accountability Act standard group codes, 27
183183 reason codes, and remark codes by payors in electronic remittances sent to providers; 28
184184 (iv) Uniformity in the processing of claims by payors; and the processing of corrections to 29
185185 claims by providers and payors; 30
186186 (v) A standard payor-denial review process for providers when they request a 31
187187 reconsideration of a denial of a claim that results from differences in clinical edits where no single, 32
188188 common-standards body or process exists and multiple conflicting sources are in use by payors and 33
189189 providers. 34
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193193 (vi) Nothing in this section, nor in the guidelines developed, shall inhibit an individual 1
194194 payor’s ability to employ, and not disclose to providers, temporary code edits for the purpose of 2
195195 detecting and deterring fraudulent billing activities. The guidelines shall require that each payor 3
196196 disclose to the provider its adjudication decision on a claim that was denied or adjusted based on 4
197197 the application of such edits and that the provider have access to the payor’s review and appeal 5
198198 process to challenge the payor’s adjudication decision. 6
199199 (vii) Nothing in this subsection shall be construed to modify the rights or obligations of 7
200200 payors or providers with respect to procedures relating to the investigation, reporting, appeal, or 8
201201 prosecution under applicable law of potentially fraudulent billing activities. 9
202202 (3) Developing and promoting widespread adoption by payors and providers of guidelines 10
203203 to: 11
204204 (i) Ensure payors do not automatically deny claims for services when extenuating 12
205205 circumstances make it impossible for the provider to obtain a preauthorization before services are 13
206206 performed or notify a payor within an appropriate standardized timeline of a patient’s admission; 14
207207 (ii) Require payors to use common and consistent processes and time frames when 15
208208 responding to provider requests for medical management approvals. Whenever possible, such time 16
209209 frames shall be consistent with those established by leading national organizations and be based 17
210210 upon the acuity of the patient’s need for care or treatment. For the purposes of this section, medical 18
211211 management includes prior authorization of services, preauthorization of services, precertification 19
212212 of services, post-service review, medical-necessity review, and benefits advisory; 20
213213 (iii) Develop, maintain, and promote widespread adoption of a single, common website 21
214214 where providers can obtain payors’ preauthorization, benefits advisory, and preadmission 22
215215 requirements; 23
216216 (iv) Establish guidelines for payors to develop and maintain a website that providers can 24
217217 use to request a preauthorization, including a prospective clinical necessity review; receive an 25
218218 authorization number; and transmit an admission notification; 26
219219 (v) Develop and implement the use of programs that implement selective prior 27
220220 authorization requirements, based on stratification of healthcare providers’ performance and 28
221221 adherence to evidence-based medicine with the input of contracted healthcare providers and/or 29
222222 provider organizations. Such criteria shall be transparent and easily accessible to contracted 30
223223 providers. Such selective prior authorization programs shall be available when healthcare providers 31
224224 participate directly with the insurer in risk-based payment contracts and may be available to 32
225225 providers who do not participate in risk-based contracts; 33
226226 (vi) Require the review of medical services, including behavioral health services, and 34
227227
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230230 prescription drugs, subject to prior authorization on at least an annual basis, with the input of 1
231231 contracted healthcare providers and/or provider organizations. Any changes to the list of medical 2
232232 services, including behavioral health services, and prescription drugs requiring prior authorization, 3
233233 shall be shared via provider-accessible websites; 4
234234 (vii) Improve communication channels between health plans, healthcare providers, and 5
235235 patients by: 6
236236 (A) Requiring transparency and easy accessibility of prior authorization requirements, 7
237237 criteria, rationale, and program changes to contracted healthcare providers and patients/health plan 8
238238 enrollees which may be satisfied by posting to provider-accessible and member-accessible 9
239239 websites; and 10
240240 (B) Supporting: 11
