reglab/statecodes huggingface dataset:
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-9. - Required reports.

§ 27-41-9. Required reports.
(a)
Every health maintenance organization shall annually, on or before the first day of March, file a report verified by at least two (2) principal officers with the director, with a copy to the director of health, covering the preceding calendar year.
(b)
The annual report shall be on forms prescribed by the director in consultation with the director of health and shall include:
(1)
A financial statement of the organization, including its balance sheet and receipts and disbursements for the preceding year certified by an independent public accountant;
(2)
Any material changes in the information submitted pursuant to § 27-41-3(c);
(3)
The number of persons enrolled during the year, the number of enrollees as of the end of the year, and the number of enrollments terminated during the year;
(4)
A summary of information compiled pursuant to § 27-41-4(a)(2)(iv) in the form required by the director of health; and
(5)
Any other information relating to the performance of the health maintenance organization as is necessary to enable the director to carry out his or her duties under this chapter.
(c)
In addition to the reports required in subsection (a), every health maintenance organization shall on a form prescribed by the director report on or before September 30 of each year a filing that shall set forth the amount of uncovered and covered expenses that are payable and are more than ninety (90) days past due. That report shall cover the period January 1 through July 31 of that year. At the time of the filing of the annual report as required in subsection (a), a report shall be filed setting forth the amount of uncovered and covered expenses that are payable and are more than ninety (90) days past due; that report shall cover the preceding period of August 1 through December 31 of that year.
(d)
Every health maintenance organization shall also file quarterly statements with the insurance commissioner, due on or before forty-five (45) days after the quarter ending in accordance with the National Association of Insurance Commissioners’ guidelines and procedures, and shall be available for inspection by the public.
(e)
The insurance commissioner shall also require compliance with chapters 12 and 12.1 of this title.
History of Section.
P.L. 1983, ch. 225, § 2; P.L. 1986, ch. 198, § 12; P.L. 1994, ch. 404, § 13; P.L. 1996, ch. 188, § 16; P.L. 2002, ch. 292, § 85.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-10. - Information to enrollees.

§ 27-41-10. Information to enrollees.
Every health maintenance organization shall promptly provide to its enrollees notice of any material change in the operation of the organization that will affect them directly. New enrollees shall receive at least the following information:
(1)
The most recent annual statement of financial condition including a balance sheet and summary of receipts and disbursements;
(2)
A description of the organizational structure and operation of the health maintenance organization;
(3)
A description of services and information as to where and how to secure them; and
(4)
A clear and understandable description of the health maintenance organization’s method for resolving enrollee complaints.
History of Section.
P.L. 1983, ch. 225, § 2.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-11. - Complaint system.

§ 27-41-11. Complaint system.
(a)
Every health maintenance organization shall establish and maintain a complaint system that has been approved by the director after consultation with the director of health to provide reasonable procedures for the resolution of written complaints initiated by enrollees concerning healthcare services.
(b)
The health maintenance organization shall maintain records of written complaints filed with it.
(c)
The director of business regulation or the director of health, or both, may examine any complaint system.
History of Section.
P.L. 1983, ch. 225, § 2.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-13.1. - Initial net worth and capital requirements.

§ 27-41-13.1. Initial net worth and capital requirements.
Before the director issues a certificate of authority in accordance with § 27-41-4 of this act, an applicant seeking to establish or operate a health maintenance organization shall have the greater of:
(1)
The amount of capital required for a health organization under chapter 4.7 of this title;
(2)
An initial net worth of three million dollars ($3,000,000); or
(3)
At the commissioner’s discretion, an amount greater than required under subsection (1) or (2), as indicated by a business plan and a projected risk-based capital calculation after the first full year of operation based on the most current National Association of Insurance Commissioners Health Annual Statements Blank.
History of Section.
P.L. 2005, ch. 176, § 2; P.L. 2023, ch. 395, art. 1, § 14, effective December 31, 2023.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-13.2. - Ongoing net worth and capital requirements.

§ 27-41-13.2. Ongoing net worth and capital requirements.
(a)
A health maintenance organization shall maintain minimum net worth equal to the greater of two million five hundred thousand dollars ($2,500,000) or the amount necessary to maintain capital required pursuant to chapter 4.7 of this title.
(b)
The amount in subsection (a) may be adjusted annually for inflation at the director’s discretion.
History of Section.
P.L. 2005, ch. 176, § 2.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-13.3. - Waiver, surplus notes, and risk-based capital requirements.

