reglab/statecodes huggingface dataset:
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 3 - Health Insurance Reserves (230-RICR-20-30-3) › Section 230-RICR-20-30-3.3 - Premium Reserves

Current through June 14, 2024
A. General
1. Unearned premium reserves are required for
				  all contracts with respect to the period of coverage for which premiums, other
				  than premiums paid in advance, have been paid beyond the date of
				  valuation.
2. If premiums due and
				  unpaid are carried as an asset, such premiums must be treated as premiums in
				  force, subject to unearned premium reserve determination. The value of unpaid
				  commissions, premium taxes, and the cost of collection associated with due and
				  unpaid premiums must be carried as an offsetting liability.
3. The gross premiums paid in advance for a
				  period of coverage commencing after the next premium due date which follows the
				  date of valuation may be appropriately discounted to the valuation date and
				  shall be held either as a separate liability or as an addition to the unearned
				  premium reserve which would otherwise be required as a minimum.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 3 - Health Insurance Reserves (230-RICR-20-30-3) › Section 230-RICR-20-30-3.4 - Contract Reserves

Current through June 14, 2024
A. General
1. Contract reserves are required, unless
				  otherwise specified in §
											3.4(A)(2)   of this Part for:
a. All individual and group contracts with
				  which level premiums are used; or
b. All individual and group contracts with
				  respect to which, due to the gross premium pricing structure at issue, the
				  value of the future benefits at any time exceeds the value of any appropriate
				  future valuation net premiums at that time. The values specified in this
				  Subparagraph (b) shall be determined on the basis specified in §
												3.4(B)   of
				  this Part.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 3 - Health Insurance Reserves (230-RICR-20-30-3) › Section 230-RICR-20-30-3.5 - Reinsurance

Current through June 14, 2024
Increases to, or credits against reserves carried, arising
					 because of reinsurance assumed or reinsurance ceded, must be determined in a
					 manner consistent with these minimum reserve standards and with all applicable
					 provisions of the reinsurance contracts which affect the insurer's
					 liabilities.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 3 - Health Insurance Reserves (230-RICR-20-30-3) › Section 230-RICR-20-30-3.6 - Severability

Current through June 14, 2024
If any provision of this Part or the application thereof to
					 any person or circumstances are for any reason held to be invalid, the
					 remainder of the Part and the application of its provisions to other persons or
					 circumstances shall not be affected thereby.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 3 - Health Insurance Reserves (230-RICR-20-30-3) › Section 230-RICR-20-30-3.7 - Applicability

Current through June 14, 2024
This Part is effective on August 1, 1996 and shall apply to
					 all quarterly and annual statements due on or after January 1,
					 1997.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 3 - Health Insurance Reserves (230-RICR-20-30-3) › Section 230-RICR-20-30-3.8 - Appendix A: Specific Standards for Morbidity, Interest and Mortality

Current through June 14, 2024
A. MORBIDITY
1. Minimum morbidity standards for valuation
				  of specified individual contract health insurance benefits are as follows:
a. Disability Income Benefits Due to Accident
				  or Sickness.
(1) Contract Reserves: Contracts
				  issued on or after January 1, 1995
(AA) The
				  1985 Commissioners Individual Disability Tables A (85CIDA); or
(BB) The 1985 Commissioners Individual
				  Disability Tables B (85CIDB).
(CC)
				  Each insurer shall elect, with respect to all individual contracts issued in
				  any one statement year, whether it will use Tables A or Tables B as the minimum
				  standard. The insurer may, however, elect to use the other tables with respect
				  to any subsequent statement year.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 3 - Health Insurance Reserves (230-RICR-20-30-3) › Section 230-RICR-20-30-3.10 - Appendix C: Reserves for Waiver of Premium (Supplementary explanatory material)

Current through June 14, 2024
A. Waiver of
				  premium reserves involve several special considerations. First, the disability
				  valuation tables promulgated by the NAIC are based on exposures that include
				  contracts on premium waiver as in-force contracts. Hence, contract reserves
				  based on these tables are NOT reserves on "active lives" but rather reserves on
				  contracts "in force." This is true for the 1964 CDT and for both the 1985 CIDA
				  and CIDB tables.
B. Accordingly,
				  tabular reserves using any of these tables should value reserves on the
				  following basis:
1. Claim reserves should
				  include reserves for premiums expected to be waived, valuing as a minimum the
				  valuation net premium being waived.
2. Premium reserves should include contracts
				  on premium waiver as in-force contracts, valuing as a minimum the unearned
				  modal valuation net premium being waived.
3. Contract reserves should include
				  recognition of the waiver of premium benefit in addition to other contract
				  benefits provided for, valuing as a minimum the valuation net premium to be
				  waived.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 4 - Powers and Duties of the Office of the Health Insurance Commissioner › Section 230-RICR-20-30-4.1 - Authority