241241 (I) Timely submission by healthcare providers of the complete information necessary to 12
242242 make a prior authorization determination, as early in the process as possible; and 13
243243 (II) Timely notification of prior authorization determinations by health plans to impacted 14
244244 health plan enrollees, and healthcare providers, including, but not limited to, ordering providers, 15
245245 and/or rendering providers, and dispensing pharmacists which may be satisfied by posting to 16
246246 provider-accessible websites or similar electronic portals or services; 17
247247 (viii) Increase and strengthen continuity of patient care by: 18
248248 (A) Defining protections for continuity of care during a transition period for patients 19
249249 undergoing an active course of treatment, when there is a formulary or treatment coverage change 20
250250 or change of health plan that may disrupt their current course of treatment and when the treating 21
251251 physician determines that a transition may place the patient at risk; and for prescription medication 22
252252 by allowing a grace period of coverage to allow consideration of referred health plan options or 23
253253 establishment of medical necessity of the current course of treatment; 24
254254 (B) Requiring continuity of care for medical services, including behavioral health services, 25
255255 and prescription medications for patients on appropriate, chronic, stable therapy through 26
256256 minimizing repetitive prior authorization requirements; and which for prescription medication shall 27
257257 be allowed only on an annual review, with exception for labeled limitation, to establish continued 28
258258 benefit of treatment; and 29
259259 (C) Requiring communication between healthcare providers, health plans, and patients to 30
260260 facilitate continuity of care and minimize disruptions in needed treatment which may be satisfied 31
261261 by posting to provider-accessible websites or similar electronic portals or services; 32
262262 (D) Continuity of care for formulary or drug coverage shall distinguish between FDA 33
263263 designated interchangeable products and proprietary or marketed versions of a medication; 34
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267267 (ix) Encourage healthcare providers and/or provider organizations and health plans to 1
268268 accelerate use of electronic prior authorization technology, including adoption of national standards 2
269269 where applicable; and 3
270270 (x) For the purposes of subsections (h)(3)(v) through (h)(3)(x) of this section, the 4
271271 workgroup meeting may be conducted in part or whole through electronic methods. 5
272272 (4) To provide a report to the house and senate, on or before January 1, 2017, with 6
273273 recommendations for establishing guidelines and regulations for systems that give patients 7
274274 electronic access to their claims information, particularly to information regarding their obligations 8
275275 to pay for received medical services, pursuant to 45 C.F.R. § 164.524. 9
276276 (5) No provision of this subsection (h) shall preclude the ongoing work of the office of 10
277277 health insurance commissioner’s administrative simplification task force, which includes meetings 11
278278 with key stakeholders in order to improve, and provide recommendations regarding, the prior 12
279279 authorization process. 13
280280 (i) To issue an anti-cancer medication report. Not later than June 30, 2014, and annually 14
281281 thereafter, the office of the health insurance commissioner (OHIC) shall provide the senate 15
282282 committee on health and human services, and the house committee on corporations, with: (1) 16
283283 Information on the availability in the commercial market of coverage for anti-cancer medication 17
284284 options; (2) For the state employee’s health benefit plan, the costs of various cancer-treatment 18
285285 options; (3) The changes in drug prices over the prior thirty-six (36) months; and (4) Member 19
286286 utilization and cost-sharing expense. 20
287287 (j) To monitor the adequacy of each health plan’s compliance with the provisions of the 21
288288 federal Mental Health Parity Act, including a review of related claims processing and 22
289289 reimbursement procedures. Findings, recommendations, and assessments shall be made available 23
290290 to the public. 24
291291 (k) To monitor the transition from fee-for-service and toward global and other alternative 25
292292 payment methodologies for the payment for healthcare services. Alternative payment 26
293293 methodologies should be assessed for their likelihood to promote access to affordable health 27
294294 insurance, health outcomes, and performance. 28