§ 27-41-13.3. Waiver, surplus notes, and risk-based capital requirements.
(a)
The director may waive any of the net worth or total adjusted capital requirements, or both, as set forth in § 27-41-13.1 or § 27-41-13.2, whenever satisfied that the health maintenance organization has sufficient net worth or total adjusted capital, or both, and an adequate history of generating net income to ensure its financial viability for the next year, or its performance and obligations are guaranteed by an organization with sufficient net worth and an adequate history of generating net income, or the assets of the health maintenance organization or its contracts with insurers, hospital or medical service corporations, governments, or other organizations are sufficient to reasonably assure the performance of its obligations; provided, however, that in no event shall the net worth requirement be less than two million five hundred thousand dollars ($2,500,000).
(b) Surplus notes.
(1)
In determining net worth, no debt is considered fully subordinated unless the subordination clause is in a form acceptable to the director. Any interest obligation relating to the repayment of any subordinated debt must be similarly subordinated.
(2)
The interest expenses relating to the repayment of any fully subordinated debt are considered covered expenses.
(3)
Any debt incurred by a note meeting the requirements of this section, and otherwise acceptable to the director, is not considered a liability and is recorded as equity.
(c)
In addition to the net worth and capital requirements of §§ 27-41-13.1 through 27-41-13.3, all requirements of chapter 4.7 of this title shall apply to health maintenance organizations.
History of Section.
P.L. 2005, ch. 176, § 2.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-14.1. - Prohibition against restraint on provider — Patient communications.

§ 27-41-14.1. Prohibition against restraint on provider — Patient communications.
No health maintenance organization shall refuse to contract with or compensate for covered services an otherwise eligible healthcare provider solely because the provider has in good faith communicated with one or more of his or her current, former, or prospective patients regarding the provisions, terms, requirements, restrictions, or other treatment options not provided by the health maintenance organization and of the health maintenance organization’s products or services, or both, as they relate to the needs of the provider’s patients. By way of illustration only, and without limiting the protections afforded in this section, the communications within this section may involve hospital stays, emergency room use, and referral to specialists. Any provision contained in any contract between a health maintenance organization and a healthcare provider that violates the provisions of this section shall be null and void, and any attempt by a health maintenance organization to enforce that provision shall subject the health maintenance organization to assessment of a penalty of up to five thousand dollars ($5,000). These penalties shall be enforced by the consumer protection division of the department of the attorney general in the district court.
History of Section.
P.L. 1997, ch. 352, § 1.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-15. - Powers of insurers and hospital and medical service corporations.

§ 27-41-15. Powers of insurers and hospital and medical service corporations.
An insurance company licensed in this state may either directly or through a subsidiary or affiliate organize and operate a health maintenance organization under the provisions of this chapter. Notwithstanding any other law that may be inconsistent with this section, any two (2) or more state insurance companies, or subsidiaries or affiliates of those companies, may jointly organize and operate a health maintenance organization. A hospital or medical service corporation may own and operate a health maintenance organization. With respect to those corporations, operation of a health maintenance organization shall not be deemed to be participation in the business of insurance. The business of insurance is deemed to include the providing of health care by a health maintenance organization owned or operated by an insurer or a subsidiary of an insurer.
History of Section.
P.L. 1983, ch. 225, § 2.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-16. - Examination.

§ 27-41-16. Examination.
(a)
The director of business regulation may make an examination of the affairs of any health maintenance organization and the providers with whom the organization has contracts, agreements, or other arrangements pursuant to its healthcare plan as often as is reasonably necessary for the protection of the interests of the people of this state. The examination shall be performed and the associated costs shall be borne by the company in accordance with all the provisions of chapter 13.1 of this title.
(b)
The director of health may make an examination concerning the quality of healthcare services of any health maintenance organization and the providers with whom the organization has contracts, agreements, or other arrangements as often as is reasonably necessary for the protection of the interests of the people of this state.
(c)
Each health maintenance organization shall establish and maintain on an ongoing basis a quality assurance program that involves the assessment of all quality assurance activities conducted in the provision of its healthcare services to its subscribers, which shall include no less than:
(1)
Assessment of health outcomes;
(2)
Ongoing review of health services by physicians and other health professionals; and
(3)
Utilization and systematic data collection.
(d)
Every health maintenance organization and provider shall submit its books and records to those examinations and in every way facilitate them. For the purpose of examinations, the director of business regulation and the director of health may administer oaths to, and examine, the officers and agents of the health maintenance organization and the principals of their providers concerning their business.
(e)
The expenses of examinations under this section shall be assessed against the organization being examined and remitted to the director of the department for whom the examination is being conducted. The total cost of those examinations, whether made by the director of business regulation or by the director of health, shall be borne by the examined health maintenance organizations and shall be in the same amount as provided for in § 27-13-1, and shall be paid to the director of the department conducting the examination for deposit as general revenues. That assessment shall be in addition to any taxes and fees payable to the state. In instances where the examination is performed by outside accountants, the expenses of the examination shall be borne by the examined health maintenance organization.
(f)
In lieu of any state examination, the director of business regulation or the director of health may accept the report of an examination made by the director of business regulation or the director of health of another state.
History of Section.
P.L. 1983, ch. 225, § 2; P.L. 1992, ch. 133, art. 24, § 1; P.L. 1994, ch. 404, § 13; P.L. 1995, ch. 370, art. 40, § 88; P.L. 2023, ch. 395, art. 1, § 14, effective December 31, 2023.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-18. - Rehabilitation, liquidation, or conservation of health maintenance organization.