Current through June 14, 2024
This regulation is promulgated pursuant to R.I. Gen. Laws
					 §§
										42-14.5-1
et
					 seq
., 42-14-5, and 42-14-17.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 4 - Powers and Duties of the Office of the Health Insurance Commissioner › Section 230-RICR-20-30-4.2 - Purpose and Scope

Current through June 14, 2024
A. When creating
				  the Office of the Health Insurance Commissioner ("OHIC" or "Office"), the
				  General Assembly created a list of statutory purposes for the OHIC at R.I. Gen.
				  Laws §
										42-14.5-2 (the OHIC Purposes
				  Statute). In order to meet the requirements established by the OHIC Purposes
				  Statute, the OHIC has developed this regulation, which is designed to:
1. Ensure effective regulatory oversight by
				  the OHIC;
2. Provide guidance to
				  the state's health insurers, health care providers, consumers of health
				  insurance, consumers of health care services and the general public as to how
				  the OHIC will interpret and implement its statutory obligations; and
3. Implement the intent of the General
				  Assembly as expressed in the OHIC Purposes Statute.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 4 - Powers and Duties of the Office of the Health Insurance Commissioner › Section 230-RICR-20-30-4.4 - Discharging Duties and Powers

Current through June 14, 2024
A. The Commissioner
				  shall discharge the powers and duties of the Office to:
1. Guard the solvency of health
				  insurers;
2. Protect the interests
				  of the consumers of health insurance;
3. Encourage fair treatment of health care
				  providers by health insurers;
4.
				  Encourage policies and developments that improve the quality and efficiency of
				  health care service delivery and outcomes; and
5. View the health care system as a
				  comprehensive entity and encourage and direct health insurers towards policies
				  that advance the welfare of the public through overall efficiency, improved
				  health care quality, and appropriate access.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 4 - Powers and Duties of the Office of the Health Insurance Commissioner › Section 230-RICR-20-30-4.5 - Guarding the Solvency and Financial Condition of Health Insurers

Current through June 14, 2024
A. The solvency of health insurers must be
				  guarded to protect the interests of insureds, health care providers, and the
				  public generally.
B. Whenever the
				  Commissioner determines that one of the circumstances in §§
										4.5(B)(1)
				  through (4)   of this Part exist, the Commissioner shall, in addition to
				  exercising any duty or power authorized or required by R.I. Gen. Laws Titles 27
				  or 42 related specifically to the solvency or financial health of a health
				  insurer, act to guard the solvency and financial condition of a health insurer
				  when exercising any other power or duty of the Office, including, but not
				  limited to, approving or denying any request or application; approving, denying
				  or modifying any requested rate; approving or rejecting any forms, trend
				  factors, or other filings; issuing any order, decision or ruling; initiating
				  any proceeding, hearing, examination, or inquiry; or taking any other action
				  authorized or required by statute or regulation.
1. The solvency or financial condition of any
				  health insurer is in jeopardy or is likely to be in jeopardy;
2. Any action or inaction by a health insurer
				  could adversely affect the solvency or financial condition of that health
				  insurer;
3. The approval or denial
				  of any regulatory request, application or filing by a health insurer could
				  adversely affect the solvency or financial condition of that health insurer;
				  or
4. Any other circumstances exist
				  such that the solvency or financial condition of a health insurer may be at
				  risk.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 4 - Powers and Duties of the Office of the Health Insurance Commissioner › Section 230-RICR-20-30-4.6 - Protecting the Interests of Consumers

Current through June 14, 2024
A. The interests of
				  the consumers of health insurance, including individuals, groups and employers,
				  must be protected.
B. The
				  provisions of this regulation do not require the Commissioner to act as an
				  advocate on behalf of a particular health insurance consumer. Instead, while
				  the Commissioner will endeavor to address individual consumer complaints as
				  they arise, the OHIC Purposes Statute requires the OHIC to protect the
				  interests of health insurance consumers, including individuals, groups and
				  employers, on a system-wide basis.
C. Whenever the Commissioner determines that
				  one of the circumstances in §§
										4.6(C)(1) through (3)   of this Part
				  exist, the Commissioner shall, in addition to exercising any duty or power
				  authorized or required by R.I. Gen. Laws Titles 27 or 42 related specifically
				  to the protection of the interests of the consumers of health insurance, act to
				  protect the interests of consumers of health insurance when exercising any
				  other power or duty of the Office, including, but not limited to, approving or
				  denying any request or application; approving, denying or modifying any
				  requested rate; approving or rejecting any forms, trend factors, or other
				  filings; issuing any order, decision or ruling; initiating any proceeding,
				  hearing, examination, or inquiry; or taking any other action authorized or
				  required by statute or regulation.
1. The
				  interests of the state's health insurance consumers are, or are likely to be,
				  adversely affected by any policy, practice, action or inaction of a health
				  insurer;
2. The approval or denial
				  by the Commissioner of any regulatory request, application or filing made by a
				  health insurer could adversely affect the interests of the state's health
				  insurance consumers; or
3. Any
				  other circumstances exist such that the interests of the state's health
				  insurance consumers may be adversely affected.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 4 - Powers and Duties of the Office of the Health Insurance Commissioner › Section 230-RICR-20-30-4.7 - Encouraging Fair Treatment of Health Care Providers