295295 (l) To report annually, no later than July 1, 2014, then biannually thereafter, on hospital 29
296296 payment variation, including findings and recommendations, subject to available resources. 30
297297 (m) Notwithstanding any provision of the general or public laws or regulation to the 31
298298 contrary, provide a report with findings and recommendations to the president of the senate and the 32
299299 speaker of the house, on or before April 1, 2014, including, but not limited to, the following 33
300300 information: 34
301301
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304304 (1) The impact of the current, mandated healthcare benefits as defined in §§ 27-18-48.1, 1
305305 27-18-60, 27-18-62, 27-18-64, similar provisions in chapters 19, 20 and 41 of title 27, and §§ 27-2
306306 18-3(c), 27-38.2-1 et seq., or others as determined by the commissioner, on the cost of health 3
307307 insurance for fully insured employers, subject to available resources; 4
308308 (2) Current provider and insurer mandates that are unnecessary and/or duplicative due to 5
309309 the existing standards of care and/or delivery of services in the healthcare system; 6
310310 (3) A state-by-state comparison of health insurance mandates and the extent to which 7
311311 Rhode Island mandates exceed other states benefits; and 8
312312 (4) Recommendations for amendments to existing mandated benefits based on the findings 9
313313 in (m)(1), (m)(2), and (m)(3) above. 10
314314 (n) On or before July 1, 2014, the office of the health insurance commissioner, in 11
315315 collaboration with the director of health and lieutenant governor’s office, shall submit a report to 12
316316 the general assembly and the governor to inform the design of accountable care organizations 13
317317 (ACOs) in Rhode Island as unique structures for comprehensive healthcare delivery and value-14
318318 based payment arrangements, that shall include, but not be limited to: 15
319319 (1) Utilization review; 16
320320 (2) Contracting; and 17
321321 (3) Licensing and regulation. 18
322322 (o) On or before February 3, 2015, the office of the health insurance commissioner shall 19
323323 submit a report to the general assembly and the governor that describes, analyzes, and proposes 20
324324 recommendations to improve compliance of insurers with the provisions of § 27-18-76 with regard 21
325325 to patients with mental health and substance use disorders. 22
326326 (p) To work to ensure the health insurance coverage of behavioral health care under the 23
327327 same terms and conditions as other health care, and to integrate behavioral health parity 24
328328 requirements into the office of the health insurance commissioner insurance oversight and 25
329329 healthcare transformation efforts. 26
330330 (q) To work with other state agencies to seek delivery system improvements that enhance 27
331331 access to a continuum of mental health and substance use disorder treatment in the state; and 28
332332 integrate that treatment with primary and other medical care to the fullest extent possible. 29
333333 (r) To direct insurers toward policies and practices that address the behavioral health needs 30
334334 of the public and greater integration of physical and behavioral healthcare delivery. 31
335335 (s) The office of the health insurance commissioner shall conduct an analysis of the impact 32
336336 of the provisions of § 27-38.2-1(i) on health insurance premiums and access in Rhode Island and 33
337337 submit a report of its findings to the general assembly on or before June 1, 2023. 34
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341341 (t) To undertake the analyses, reports, and studies contained in this section: 1
342342 (1) The office shall hire the necessary staff and prepare a request for proposal for a qualified 2
343343 and competent firm or firms to undertake the following analyses, reports, and studies: 3
344344 (i) The firm shall undertake a comprehensive review of all social and human service 4
345345 programs having a contract with or licensed by the state or any subdivision of the department of 5
346346 children, youth and families (DCYF), the department of behavioral healthcare, developmental 6
347347 disabilities and hospitals (BHDDH), the department of human services (DHS), the department of 7
348348 health (DOH), and Medicaid for the purposes of: 8
349349 (A) Establishing a baseline of the eligibility factors for receiving services; 9
350350 (B) Establishing a baseline of the service offering through each agency for those 10
351351 determined eligible; 11
352352 (C) Establishing a baseline understanding of reimbursement rates for all social and human 12
353353 service programs including rates currently being paid, the date of the last increase, and a proposed 13