§ 27-41-18. Rehabilitation, liquidation, or conservation of health maintenance organization.
(a)
Any rehabilitation, liquidation, or conservation of a health maintenance organization shall be deemed to be the rehabilitation, liquidation, or conservation of an insurance company and shall be conducted under the supervision of the director of business regulation pursuant to chapters 14.1, 14.2, and 14.3 of this title. The director of business regulation may apply for an order from the superior court directing the director to rehabilitate, liquidate, or conserve a health maintenance organization upon any one or more of the grounds included in chapter 14.3 of this title or upon any one or more of the following grounds:
(1)
That the health maintenance organization is insolvent;
(2)
That the health maintenance organization is in an unsound financial condition;
(3)
That the health maintenance organization’s business policies are unsound or improper;
(4)
That the health maintenance organization’s condition or management is such as to render its further transaction of business hazardous to the public or its enrollees;
(5)
That the health maintenance organization’s funds, net cash, or contingent assets are deficient; or
(6)
That the health maintenance organization is conducting its business fraudulently or refuses or neglects to comply with the laws of this state.
(b)
A claim by a healthcare provider who agrees not to assert that claim against any enrollee of the health maintenance organization for an uncovered expenditure has priority over other providers of services.
(c)
For purposes of determining the priority of distribution of general assets, claims of enrollees and enrollees’ beneficiaries shall have the same priority as established in chapter 14.3 of this title for policyholders and beneficiaries of insureds of insurance companies. If an enrollee is liable to a provider for services provided pursuant to and covered by the health benefit plan, that liability shall have the status of an enrollee claim for distribution of general assets. A provider who is obligated by statute or agreement to hold enrollees harmless from liability for services provided pursuant to and covered by a health benefit plan shall have a priority of distribution of the general assets immediately following that of enrollees and enrollees’ beneficiaries as described herein, and immediately preceding the priority of distribution for priority Class 7 described in § 27-14.3-46.
History of Section.
P.L. 1983, ch. 225, § 2; P.L. 1991, ch. 370, § 4; P.L. 2005, ch. 176, § 1.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-18.1. - Summary orders and supervision.

§ 27-41-18.1. Summary orders and supervision.
(a)
Whenever the director determines that the financial condition of a health maintenance organization is such that its continued operation must be hazardous to its enrollees, creditors, or the general public, or that it has violated any provision of this chapter, the director may, after notice and hearing, order the health maintenance organization to take action reasonably necessary to rectify the condition or violation, including, but not limited to, one or more of the following:
(1)
Reduce the total amount of present and potential liability for benefits by reinsurance or other method acceptable to the director;
(2)
Reduce the volume of new business being accepted;
(3)
Reduce expenses by specified methods;
(4)
Suspend or limit the writing of new business for a period of time;
(5)
Increase the health maintenance organization’s capital and surplus by contribution;
(6)
Initiate administrative supervision proceedings against the health maintenance organization in accordance with chapter 14.1 of this title; or
(7)
Take other steps the director may deem appropriate under the circumstances.
(b)
For purposes of this section, the violation by a health maintenance organization of any law of this state to which the health maintenance organization is subject shall be deemed a violation of this chapter.
(c)
The director is authorized to adopt regulations to set uniform standards and criteria for early warning that the continued operation of any health maintenance organization might be hazardous to its enrollees, creditors, or the general public and to set standards for evaluating the financial condition of any health maintenance organization.
(d)
The remedies and measures available to the director under this section shall be in addition to, and not in lieu of, the remedies and measures available to the director under the provisions of chapters 14.1, 14.2, and 14.3 of this title.
History of Section.
P.L. 2005, ch. 176, § 2; P.L. 2023, ch. 395, art. 1, § 14, effective December 31, 2023.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-19. - Rules and regulations.