Current through June 14, 2024
A. The Commissioner will act to encourage the
				  fair treatment of health care providers by health insurers.
B. The provisions of this regulation do not
				  require the Commissioner to act as an advocate for a particular health care
				  provider or for a particular group of health care providers. Instead, while the
				  Commissioner will endeavor to address individual health care provider
				  complaints as they arise, the OHIC Purposes Statute requires the OHIC to act to
				  enhance system-wide treatment of providers.
C. Whenever the Commissioner determines that
				  any of the circumstances in §§
										4.7(C)(1) through (4)   of this Part
				  exist, the Commissioner shall, in addition to exercising any duty or power
				  authorized or required by R.I. Gen. Laws Titles 27 or 42 related specifically
				  to the fair treatment of health care providers, take the treatment of health
				  care providers by a health insurer into consideration when exercising any other
				  power or duty of the Office, including, but not limited to, approving or
				  denying any request or application; approving, denying or modifying any
				  requested rate; approving or rejecting any forms, trend factors, or other
				  filings; issuing any order, decision or ruling; initiating any proceeding,
				  hearing, examination, or inquiry; or taking any other action authorized or
				  required by statute or regulation.
1. Health
				  care providers are being treated unfairly by a health insurer;
2. The policies or procedures of a health
				  insurer place an undue, inconsistent or disproportionate burden upon a class or
				  providers;
3. The approval or
				  denial by the Commissioner of any regulatory request, application or filing
				  made by a health insurer will result in unfair treatment of a health care
				  providers by a health insurer; or
4. Any other circumstances exist such that
				  Commissioner is concerned that health care providers will be treated unfairly
				  by a health insurer.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 4 - Powers and Duties of the Office of the Health Insurance Commissioner › Section 230-RICR-20-30-4.8 - Improving the Efficiency and Quality of Health Care Delivery and Increasing Access to Health Care Services

Current through June 14, 2024
A. Consumers,
				  providers, health insurers and the public generally have an interest in:
1. Improving the quality and efficiency of
				  health care service delivery and outcomes in Rhode Island;
2. Viewing the health care system as a
				  comprehensive entity; and
3.
				  Encouraging and directing insurers towards policies that advance the welfare of
				  the public through overall efficiency, improved health care quality, and
				  appropriate access.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 4 - Powers and Duties of the Office of the Health Insurance Commissioner › Section 230-RICR-20-30-4.9 - Affordable Health Insurance - General

Current through June 14, 2024
A. Consumers of
				  health insurance have an interest in stable, predictable, affordable rates for
				  high quality, cost efficient health insurance products. Achieving an economic
				  environment in which health insurance is affordable will depend in part on
				  improving the performance of the Rhode Island health care system as a whole,
				  including but not limited to the following areas:
1. Improved primary care supply, measured by
				  the total number of primary care providers, and by the percentage of physicians
				  identified as primary care providers.
2. Improved integration of behavioral health
				  services into the primary care delivery system to meet the physical and
				  behavioral health needs of the public.
3. Reduced incidence of hospitalizations for
				  ambulatory care-sensitive conditions, and of re-hospitalizations.
4. Reduced incidence of emergency room visits
				  for ambulatory care-sensitive conditions.
5. Reduced provision of low-value
				  care.
6. Reduced rates of premium
				  increase for fully insured, commercial health insurance.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 4 - Powers and Duties of the Office of the Health Insurance Commissioner › Section 230-RICR-20-30-4.10 - Affordable Health Insurance - Affordability Standards

