reglab/statecodes huggingface dataset:
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 12 - Tobacco Cessation Treatment Coverage (230-RICR-20-30-12) › Section 230-RICR-20-30-12.4 - Standards for Tobacco Cessation Programs

Current through June 14, 2024
A.
				  Every individual or group health insurance contract, plan or policy delivered,
				  issued for delivery or renewed in this state that provides medical coverage
				  that includes coverage for physician services in a physician's office or that
				  provides major medical or similar comprehensive-type coverage shall include
				  coverage for smoking cessation treatment, provided that if such medical
				  coverage does not include prescription drug coverage, such contract, plan or
				  policy shall not be required to include coverage for nicotine replacement
				  therapy or any prescription drugs. Such medical coverage will, however, be
				  required to provide outpatient counseling benefits for smoking
				  cessation.
B. As used in this Part,
				  smoking cessation treatment includes the tobacco dependence treatments
				  identified as effective in the most recent clinical practice guideline
				  published by the United States Department of Health and Human Services for
				  treating tobacco use and dependence. (Fiore MC, Bailey WC, Cohen SJ, et al.
				  Treating Tobacco Use and Dependence. A Clinical Practice Guideline. US
				  Department of Health and Human Services. Public Health Service, 2008. Available
				  at: http://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf.)
C. Nicotine replacement therapy includes but
				  is not limited to nicotine gum, patches, lozenges, nasal spray, and
				  inhaler.
D. Health insurance
				  contracts, plans, or policies to which this Part applies, may impose copayments
				  and/or deductibles for smoking cessation treatment mandated by this section
				  consistent with the contracts', plans' or policies' copayments and/or
				  deductibles for physician services and medications. Nothing contained in this
				  regulation shall impact the reimbursement, medical necessity or utilization
				  review, managed care, or case management practices of these health insurance
				  contracts, plans or policies.
E.
				  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.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 12 - Tobacco Cessation Treatment Coverage (230-RICR-20-30-12) › Section 230-RICR-20-30-12.5 - Reporting

Current through June 14, 2024
A. Each carrier that issues an individual or
				  group health insurance contract, plan or policy subject to this Part shall, no
				  later than March 15 of each year, submit to the Director of the Department of
				  Health a report describing the carrier's compliance with this regulation during
				  the previous calendar year. Such report shall substantially conform to the
				  model report established by the Department of Health and posted on the
				  Department's website.
B. Any
				  carrier that fails to submit a report to the Department of Health as required
				  by this Part shall be subject to the administrative penalties provided for in
				  R.I. Gen. Laws §
										42-14-16.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 12 - Tobacco Cessation Treatment Coverage (230-RICR-20-30-12) › Section 230-RICR-20-30-12.6 - Severability

Current through June 14, 2024
If any provision of this Part 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 Part which can be given effect without the invalid or unconstitutional
					 provision or application, and to this end the provisions of this Part are
					 severable.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 13 - Discount Medical Plan Organizations (formerly OHIC Regulation 15) (230-RICR-20-30-13) › Section 230-RICR-20-30-13.1 - Statement of Authority and Purpose

Current through June 14, 2024
A. This Part is
				  promulgated pursuant to the authority granted to the Rhode Island Health
				  Insurance Commissioner ("Commissioner") by R.I. Gen. Laws §§
										27-74-16,
				  42-14-5 and
				  42-14-17.
B. This Part is intended to implement the
				  provisions of R.I. Gen. Laws Chapter 27-74, the "Discount Medical Plan
				  Organization Act" (the "Act"). The purpose of the Act and this Part is to
				  promote the public interest by establishing standards for discount medical plan
				  organizations; to protect consumers from unfair or deceptive marketing, sales
				  or enrollment practices of discount medical plans; and to facilitate consumer
				  understanding of the role and function of discount medical plans in providing
				  access to medical or ancillary services.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 13 - Discount Medical Plan Organizations (formerly OHIC Regulation 15) (230-RICR-20-30-13) › Section 230-RICR-20-30-13.2 - Definitions

Current through June 14, 2024
All words or phrases used in this Part already defined in
					 R.I. Gen. Laws §
										27-74-3 shall have the meaning
					 therein.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 13 - Discount Medical Plan Organizations (formerly OHIC Regulation 15) (230-RICR-20-30-13) › Section 230-RICR-20-30-13.3 - Registration Requirements