§ 27-41-19. Rules and regulations.
The director of business regulation and the director of health shall, after notice and hearing, promulgate reasonable rules and regulations that are necessary or proper to carry out the provisions of this chapter. Those rules and regulations shall be subject to review in accordance with the provisions of chapter 35 of title 42.
History of Section.
P.L. 1983, ch. 225, § 2; P.L. 1995, ch. 334, § 1; P.L. 2002, ch. 292, § 85.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-20. - Administrative procedures.

§ 27-41-20. Administrative procedures.
(a)
When the director of business regulation has cause to believe that grounds for the denial of an application for a license exist, or that grounds for the suspension or revocation of a license exist, the director shall notify the health maintenance organization and the director of health, in writing, specifically stating the grounds for denial, suspension, or revocation and fixing a time for a hearing on the matter.
(b)
The director of health, or his or her designated representative, shall be in attendance at the hearing and shall participate in the proceedings. The recommendation and findings of the director of health, with respect to matters relating to the quality of healthcare services provided by the health maintenance organization in connection with any decision regarding the denial, suspension, or revocation of a license, shall be conclusive and binding upon the director of business regulation. After the hearing, or upon the failure of the health maintenance organization to appear at the hearing, the director of business regulation shall take any action that is deemed advisable on written findings that shall be mailed to the health maintenance organization with a copy to the director of health. The action of the director of business regulation and the recommendation and findings of the director of health shall be subject to review by the superior court for the county of Providence.
(c)
The provisions of chapter 35 of title 42 shall apply to proceedings under this section to the extent they are not in conflict with subsections (a) and (b) of this section.
History of Section.
P.L. 1983, ch. 225, § 2.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-22. - Statutory construction and relationship to other laws.

§ 27-41-22. Statutory construction and relationship to other laws.
(a)
Except as otherwise provided in this chapter, provisions of chapters 19, 20, 20.1, and 20.2 of this title shall not be applicable to any health maintenance organization granted a license under this chapter. This provision shall not apply to an insurer or hospital or medical service corporation licensed and regulated pursuant to the insurance laws or the hospital or medical service corporation laws of this state except with respect to its health maintenance organization activities authorized and regulated pursuant to this chapter.
(b)
Solicitation of enrollees by a health maintenance organization granted a license, or its representatives, shall not be construed to violate any provision of law relating to solicitation or advertising by health professionals.
(c)
Any health maintenance organization authorized under this chapter shall not be deemed to be practicing a profession, and may employ, or contract with, any licensed health professional to deliver professional services.
(d)
No section of chapter 15 of title 23, the Health Care Certificate of Need Act, shall be abridged by this chapter.
(e)
All information relating to a subscriber’s healthcare history, diagnosis, condition, treatment, or evaluation shall be considered confidential healthcare information and shall not be released or transferred except under the safeguards established by chapter 37.3 of title 5, the Confidentiality of Health Care Information Act.
(f)
The provisions of chapter 19.1 of this title, relating to extended medical benefits, shall be construed to apply to enrollees of health maintenance organizations.
(g)
Any health maintenance organization authorized under this chapter shall be deemed to be an insurer, for the purposes of compliance with chapter 17 of title 44.
History of Section.
P.L. 1983, ch. 225, § 2; P.L. 2007, ch. 73, art. 28, § 3.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-23. - Filings and reports as public documents.

§ 27-41-23. Filings and reports as public documents.
The provisions of chapter 2 of title 38, relating to access to public records, shall apply to all applications, filings, and reports required under this chapter. Annual and quarterly financial statements shall be treated as public documents.
History of Section.
P.L. 1983, ch. 225, § 2; P.L. 1994, ch. 404, § 13.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-24. - Director of health’s authority to contract.

§ 27-41-24. Director of health’s authority to contract.
The director of health, in carrying out his or her obligations under §§ 27-41-4(a)(2), 27-41-16(b), and 27-41-17(b), may contract with qualified persons to make recommendations concerning the determinations required to be made by the director. Those recommendations may be accepted in full or in part by the director of health.
History of Section.
P.L. 1983, ch. 225, § 2.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-25. - Holding company systems.