Current through June 14, 2024
A. Health insurers with at least 10,000
				  covered lives under a health insurance plan issued, delivered, or renewed in
				  Rhode Island shall comply with the delivery system and payment reform strategy
				  requirements set forth in this §
										4.10   of this Part. For purposes of this
				  §
										4.10   of this Part only, a health insurer shall not include a non-profit
				  dental service corporation, or a non-profit optometric service
				  corporation.
B. Primary care and
				  behavioral health care expenditure obligation. The purpose of §
										4.10(B)   of
				  this Part is to ensure financial support for primary care providers and
				  providers of behavioral health services in Rhode Island that will assist in
				  achieving the goals of these Affordability Standards.
1. Primary care expenditures.
a. Each health insurer's annual, actual
				  Primary Care Expenses, including both Direct and Indirect Primary Care
				  Expenses, shall be at least an amount calculated as 10.7% of its annual medical
				  expenses for all insured lines of business. Of the health insurer's annual
				  Primary Care Expense financial obligation, at least 9.7% of the calculated
				  amount shall be for Direct Primary Care Expenses. Each health insurer's
				  Indirect Primary Care Expenses shall include at least its proportionate share
				  for the administrative expenses of the medical home initiative endorsed by R.I.
				  Gen. Laws Chapter 42-14.6, and for its proportionate share of the expenses of
				  the health information exchange established by R.I. Gen. Laws Chapter
				  5-37.7.
b. Direct Primary Care
				  Expenses shall be accounted for as medical expenses on the health insurer's
				  annual financial statements. Indirect Primary Care Expenses shall be accounted
				  for as administrative costs on the health insurer's annual financial
				  statements. Indirect Primary Care Expenses may be deducted from the statement's
				  administrative cost category as cost containment expenses, in accordance with
				  federal Medical Loss Ratio calculation rules.
c. In meeting its annual primary care
				  spending obligations, a health insurer's insured covered lives shall not bear a
				  financial burden greater than their fair share of expenses that benefit both
				  insured covered lives, and non-insured covered lives whose health plans are
				  administered by the health insurer.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 4 - Powers and Duties of the Office of the Health Insurance Commissioner › Section 230-RICR-20-30-4.11 - Administrative Simplification

Current through June 14, 2024
A. Administrative
				  Simplification Task Force
1. An Administrative
				  Simplification Task Force is established to make recommendations to the
				  Commissioner for streamlining health care administration so as to be more
				  cost-effective, and less time-consuming for hospitals, providers, consumers,
				  and insurers, and to carry out the purposes of R.I. Gen. Laws §
											42-14.5-3(h). The
				  Commissioner shall appoint as members of the Task Force representatives of
				  hospitals, physician practices, community behavioral health organizations, each
				  health insurer, consumers, businesses, and other affected entities, as
				  necessary and relevant to the issues and work of the Task Force. The Task force
				  shall also include at least one designee each from the Rhode Island Medical
				  Society, Rhode Island Council of Community Mental Health Organizations, the
				  Rhode Island Health Center Association, and the Hospital Association of Rhode
				  Island. The Chair or Co-Chairs of the Task Force shall be selected annually by
				  its members.
2. At the discretion
				  of, and as directed by the Commissioner, the Task Force shall convene to
				  consider issues of streamlining health care administration. Members of the Task
				  Force may propose and substantiate such issues for review and inclusion in a
				  work plan, together with such data and analysis that demonstrates the need to
				  address the issue. The Task Force will meet during September, October and
				  November to make its recommendations to the Commissioner for resolving issues
				  identified in the work plan no later than December 31 of each year. If the Task
				  Force agrees on recommendations for resolving the identified issues, those
				  recommendations will be submitted to the Commissioner for her or his
				  consideration. If the Task Force cannot agree on recommendations, a report will
				  be submitted to the Commissioner on the Task Force's activities, together with
				  comments by members concerning the identified issues. The Commissioner shall
				  consider the report of the Task Force, and may adopt such regulations as are
				  necessary to carry out the purposes of §
											4.11   of this Part, and the
				  purposes of R.I. Gen. Laws §
											42-14.5-3(h).
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 4 - Powers and Duties of the Office of the Health Insurance Commissioner › Section 230-RICR-20-30-4.12 - Price Disclosure

Current through June 14, 2024
A. The purpose of
				  this §
										4.12   of this Part is to empower consumers who are enrollees in a
				  health insurance plan to make cost effective decisions concerning their health
				  care, and to enable providers to make cost-effective treatment decisions on
				  behalf of their patients who are enrollees of a health insurance plan,
				  including referral and care coordination decisions.
B. A health insurer shall not enforce a
				  provision in any participating provider agreement which purports to obligate
				  the health insurer or health care provider to keep confidential price
				  information requested by a health care provider for the purpose of making
				  cost-effective clinical referrals, and for the purpose of making other care
				  coordination or treatment decisions on behalf of their patients who are
				  enrollees in the health benefit plan of the health insurer.
C. At the request of a health care provider
				  acting on behalf of an enrollee-patient, a health insurer shall disclose in a
				  timely manner to the health care provider such price information as the
				  provider determines is necessary to make cost-effective treatment decisions on
				  behalf of their patients, including clinical referrals, care coordination, and
				  other treatment decisions.
D. A
				  health insurer may adopt reasonable policies and procedures designed to limit
				  the disclosure of price information for unauthorized purposes.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 4 - Powers and Duties of the Office of the Health Insurance Commissioner › Section 230-RICR-20-30-4.13 - Severability