354354 model that the state may use to conduct future studies and analyses; 14
355355 (D) Ensuring accurate and adequate reimbursement to social and human service providers 15
356356 that facilitate the availability of high-quality services to individuals receiving home and 16
357357 community-based long-term services and supports provided by social and human service providers; 17
358358 (E) Ensuring the general assembly is provided accurate financial projections on social and 18
359359 human service program costs, demand for services, and workforce needs to ensure access to entitled 19
360360 beneficiaries and services; 20
361361 (F) Establishing a baseline and determining the relationship between state government and 21
362362 the provider network including functions, responsibilities, and duties; 22
363363 (G) Determining a set of measures and accountability standards to be used by EOHHS and 23
364364 the general assembly to measure the outcomes of the provision of services including budgetary 24
365365 reporting requirements, transparency portals, and other methods; and 25
366366 (H) Reporting the findings of human services analyses and reports to the speaker of the 26
367367 house, senate president, chairs of the house and senate finance committees, chairs of the house and 27
368368 senate health and human services committees, and the governor. 28
369369 (2) The analyses, reports, and studies required pursuant to this section shall be 29
370370 accomplished and published as follows and shall provide: 30
371371 (i) An assessment and detailed reporting on all social and human service program rates to 31
372372 be completed by January 1, 2023, including rates currently being paid and the date of the last 32
373373 increase; 33
374374 (ii) An assessment and detailed reporting on eligibility standards and processes of all 34
375375
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378378 mandatory and discretionary social and human service programs to be completed by January 1, 1
379379 2023; 2
380380 (iii) An assessment and detailed reporting on utilization trends from the period of January 3
381381 1, 2017, through December 31, 2021, for social and human service programs to be completed by 4
382382 January 1, 2023; 5
383383 (iv) An assessment and detailed reporting on the structure of the state government as it 6
384384 relates to the provision of services by social and human service providers including eligibility and 7
385385 functions of the provider network to be completed by January 1, 2023; 8
386386 (v) An assessment and detailed reporting on accountability standards for services for social 9
387387 and human service programs to be completed by January 1, 2023; 10
388388 (vi) An assessment and detailed reporting by April 1, 2023, on all professional licensed 11
389389 and unlicensed personnel requirements for established rates for social and human service programs 12
390390 pursuant to a contract or established fee schedule; 13
391391 (vii) An assessment and reporting on access to social and human service programs, to 14
392392 include any wait lists and length of time on wait lists, in each service category by April 1, 2023; 15
393393 (viii) An assessment and reporting of national and regional Medicaid rates in comparison 16
394394 to Rhode Island social and human service provider rates by April 1, 2023; 17
395395 (ix) An assessment and reporting on usual and customary rates paid by private insurers and 18
396396 private pay for similar social and human service providers, both nationally and regionally, by April 19
397397 1, 2023; and 20
398398 (x) Completion of the development of an assessment and review process that includes the 21
399399 following components: eligibility; scope of services; relationship of social and human service 22
400400 provider and the state; national and regional rate comparisons and accountability standards that 23
401401 result in recommended rate adjustments; and this process shall be completed by September 1, 2023, 24
402402 and conducted biennially hereafter. The biennial rate setting shall be consistent with payment 25
403403 requirements established in § 1902(a)(30)(A) of the Social Security Act, 42 U.S.C. § 26
404404 1396a(a)(30)(A), and all federal and state law, regulations, and quality and safety standards. The 27
405405 results and findings of this process shall be transparent, and public meetings shall be conducted to 28
406406 allow providers, recipients, and other interested parties an opportunity to ask questions and provide 29
407407 comment beginning in September 2023 and biennially thereafter. 30
408408 (3) In fulfillment of the responsibilities defined in subsection (t), the office of the health 31
409409 insurance commissioner shall consult with the Executive Office of Health and Human Services. 32