§ 27-41-25. Holding company systems.
Except to the extent superseded by chapter 64 of this title, all of the provisions of chapter 35 of this title apply to corporations organized or licensed pursuant to this chapter.
History of Section.
P.L. 1983, ch. 225, § 2; P.L. 1998, ch. 90, § 5; P.L. 2000, ch. 178, § 9; P.L. 2000, ch. 200, § 19; P.L. 2000, ch. 229, § 19.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-26. - Enrollee liability.

§ 27-41-26. Enrollee liability.
No enrollee is liable to any provider for charges for covered health services, except for amounts due for copayments, when provided or made available to enrolled participants by a licensed health maintenance organization during a period in which premiums were paid by or on behalf of the enrollee.
History of Section.
P.L. 1983, ch. 225, § 2; P.L. 2003, ch. 341, § 1.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-26.1. - Patient responsibility — Administrative requirements.

§ 27-41-26.1. Patient responsibility — Administrative requirements.
For health benefit contracts issued, renewed, or delivered in this state the following shall apply:
(1)
The amount of copayments for physician office visits and hospital emergency room visits shall be printed on the subscriber identification cards issued to the insured.
(2)
A schedule of all applicable copayments, by product or by group, in paper or electronic format, or both, shall be published, updated, and distributed to participating providers.
(3)
On an annual basis, notification shall be provided to subscribers regarding their responsibility for copayments and deductibles.
History of Section.
P.L. 2001, ch. 283, § 3; P.L. 2002, ch. 292, § 85.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-27.1. - No derogation of attorney general.

§ 27-41-27.1. No derogation of attorney general.
No provision of this chapter shall derogate from the common law or statutory authority of the attorney general nor shall any provision be construed as a limitation on the common law or statutory authority of the attorney general, including the authority to investigate at any time charitable assets for the purpose of determining and ascertaining whether they are being administered in accordance with law and with the terms and purposes of the law.
History of Section.
P.L. 1998, ch. 90, § 10.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-27.2. - Health insurance rates.

§ 27-41-27.2. Health insurance rates.
No insurance company organized as a stock or mutual corporation that merges or consolidates with, acquires ownership or control or possession of twenty percent (20%) or greater of the operating assets of, or acquires control of a nonprofit hospital service corporation organized under chapter 19 of this title, a nonprofit medical service corporation organized under chapter 20 of this title, or a health maintenance organization organized under chapter 41 of this title: (1) May file with any state agency for review or approval any proposed rate to be used by the company in the state, or (2) May charge to any party in the state any rate or premium, that takes into account or reflects in any manner the value of any contribution, distribution, or allocation the company expends or incurs in establishing or funding a charitable foundation organized to maintain or account for the assets of a nonprofit hospital service corporation, nonprofit medical service corporation, or health maintenance organization. For any rate that is to be charged to policyholders, regardless of whether this rate is subject to approval by a state agency under this or another chapter, the company shall at least thirty (30) days before implementing the rate submit under oath to the commissioner of insurance an accounting that documents the cost structure on which the rate is based and demonstrates the company’s compliance with this section.
History of Section.
P.L. 1999, ch. 215, § 5; P.L. 1999, ch. 376, § 5.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-28. - Applicability.

§ 27-41-28. Applicability.
Notwithstanding any of the provisions of this chapter, except for §§ 27-41-5, 27-41-26, 27-41-35, and 27-41-37 which shall apply to all licensed health maintenance organizations including health maintenance organizations licensed pursuant to chapter 17 of title 23, nothing contained in this chapter shall apply to those health maintenance organizations licensed pursuant to chapter 17 of title 23 that were actively engaged in the provision of or making available to enrolled participants healthcare services prior to January 1, 1982; provided, that this exemption shall not under any circumstances have effect beyond July 1, 1994, and that on and after July 1, 1991, § 27-41-18 shall also apply to all licensed health maintenance organizations licensed pursuant to chapter 17 of title 23. Any health maintenance organization that was actively engaged in the provision of or making available to enrolled participants healthcare services prior to January 1, 1982, including a health maintenance organization that experiences a “change in owner” or “change in operator” as defined in § 23-17-2, may, at its discretion, continue to be licensed under the requirements and provisions of chapter 17 of title 23 until July 1, 1994, or under the requirements and provisions of this chapter. That health maintenance organization shall be deemed to be licensed under the requirements and the provisions of this chapter upon submission of materials required under § 27-41-3(b)(1), (2), (3), (4), and (11) sufficient and satisfactory to the director. Until July 1, 1998, the director shall waive, reduce, or alter the requirements of §§ 27-41-4 and 27-41-13 for licensure for this defined class of health maintenance organizations unless after notice and hearing the director finds that reasonable progress is not being made toward meeting the requirements of those sections. After July 1, 1998, the director may waive, reduce, or alter the requirements of §§ 27-41-4 and 27-41-13 for licensure for this defined class of health maintenance organizations if the licensee demonstrates to the satisfaction of the director that it is making satisfactory progress toward compliance with the requirements of those sections.
History of Section.
P.L. 1983, ch. 225, § 2; P.L. 1990, ch. 161, § 1; P.L. 1991, ch. 345, § 5; P.L. 1991, ch. 370, § 4.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-29. - Severability.