Current through June 14, 2024
If any section, term, or provision of this regulation is
					 adjudged invalid for any reason, that judgment shall not affect, impair, or
					 invalidate any remaining section, term, or provision, which shall remain in
					 full force and effect.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 4 - Powers and Duties of the Office of the Health Insurance Commissioner › Section 230-RICR-20-30-4.14 - Construction

Current through June 14, 2024
A. This regulation shall be liberally
				  construed to give full effect to the purposes stated in R.I. Gen. Laws §
										42-14.5-2.
B. This regulation shall not be interpreted
				  to limit the powers granted the Commissioner by other provisions of the law.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 5 - Standards for Readability of Health Insurance Forms (230-RICR-20-30-5) › Section 230-RICR-20-30-5.1 - Authority

Current through June 14, 2024
This regulation is promulgated pursuant to R.I. Gen Laws
					 §§
										42-62-1, et seq.; 42-14.5-1, et
					 seq.; 42- 14-5; and 42-14-17.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 5 - Standards for Readability of Health Insurance Forms (230-RICR-20-30-5) › Section 230-RICR-20-30-5.2 - Purpose

Current through June 14, 2024
This regulation is intended to make health insurance forms
					 easier to read.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 5 - Standards for Readability of Health Insurance Forms (230-RICR-20-30-5) › Section 230-RICR-20-30-5.3 - Definitions

Current through June 14, 2024
A. As used in this regulation:
1. "Policy" or "policy form" means all health
				  insurance forms required to be submitted to OHIC for approval. These forms
				  include, but are not limited to, certificates of coverage, subscriber
				  agreements, endorsements and modifications to contracts, policies, benefits
				  booklets, and summary plan descriptions.
2. "Carrier" or "insurer" or "health
				  insurance carrier" means any entity subject to the insurance laws and
				  regulations of this state, or subject to the jurisdiction of the health
				  insurance commissioner, that contracts or offers to contract to provide,
				  deliver, arrange for, pay for, or reimburse any of the costs of health care
				  services, including, without limitation, an insurance company offering accident
				  and sickness insurance, health insurer, dental insurer, nonprofit hospital
				  service corporation, nonprofit medical service corporation, nonprofit dental
				  service corporation, nonprofit optometric service corporation, association,
				  fraternal benefit society, health maintenance organization or similar entity
				  subject to the provisions of R.I. Gen. Laws Title 27, or any other entity
				  providing a plan of health insurance or health benefits by which health care
				  services are paid or financed for an eligible individual or his or her
				  dependents by such entity on the basis of a periodic premium, paid directly or
				  through an association, trust, or other intermediary, and is either issued,
				  renewed, or delivered within Rhode Island, including a certificate issued that
				  evidences coverage under a policy or contract issued to a trust or
				  association.
3. "Health insurance"
				  means any policy, contract, certificate, or agreement offered by a health
				  insurance carrier to provide, deliver, arrange for, pay for or reimburse any of
				  the costs of health care services. It also includes "health insurance
				  coverage," as defined in R.I. Gen Laws §§
											27-18.5-2 and
				  27-18.6-2; "health benefit plan,"
				  as defined in R.I. Gen Laws §
											27-50-3; and a "medical supplement
				  policy," as defined in R.I. Gen Laws §
											27   - 18.2-1 or coverage similar to a
				  Medicare supplement policy that is issued to an employer to cover
				  retirees.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 5 - Standards for Readability of Health Insurance Forms (230-RICR-20-30-5) › Section 230-RICR-20-30-5.4 - Applicability

Current through June 14, 2024
A. This regulation applies to the policy
				  forms of every individual or group health insurance policy, contract,
				  certificate or agreement delivered, issued for delivery, or renewed in Rhode
				  Island on or after August 31, 2010.
B. Any non-English language policy form
				  delivered or issued for delivery in Rhode Island on or after August 31, 2010
				  shall be deemed to be in compliance with this regulation if the insurer
				  certifies that the policy is translated from an English language policy that
				  does comply with this regulation.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 5 - Standards for Readability of Health Insurance Forms (230-RICR-20-30-5) › Section 230-RICR-20-30-5.5 - Minimum Policy Language Simplification Standards