Current through June 14, 2024
A. Before doing
				  business in or from this state, a discount medical plan organization shall
				  complete an application for a certificate of registration. The application to
				  operate as a discount medical plan will be as promulgated by the Commissioner.
				  All sections of the application must be completed in order for the application
				  to be accepted by the Commissioner. The application must be accompanied by a
				  non-refundable fee of two hundred and fifty dollars ($250) made payable to the
				  General Treasurer, State of Rhode Island.
B. Once the application has been filed, the
				  Commissioner shall review the application and notify the applicant of any
				  deficiency therein. The ninety (90) day review period shall not commence until
				  the Commissioner has received a completed application.
C. The Commissioner shall renew the
				  certificate of registration of each holder that meets the requirements of the
				  Act and this regulation upon receipt of a completed application and payment of
				  a non-refundable fee of two hundred and fifty dollars ($250) made payable to
				  the General Treasurer, State of Rhode Island. Each registration is issued on a
				  biennial basis. A discount medical plan which registers during the registration
				  term shall be issued a registration for the time period remaining and will have
				  to renew at the expiration of the registration, regardless of the period of
				  time it has been registered. The Commissioner does not prorate license fees.
				  This renewal requirement is separate from the obligation to file an annual
				  report under R.I. Gen. Laws §
										27-74-13; however, at the option
				  of the registrant the annual report shall be filed either at the time of the
				  renewal application is filed in accordance with R.I. Gen. Laws §
										27-74-5(f) during
				  the calendar year in which the application must be renewed, or on or before
				  September 30 during any calendar year.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 13 - Discount Medical Plan Organizations (formerly OHIC Regulation 15) (230-RICR-20-30-13) › Section 230-RICR-20-30-13.4 - Reporting of Actions

Current through June 14, 2024
A. The registrant
				  shall report to the Commissioner any administrative action taken against the
				  registrant in another jurisdiction or by another governmental agency in this
				  state immediately in accordance with R.I. Gen. Laws §
										27-74-5(l).
B. Within thirty (30) days of the initial
				  pretrial hearing date, the registrant shall report to the Commissioner any
				  criminal prosecution of any of the principals or employees of the registrant
				  taken in any jurisdiction if the prosecution is of a felony of any sort, and if
				  the prosecution is of a misdemeanor alleging facts relating to the business of
				  discount medical plans, or the business of insurance, or of any financial
				  services business. The report shall include a copy of the initial complaint
				  filed, the order resulting from the hearing, and any other relevant legal
				  documents.
C. The registrant shall
				  report the Commissioner any change to the information contained in the original
				  application within thirty (30) days of the change. With regard to the
				  registrant's name, address or website address, notice must be given thirty (30)
				  days before the change is made in accordance with R.I. Gen. Laws §
										27-74-12.
D. Reports required to be filed pursuant to
				  this section may be filed with the Office electronically. Reports shall include
				  the name and address of the registrant, the name of the officer or employee
				  authorized to file the report, and the phone number and email address where
				  such officer or employee can be contacted.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 13 - Discount Medical Plan Organizations (formerly OHIC Regulation 15) (230-RICR-20-30-13) › Section 230-RICR-20-30-13.5 - Denial, Suspension, Revocation or Non-Renewal