§ 27-41-29. Severability.
If any section, term, or provision of this chapter shall be adjudged invalid for any reason, that judgment shall not affect, impair, or invalidate any other section, term, or provision of this chapter, but the remaining sections, terms, and provisions shall be and remain in full force and effect.
History of Section.
P.L. 1983, ch. 225, § 2.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-29.1. - Uniform explanation of benefits and coverage.

§ 27-41-29.1. Uniform explanation of benefits and coverage.
(a)
A health maintenance organization shall provide a summary of benefits and coverage explanation and definitions to policyholders and others required by, and at the times and in the format required by, the federal regulations adopted under section 2715 of the Public Health Service Act, as amended by the Patient Protection and Affordable Care Act [42 U.S.C. § 300gg-15]. The forms required by this section shall be made available to the commissioner on request. Nothing in this section shall be construed to limit the authority of the commissioner under existing state law.
(b)
The provisions of this section shall apply to grandfathered health plans. This section shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by accident or both; and (9) Other limited benefit policies.
(c)
If the commissioner of the office of the health insurance commissioner determines that the corresponding provision of the Patient Protection and Affordable Care Act has been declared invalid by a final judgment of the federal judicial branch or has been repealed by an act of Congress, on the date of the commissioner’s determination this section shall have its effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this section. Nothing in this section shall be construed to limit the authority of the commissioner under existing state law.
History of Section.
P.L. 2012, ch. 256, § 10; P.L. 2012, ch. 262, § 10.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-29.2. - Filing of policy forms.

§ 27-41-29.2. Filing of policy forms.
(a)
A health maintenance organization shall file all policy forms and rates used by it in the state with the commissioner, including the forms of any rider, endorsement, application blank, and other matter generally used or incorporated by reference in its policies or contracts of insurance. No such form shall be used if disapproved by the commissioner under this section, or if the commissioner’s approval has been withdrawn after notice and an opportunity to be heard, or until the expiration of sixty (60) days following the filing of the form. Such a company shall comply with its filed and approved forms. If the commissioner finds from an examination of any form that it is contrary to the public interest or the requirements of this code or duly promulgated regulations, he or she shall forbid its use, and shall notify the corporation in writing.
(b)
Each rate filing shall include a certification by a qualified actuary that to the best of the actuary’s knowledge and judgment, the entire rate filing is in compliance with applicable laws and that the benefits offered or proposed to be offered are reasonable in relation to the premium to be charged. A health insurance carrier shall comply with its filed and approved rates and forms.
History of Section.
P.L. 2012, ch. 256, § 10; P.L. 2012, ch. 262, § 10.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-30. - Mammograms and pap smears — Coverage mandated. [Effective until January 1, 2024.]

§ 27-41-30. Mammograms and pap smears — Coverage mandated. [Effective until January 1, 2024.]
(a)
Subscribers to any health maintenance organization plan shall be afforded coverage under that plan for mammograms and pap smears, in accordance with guidelines established by the American Cancer Society.
(b)
Notwithstanding the provisions of this chapter, subscribers to any health maintenance organization plan shall be afforded coverage for two (2) paid screening mammograms per year when recommended by a physician for women who have been treated for breast cancer within the last five (5) years or who are at high risk of developing breast cancer due to genetic predisposition (BRCA gene mutation or multiple first-degree relatives) or high risk lesion on prior biopsy (lobular carcinoma in situ) or atypical ductal hyperplasia.
History of Section.
P.L. 1988, ch. 532, § 3; P.L. 2005, ch. 405, § 4.
§ 27-41-30. Mammograms and pap smears — Coverage mandated. [Effective January 1, 2024.]
(a)
Subscribers to any health maintenance organization plan shall be afforded coverage under that plan for mammograms and pap smears, in accordance with guidelines established by the American Cancer Society.
(b)
Notwithstanding the provisions of this chapter, subscribers to any health maintenance organization plan shall be afforded coverage for:
(1)
Two (2) paid screening mammograms per year when recommended by a physician for women who have been treated for breast cancer within the last five (5) years or who are at high risk of developing breast cancer due to genetic predisposition (BRCA gene mutation or multiple first-degree relatives) or high risk lesion on prior biopsy (lobular carcinoma in situ) or atypical ductal hyperplasia; and
(2)
Any screening deemed medically necessary for proper breast cancer screening in accordance with applicable American College of Radiology guidelines including, but not limited to, magnetic resonance imaging, ultrasound, or molecular breast imaging for any person who has received notice pursuant to § 23-12.9-2 of the existence of dense breast tissue.
History of Section.
P.L. 1988, ch. 532, § 3; P.L. 2005, ch. 405, § 4; P.L. 2023, ch. 331, § 4, effective January 1, 2024; P.L. 2023, ch. 332, § 4, effective January 1, 2024.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-30.1. - Postpartum hospital stays.