Current through June 14, 2024
A. In addition to any other requirements of
				  law, no policy form may be approved under this regulation, unless:
1. The text of the policy form does not
				  exceed the eighth-grade reading level as measured by the Flesch-Kincaid
				  formula;
2. The policy form is
				  printed in not less than twelve-point type, except for type used for
				  specification pages, schedules, tables and minor instructions concerning the
				  preparation of forms by the consumer (e.g., instructions indicating where a
				  consumer should provide his or her name, address or other
				  information);
3. The style,
				  arrangement and overall appearance of the policy form gives no undue prominence
				  to any portion of the text of the policy or to any endorsements or riders;
				  and
4. The policy form contains a
				  table of contents or an index of the principal sections of the policy form, if
				  the policy has more than 3,000 words or than three pages regardless of the
				  number of words.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 5 - Standards for Readability of Health Insurance Forms (230-RICR-20-30-5) › Section 230-RICR-20-30-5.6 - Power of the Commissioner to Approve a Higher Reading Level

Current through June 14, 2024
A. Every request by a carrier for approval
				  pursuant to this shall include a statement explaining why the request is being
				  sought and shall provide documentation and information to support the
				  request.
B. The commissioner may
				  authorize a level higher than an eighth-grade reading level required by
				  §
										5.5   of this Part or a waiver or modification of the other standards
				  established by §
										5.5   of this Part whenever, in his sole discretion, he
				  finds that a higher level or a waiver or modification of the other standards:
1. Will provide a more accurate reflection of
				  the readability of a policy form;
2. Is warranted by the nature of a particular
				  policy form or type or class of policy forms; or
3. Is caused by certain policy language that
				  is drafted to conform to the requirements of any state law, regulation or
				  agency interpretation.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 5 - Standards for Readability of Health Insurance Forms (230-RICR-20-30-5) › Section 230-RICR-20-30-5.7 - Approval of Forms

Current through June 14, 2024
A policy form meeting the requirements of §
										5.5(A)   of
					 this Part shall be approved notwithstanding the provisions of any other laws
					 which specify the content of policies, if the policy form provides the
					 policyholders and claimants protection not less favorable than they would be
					 entitled to under such laws.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 5 - Standards for Readability of Health Insurance Forms (230-RICR-20-30-5) › Section 230-RICR-20-30-5.8 - Severability

Current through June 14, 2024
If any provision of this regulation or the application
					 thereof to any person or circumstances is held invalid or unconstitutional, the
					 invalidity or unconstitutionality shall not affect other provisions or
					 applications of this regulation which can be given effect without the invalid
					 or unconstitutional provision or application, and to this end the provisions of
					 this regulation are severable.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 6 - Prompt Processing of Claims › Section 230-RICR-20-30-6.1 - Authority

Current through June 14, 2024
This Part is promulgated pursuant to R.I. Gen. Laws
					 §§
										27-18-3.2,
					 27-18-3.3, 27- 18-3.4, 27-18-20,
					 27-18-21, 27-18-46, 27-18-47, 27-18-61, 27-19-30, 27-19-38, 27-19 - 39,
					 27-19-52, 27-20-26, 27-20-33, 27-20-34, 27-20-47, 27-20.1-2, 27-41-19,
					 27-41-21, 27-41-47, 27-41-48, 27-41-64, 42-14-5, 42-14-16, 42-14-16.1,
					 42-14-17, 42-14.5-1, 42- 14.5-2, 42-14.5-3 and 42-35-3.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 6 - Prompt Processing of Claims › Section 230-RICR-20-30-6.2 - Purpose and Scope

Current through June 14, 2024
A. This Part is
				  designed to effectuate administration and enforcement of Rhode Island's prompt
				  processing statutes, set out at R.I. Gen. Laws §§
										27-18-61,
				  27-19-52,
				  27-20-47 and
				  27-41-64.
B. This Part, like the state's prompt
				  processing statutes, is very broad in scope. The prompt processing requirements
				  established by R.I. Gen. Laws §§
										27-18-61,
				  27-19-52,
				  27-20-47 and
				  27-41-64 apply to all health
				  insurers, health plans, dental plans, nonprofit hospital and medical service
				  corporations, nonprofit dental service corporations, health maintenance
				  organizations, licensed third party administrators and contractors operating in
				  Rhode Island. These entities and plans are required to process electronic
				  claims submitted by Rhode Island health care providers and policyholders within
				  thirty calendar days from receipt of said claims and to process written claims
				  submitted by Rhode Island health care providers and policyholders within forty
				  calendar days from receipt of said claims.
C. These processing requirements apply to all
				  non-federal program claims, regardless of whether such claims are fully insured
				  or self insured. Examples of federal program claims exempt from this Part
				  include claims submitted for payment under the Medicare program and the Federal
				  Employees Health Benefits program (FEHB). The processing requirements set out
				  in this Part do apply to claims submitted for payment under the RIte Care
				  program, but not to claims submitted under other Medicaid programs.
D. Entities and plans subject to the prompt
				  processing requirement must also:
1. pay
				  interest on claims not paid within the required timeframes,
2. file claims processing reports with the
				  Office of the Health Insurance Commissioner, and
3. provide complete claim standards to
				  participating providers.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 6 - Prompt Processing of Claims › Section 230-RICR-20-30-6.5 - Complete Claim Standard