410410 (u) Annually, each department (namely, EOHHS, DCYF, DOH, DHS, and BHDDH) shall 33
411411 include the corresponding components of the assessment and review (i.e., eligibility; scope of 34
412412
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415415 services; relationship of social and human service provider and the state; and national and regional 1
416416 rate comparisons and accountability standards including any changes or substantive issues between 2
417417 biennial reviews) including the recommended rates from the most recent assessment and review 3
418418 with their annual budget submission to the office of management and budget and provide a detailed 4
419419 explanation and impact statement if any rate variances exist between submitted recommended 5
420420 budget and the corresponding recommended rate from the most recent assessment and review 6
421421 process starting October 1, 2023, and biennially thereafter. 7
422422 (v) The general assembly shall appropriate adequate funding as it deems necessary to 8
423423 undertake the analyses, reports, and studies contained in this section relating to the powers and 9
424424 duties of the office of the health insurance commissioner. 10
425425 (w) To undertake analyses, reports, studies, and recommendations with respect to 11
426426 reimbursement and financing for the provision of primary care services to Rhode Island patients, 12
427427 as follows: 13
428428 (1) These primary care financing analyses will, to the extent possible, examine all sources 14
429429 of financing for primary care from all types of health insurance including, without limitation, 15
430430 Medicaid, commercial insurance, and Medicare. In addition to fee-for-service reimbursement, the 16
431431 analysis will also examine and consider other forms of primary care financing, including, but not 17
432432 limited to, shared savings programs, capitation, specialized payment mechanisms for community 18
433433 health centers, quality bonuses, and care management funding. 19
434434 (2) These primary care financing analyses will be conducted with the goal of understanding 20
435435 if current payment methodologies for primary care support the care delivery models needed for 21
436436 primary care to achieve its full potential. These models include those defined in the 2021 National 22
437437 Academies of Sciences, Engineering, and Medicine report, “Implementing high-quality primary 23
438438 care: Rebuilding the foundation of health care.” 24
439439 (3) On or before July 1, 2026 and every two (2) years thereafter, the office shall publish 25
440440 and submit to the general assembly a report outlining current financing structures and 26
441441 reimbursement rates for Rhode Island primary care providers. For the report due in 2026, the office 27
442442 may delay completion of this report for up to ninety (90) days as long as it publishes and provides 28
443443 notice to the general assembly of the circumstances requiring delayed completion before July 1, 29
444444 2026. This report shall include detailed information on the scope of the office’s analysis, including 30
445445 the definition for primary care services that it is adopting and may update from time to time. To the 31
446446 extent possible, this report shall include: 32
447447 (i) Sufficient information to allow comparison between reimbursement by insurer, by 33
448448 insurance market segment, geography, practice type, and other circumstances that may impact 34
449449
450450
451451 LC002320 - Page 13 of 15
452452 reimbursement rates; 1
453453 (ii) Information regarding alternative payment methodologies such as shared savings 2
454454 programs, capitation, specialized payment mechanisms for federally qualified health centers, 3
455455 quality bonuses, and care management funding; and 4
456456 (iii) Sufficient historical information to see how primary care reimbursement and financing 5
457457 has changed over time. 6
458458 (4) On or before September 1, 2026 and every two (2) years thereafter, the office shall 7
459459 publish and submit to the general assembly a report making and justifying recommendations for 8
460460 adjustments to primary care reimbursement and financing. For the report due in 2026, the office 9
461461 may delay completion of this report for up to ninety (90) days as long as it publishes and provides 10
462462 notice to the general assembly of the circumstances requiring delayed completion by September 1, 11
463463 2026. In preparing these recommendations, the office may investigate and consider other relevant 12
464464 facts and circumstances, including, but not limited to, access to care, quality of care, benchmark 13
465465 reimbursement rates from other payers or jurisdictions, inflation, input costs of service provision, 14