§ 27-41-30.1. Postpartum hospital stays.
(a)
Every individual or group hospital or medical services plan contract delivered, issued for delivery, or renewed in this state shall provide coverage for a forty-eight-hour (48) time period in a hospital after a vaginal birth, and ninety-six (96) hours after a cesarean section for a mother and her newly born child. Any decision to shorten these minimum coverages shall be made by the attending healthcare provider in consultation with the mother. The decision shall be made in accordance with the standards for guidelines for perinatal care published by the American College of Obstetrics and Gynecology and the American Academy of Pediatrics. The standards shall be relative to early discharge, defined as less than forty-eight (48) hours for a vaginal delivery and ninety-six (96) hours for a cesarean delivery. In the case of early discharge, post-delivery care shall include home visits, parent education, assistance and training in breast or bottle feeding, and the performance of any necessary and appropriate clinical tests or any other tests or services consistent with the guidelines in this subsection.
(b)
For the purposes of this section, “attending healthcare provider” includes the attending obstetrician, pediatrician, family practitioner, general practitioner, or certified nurse midwife attending the mother and newly born child.
(c)
Any member who is aggrieved by a denial of benefits to be provided under this section may appeal the denial in accordance with regulations of the department of health that have been promulgated pursuant to chapter 17.12 of title 23 [repealed]. No policy or plan covered under this chapter shall terminate the services, reduce capitation payment, or penalize an attending physician or other healthcare provider who orders care consistent with the provisions of this section.
History of Section.
P.L. 1996, ch. 246, § 5; P.L. 1996, ch. 260, § 5; P.L. 2002, ch. 292, § 85.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-31. - Mammograms — Quality assurance standards.

§ 27-41-31. Mammograms — Quality assurance standards.
A mammogram eligible for reimbursement under § 27-41-30 shall be reimbursed only if the facility in which the mammogram has been taken and processed, and the licensed physician interpreting the mammogram both meet state-approved quality assurance standards for taking, processing, and interpreting mammograms. The director of health shall have the authority to promulgate rules and regulations necessary to carry out the provisions of this section.
History of Section.
P.L. 1989, ch. 217, § 4.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-32. - Pap smears — Quality assurance standards.

§ 27-41-32. Pap smears — Quality assurance standards.
A pap smear eligible for reimbursement under § 27-41-30 shall be reimbursed only if the laboratory in which the pap smear is processed is licensed by the department of health specifically to perform cervical cytology, or is accredited by the American Society of Cytology, or is accredited by the College of American Pathologists, or is a hospital accredited by the Joint Commission on Accreditation of HealthCare Organizations or the American Osteopathic Association at the time the pap smear is processed.
History of Section.
P.L. 1989, ch. 217, § 11.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-33. - Coverage for infertility.