Current through June 14, 2024
A. Each subject
				  entity operating in this state shall establish a written standard defining a
				  complete claim.
B. Each subject
				  entity operating in this state shall distribute its complete claim standard to
				  all participating providers.
C.
				  Each subject entity operating in this state shall make an initial filing of its
				  complete claim standard with the OHIC within ninety days of January 1, 2007.
				  When filing its initial complete claim standard, an officer of the subject
				  entity must certify that, to the best of his or her knowledge, all
				  participating providers have been provided a copy of the complete claim
				  standard.
D. If a subject entity
				  intends to commence operations in this state after January 1, 2007, the subject
				  entity must make an initial filing of its complete claim standard with the OHIC
				  prior to commencing operations. When filing its initial complete claim
				  standard, an officer of the subject entity must certify that, to the best of
				  his or her knowledge, all participating providers have been provided a copy of
				  the complete claim standard.
E. If
				  a subject entity intends to amend its complete claim standard after filing its
				  initial complete claim standard as required by §
										6.5(C) or (D)   of this
				  Part, the subject entity shall
1. provide a
				  copy of the amended complete claim standard to participating providers at least
				  thirty calendar days before the effective date of the amended complete claim
				  standard;
2. file the amended
				  complete claim standard with the OHIC at least thirty calendar days before the
				  effective date of the amended complete claim standard; and
3. file a certification by an officer of the
				  subject entity that, to the best of his or her knowledge, all participating
				  providers have been provided a copy of the amended complete claim
				  standard.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 6 - Prompt Processing of Claims › Section 230-RICR-20-30-6.6 - Substantial Compliance

Current through June 14, 2024
A. All findings of
				  substantial compliance shall be based on calendar year data. Requests for a
				  finding of substantial compliance must be submitted by a subject entity no
				  later than March 1st of the immediately following calendar year. Exemption from
				  the requirement that interest be paid on claims not processed within the
				  timeframes established by §
										6.4(A)   of this Part will be from the period set
				  forth in the OHIC's order finding substantial compliance and will apply only to
				  claims received by the subject entity during that time period. A finding of
				  substantial compliance is only prospective from the date set forth in the
				  OHIC's order and will not be retroactively applied to claims received by the
				  subject entity prior to that date.
B. A subject entity requesting a finding of
				  substantial compliance under this Part from the OHIC shall submit such
				  supporting documentation as the OHIC may require, including but not limited to
1. a report in the form promulgated by OHIC
				  in a Bulletin issued for that purpose, certified by either the chief operating
				  officer or the chief financial officer of the subject entity;
2. claims processing and payment data for the
				  immediately preceding calendar year;
3. a declaration of substantial compliance
				  (e.g., a management representation letter) declaring conformity with the
				  applicable requirements of R.I. Gen. Laws §§
											27-18-61(a),
				  27-19-52(a),
				  27-20-41(a),
				  27-41-64(a) and
				  this Part; and
4. a written report
				  of an independent certified public accountant setting forth an opinion with
				  respect to the accuracy of the representations made in management's declaration
				  of substantial compliance. The OHIC may require additional information and/or
				  may audit, examine or hold hearings as it deems necessary to arrive at a
				  finding as to whether the subject entity is in substantial compliance. The
				  total cost of any audit, examination or hearing held with respect to a request
				  for a finding of substantial compliance shall be borne by the subject entity
				  requesting such finding. The OHIC considers requests for a finding of
				  substantial compliance and any supporting documentation public records under
				  R.I. Gen. Laws §
											38-2-1 et seq., but only to the
				  extent that the request and supporting documentation do not include personal,
				  identifiable health information.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 6 - Prompt Processing of Claims › Section 230-RICR-20-30-6.7 - Reporting Requirements