466466 and/or the reimbursement environment for other clinical services. Such rate adjustment 15
467467 recommendations may also include recommended adjustments to primary care financing 16
468468 mechanisms other than fee-for-service including, but not limited to, shared savings programs, 17
469469 capitation, specialized payment mechanisms for federally qualified health centers, quality bonuses, 18
470470 and care management funding, with a goal of supporting best practice team-based models of 19
471471 primary care. 20
472472 (5) With respect to rate adjustment recommendations for Medicaid fee-for-service and 21
473473 Medicaid managed care, each state government department involved in the financing of Medicaid 22
474474 primary care shall include the recommended rates in their annual budget submission to the office 23
475475 of management and budget and provide a detailed explanation and impact statement if any rate 24
476476 variances exist between the submitted recommended budget and the corresponding recommended 25
477477 rate from the office's most recent review under this subsection. 26
478478 (6) With respect to commercial insurance reimbursement, the office shall use the analyses 27
479479 and recommendations under this subsection to inform existing regulatory activities (e.g. its 28
480480 affordability standards regulations), and shall further determine whether it is necessary or desirable 29
481481 to use existing regulatory authority to promote adoption of the office's recommendations in other 30
482482 ways. To the extent allowable under federal law (including Rutledge v. PCMA, 141 S.Ct. 474 31
483483 (2020)), self-insured commercial insurance shall be within the scope of the office's analysis, 32
484484 recommendations, and regulatory approach. 33
485485 (7) With respect to Medicare reimbursement policies, the office shall seek opportunities 34
486486
487487
488488 LC002320 - Page 14 of 15
489489 for its recommendations under this subsection to be influential proposed potential language: With 1
490490 respect to Medicare reimbursement policies, the office shall use the analyses and recommendations 2
491491 under this subsection to inform the Centers for Medicare and Medicaid services of the adequacy of 3
492492 Medicare’s primary care investment in Rhode Island and to inform state healthcare planning efforts. 4
493493 (8) In performing this work, the office shall convene and regularly consult an advisory 5
494494 committee with the following membership: 6
495495 (i) Nine (9) members, selected by the governor, one of whom shall be the executive 7
496496 secretary of the executive office of health and human services, or designee; one of whom shall be 8
497497 the director of the department of health, or designee; one of whom shall be a representative of a 9
498498 large primary care provider that for purposes of this section is a provider with greater than ten (10) 10
499499 medical professionals on staff (including pediatrics); one of whom shall be a representative of a 11
500500 small primary care provider that for the purposes of this section is a provider with less than ten (10) 12
501501 medical professionals on staff (including pediatrics); one of whom shall be a member of the staff 13
502502 of a hospital operated by Brown University Health; one of whom shall be a member of the staff at 14
503503 a hospital operated by Care New England; one of whom shall be a representative of a community 15
504504 health center; one of whom shall be a representative of a Medicaid Managed Care Organization 16
505505 (MCO); and one of whom shall be a representative of a patient care advocacy group 17
506506 (ii) Proceedings of this advisory committee shall be subject to, chapter 46 of title 42 (“open 18
507507 meetings”). 19
508508 SECTION 2. This act shall take effect upon passage. 20
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512512
513513
514514 LC002320 - Page 15 of 15
515515 EXPLANATION
516516 BY THE LEGISLATIVE COUNCIL
517517 OF
518518 A N A C T
519519 RELATING TO STATE AFFAIRS AND GOVERNMENT -- THE RHODE ISLAND HEALTH
520520 CARE REFORM ACT OF 2004 -- HEALTH INSURANCE OVERSIGHT
521521 ***
522522 This act would add to the powers and duties of the office of the health insurance 1
523523 commissioner (OHIC) the undertaking of analyses, reports, studies, and recommendations with 2
524524 respect to reimbursement and financing for the provision of primary care services to Rhode 3
525525 Islanders. The act would establish a nine (9) member advisory committee to advise the OHIC. 4
526526 This act would take effect upon passage. 5
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528528 LC002320
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