§ 27-41-33. Coverage for infertility.
(a)
Any health maintenance organization service contract plan or policy delivered, issued for delivery, or renewed in this state, except a contract providing supplemental coverage to Medicare or other governmental programs, that includes pregnancy-related benefits, shall provide coverage for medically necessary expenses of diagnosis and treatment of infertility for women between the ages of twenty-five (25) and forty-two (42) years and for standard fertility-preservation services when a medically necessary medical treatment may directly or indirectly cause iatrogenic infertility to a covered person. To the extent that a health maintenance organization provides reimbursement for a test or procedure used in the diagnosis or treatment of conditions other than infertility, those tests and procedures shall not be excluded from reimbursement when provided attendant to the diagnosis and treatment of infertility for women between the ages of twenty-five (25) and forty-two (42) years; provided, that subscriber copayment, not to exceed twenty percent (20%), may be required for those programs and/or procedures the sole purpose of which is the treatment of infertility.
(b)
For purposes of this section, “infertility” means the condition of an otherwise healthy individual who is unable to conceive or sustain a pregnancy during a period of one year.
(c)
For purposes of this section, “standard fertility-preservation services” means procedures consistent with established medical practices and professional guidelines published by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or other reputable professional medical organizations.
(d)
For purposes of this section, “iatrogenic infertility” means an impairment of fertility by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes.
(e)
For purposes of this section, “may directly or indirectly cause” means treatment with a likely side effect of infertility as established by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or other reputable professional organizations.
(f)
The health insurance contract may limit coverage to a lifetime cap of one hundred thousand dollars ($100,000).
History of Section.
P.L. 1989, ch. 478, § 4; P.L. 2002, ch. 292, § 85; P.L. 2006, ch. 246, art. 34, § 4; P.L. 2007, ch. 411, § 4; P.L. 2017, ch. 132, § 4; P.L. 2017, ch. 150, § 4.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-34. - Health maintenance organizations’ assessment.

§ 27-41-34. Health maintenance organizations’ assessment.
(a)
Notwithstanding any other provisions of law, each domestic HMO shall be charged an assessment to partially support the activities of the division of insurance in the department of business regulation.
(b)
Each domestic HMO assessment shall be determined in accordance with the following ratio: (1) By dividing the HMO total direct premiums by the total direct premiums, including annuities, less policyholder dividends of all domestic insurance companies plus the total direct premiums of domestic companies licensed or regulated pursuant to chapters 19, 20, 20.1, 20.2, 20.3, 25, and 41 of this title, and chapter 62 of title 42; (2) And then by multiplying the resulting ratio times two hundred thousand dollars ($200,000).
(c)
The minimum assessment charged shall be the greater of the sum determined by subsection (b) of this section or one thousand dollars ($1,000).
History of Section.
P.L. 1990, ch. 65, art. 29, § 8; P.L. 2002, ch. 292, § 85.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-36. - Services of midwives.

§ 27-41-36. Services of midwives.
Every health maintenance organization plan contract delivered, issued for delivery, or renewed in this state shall provide coverage for the services of licensed midwives in accordance with each health maintenance organization’s respective principles and mechanisms of reimbursement, credentialing, and contracting if the services are within the licensed midwives’ area of professional competence as defined by regulations promulgated pursuant to § 23-13-9 and are currently reimbursed when rendered by any other licensed healthcare provider. No health maintenance organization may require supervision, signature, or referral by any other healthcare provider as a condition of reimbursement to a licensed midwife whose services are provided pursuant to § 27-41-5(a)(6)(ii), except when the requirements are also applicable to other categories of healthcare providers. No health maintenance organization or patient may be required to pay for duplicate services actually rendered by both a licensed midwife and any other healthcare provider. Direct payment for licensed midwives will be contingent upon services rendered in a licensed healthcare facility and for services rendered in accordance with rules and regulations promulgated by the department of health; provided, that this provision shall not prohibit payment for services pursuant to § 42-62-26 or for other services reimbursed by third-party payors.
History of Section.
P.L. 1990, ch. 168, § 4; P.L. 2002, ch. 292, § 85.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-37. - Discontinuance of coverage — Chronic disabilities.

§ 27-41-37. Discontinuance of coverage — Chronic disabilities.
No health maintenance organization subject to the provisions of this chapter shall discontinue reimbursement for or providing services for covered healthcare services of chronic disabilities, unless the patient has exhausted benefits to which he or she is entitled under the basic subscriber agreement, or unless it is at the end of the open enrollment period; provided notice of the discontinuation of reimbursement for the services is sent to subscribers who have been reimbursed for or utilized those services in the past three (3) years. The notice shall be mailed at least sixty (60) days prior to the beginning of the open enrollment period. For the purposes of this section, “chronic disability” means an impairment or illness that is likely to continue indefinitely.
History of Section.
P.L. 1991, ch. 127, § 4.
2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-38. - Drug coverage.

§ 27-41-38. Drug coverage.
No health maintenance organization that provides coverage for prescription drugs under a group plan master contract delivered, issued for delivery, or renewed in this state may require any person covered under the contract to obtain prescription drugs from a mail order pharmacy as a condition of obtaining benefits for the drugs.
History of Section.
P.L. 1991, ch. 345, § 4; P.L. 2002, ch. 292, § 85.