Current through June 14, 2024
A. A subject entity
				  that does not have a finding of substantial compliance from the OHIC in effect
				  shall submit a report to the OHIC based on the following guidelines:
1. a subject entity that processed, on
				  average, fewer than 10,000 claims per month during the previous calendar year
				  shall, no later than January 31st of the following calendar year, submit a
				  report to the OHIC in the form promulgated by OHIC in a Bulletin issued for
				  that purpose; and
2. a subject
				  entity that processed, on average, 10,000 or more claims per month during the
				  previous calendar year shall, within thirty days following the end of each
				  month, submit a report to the OHIC in the form promulgated by OHIC in a
				  Bulletin issued for that purpose.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 6 - Prompt Processing of Claims › Section 230-RICR-20-30-6.8 - Notification/Reports

Current through June 14, 2024
A. All reports, notices, complaints or
				  filings required and/or authorized under this Part shall be submitted to the
				  following address:
Office of the Health Insurance Commissioner
1511 Pontiac Avenue
Building #69, First Floor
Cranston, RI 02920
OHIC.HealthInsInq@ohic.ri.gov
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 6 - Prompt Processing of Claims › Section 230-RICR-20-30-6.9 - Provider Complaint Process

Current through June 14, 2024
A. A health care
				  provider who alleges a violation of this Part by a subject entity may file a
				  complaint with this Office using the complaint form promulgated by OHIC in a
				  Bulletin issued for that purpose. This Office will not accept written
				  complaints from health care providers unless the procedures established by
				  §
										6.9(B)   of this Part have been followed.
B. As a prerequisite to filing a complaint
				  with this Office, a health care provider must file the complaint form
				  (promulgated by OHIC in a Bulletin issued for that purpose) directly with the
				  subject entity that is alleged to have violated this Part. The complaint must
				  be mailed to the subject entity by certified or registered mail, with a return
				  receipt requested, or by any other method of delivery that provides a written
				  proof of delivery to the subject entity. If the complaint is not resolved
				  within forty-five days of receipt by the subject entity, the health care
				  provider may file with this Office a copy of the complaint, along with written
				  proof of delivery of the complaint to the subject entity and any written
				  response from the subject entity. The copy of the complaint, the proof of
				  delivery and the written response from the subject entity should be submitted
				  to the address specified in §
										6.8   of this Part.
C. The requirements of this §
										6.9   of this
				  Part do not apply to complaints by policyholders. Such complaints may be filed
				  directly with this Office.
D.
				  Examples
1. Example 1. A Rhode Island
				  physician submitted the complaint form (promulgated by OHIC in a Bulletin
				  issued for that purpose) to a subject entity by certified mail with return
				  receipt requested. The subject entity signed the return receipt for the
				  complaint on May 1st. As of June 15th, the subject entity had not responded to
				  the physician. The physician may thereafter submit a copy of the complaint and
				  a copy of the return receipt to this Office.
2. Example 2. A Rhode Island physician
				  submits the complaint form (promulgated by OHIC in a Bulletin issued for that
				  purpose) directly to this Office without first submitting the complaint to the
				  subject entity. Because the complaint was not first submitted to the subject
				  entity, this Office will return the complaint to the physician without taking
				  any action on the complaint.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 6 - Prompt Processing of Claims › Section 230-RICR-20-30-6.10 - Penalties

Current through June 14, 2024
A failure to comply with any of the requirements of this
					 Part may result in the imposition of any or all administrative penalties
					 authorized by R.I. Gen. Laws Titles 27 and 42, including R.I. Gen. Laws
					 §§
										42-14-16, §
										42-14-16.1,
					  27-18-3.3,  27-18-20,  27-18-46,  27  - 19-39, 27-20-33, 27-41-19, 27-41-21, and
					 27-41-47.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 6 - Prompt Processing of Claims › Section 230-RICR-20-30-6.11 - Judicial Review

Current through June 14, 2024
Any request for a finding of substantial compliance and
					 decision thereon by the OHIC under this Part or any administrative penalty
					 imposed by the OHIC for a violation of this Part shall be subject to judicial
					 review pursuant to R.I. Gen. Laws §
										42-35-15.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 6 - Prompt Processing of Claims › Section 230-RICR-20-30-6.12 - Private Cause of Action

Current through June 14, 2024
A. A health care
				  provider who alleges a violation of this Part by a subject entity may, in
				  addition to filing a complaint in the manner described in §
										6.9   of this
				  Part, bring a civil action for appropriate injunctive relief, actual and
				  punitive damages and costs including reasonable attorney fees.
B. An action commenced pursuant to
				  §
										6.12(A)   of this Part may be brought in the superior court for the county
				  where the alleged violation occurred, the county where the health care provider
				  resides or the county in which the subject entity maintains its principal place
				  of business.