Current through June 14, 2024
A. The
				  Commissioner may place on probation, suspend, revoke or refuse to issue or
				  renew a plan's registration or may levy a civil penalty in accordance with R.I.
				  Gen. Laws §§
										27-74-14 and
				  42-14-16. Whenever the
				  Commissioner denies an application to operate as a discount medical plan or
				  suspends, revokes or fails to renew the certificate of registration of a
				  discount medical plan, the Commissioner will set forth the ground(s) for
				  disapproval.
B. In the event that
				  the action by the Commissioner is to deny an application for or not renew a
				  registration, the Commissioner shall notify the Applicant or registrant, in
				  writing, of the reason for the non-renewal or denial of the registration. The
				  Applicant or registrant may make written demand upon the Commissioner within
				  thirty (30) days for a hearing before the Commissioner to determine the
				  reasonableness of the Commissioner's action. The hearing shall be held pursuant
				  to R.I. Gen. Laws §§
										42-35-9 through 14.
C. The registration of a business entity may
				  be suspended, revoked or refused if the Commissioner finds, after hearing, that
				  the violation was known or should have been known by one or more of the
				  partners, officers or managers acting on behalf of the business entity and the
				  violation was neither reported to the Commissioner nor corrective action taken.
				  Corrective action will not prohibit action by the Commissioner but will be
				  taken into consideration.
D. In
				  addition to or in lieu of any applicable denial, suspension or revocation of a
				  registration, a person may, after hearing, be subject to a fine and/or any
				  other appropriate remedies according to R.I. Gen. Laws §§
										27-74-14 and
				  42-14-16.
E. The Commissioner shall retain the
				  authority to enforce the provisions of and impose any penalty or remedy
				  authorized by R.I. Gen. Laws §§
										27-74-14 and/or 42-14-16 against
				  any registrant who is under investigation for or charged with a violation even
				  if the registration has been surrendered or has lapsed by operation of
				  law.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 13 - Discount Medical Plan Organizations (formerly OHIC Regulation 15) (230-RICR-20-30-13) › Section 230-RICR-20-30-13.6 - Readability of Forms and Advertising

Current through June 14, 2024
All discount medical plan forms, marketing materials,
					 brochures, discount medical plan cards and any other communications by discount
					 medical plan organizations to members and prospective members shall comply with
					 the standards for readability set forth in Part 5 of this
					 Subchapter.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 13 - Discount Medical Plan Organizations (formerly OHIC Regulation 15) (230-RICR-20-30-13) › Section 230-RICR-20-30-13.7 - 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 14 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-14.1 - Authority

Current through June 14, 2024
These rules and regulations are promulgated pursuant to
					 R.I. Gen. Laws Chapter 27-18.9 entitled Benefit Determination and Utilization
					 Review Act (the Act).
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 14 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-14.2 - Purpose and Scope

Current through June 14, 2024
A. It is in the
				  best interest of the public that those individuals and health care entities
				  involved with the determination of health plan benefit determinations,
				  administrative and non-administrative, in our state meet the standards set
				  forth in R.I. Gen. Laws Chapter 27-18.9 (the Act) and this Part;
B. To establish reasonable standards for
				  review agencies to ensure the timely approval of and payment for covered health
				  care services to health care entity beneficiaries;
C. To protect health care entity
				  beneficiaries from benefit determination processes that may unreasonably impede
				  access to covered health care services;
D. To require health care entities and review
				  agencies to improve and maintain coordination of benefit determination
				  activities among all stakeholders and to the benefit of beneficiaries;
				  and
E. Nothing in the Act and this
				  Part is intended to prohibit a health care entity or its review agencies from
				  performing medical necessity determinations or maintaining processes to assess
				  the accuracy of benefit coverage for its beneficiaries.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 14 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-14.3 - Definitions

Current through June 14, 2024
A. As used in this Part:
1. "Adverse benefit determination" means a
				  decision not to authorize a health care service, including a denial, reduction,
				  or termination of, or a failure to provide or make a payment, in whole or in
				  part, for a benefit. A decision by a review agent to authorize a health care
				  service in an alternative setting, a modified extension of stay, or an
				  alternative treatment shall not constitute an adverse benefit determination if
				  the review agent and provider are in agreement regarding the decision. Adverse
				  benefit determinations include:
a.
				  "Administrative adverse benefit determinations," meaning any adverse benefit
				  determination that does not require the use of medical judgment or clinical
				  criteria such as a determination of an individual's eligibility to participate
				  in coverage, a determination that a benefit is not a covered benefit, a
				  determination that an administrative requirement was not followed, or any
				  rescission of coverage; and
b.
				  "Non-administrative adverse benefit determinations," or "utilization review
				  adverse benefit determinations," meaning any adverse benefit determination that
				  requires or involves the use of medical judgment or clinical criteria to
				  determine whether the service being reviewed is medically necessary and/or
				  appropriate. This includes the denial of treatments determined to be
				  experimental or investigational, and any denial of coverage of a prescription
				  drug because that drug is not on the health-care entity's formulary.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 14 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-14.4 - General Requirements

Current through June 14, 2024
A. A review agent
				  must establish and submit to the Office standards and procedures for its
				  benefit determination activity that demonstrates compliance with the Act and
				  this Part to include administrative and non-administrative benefit
				  determinations as defined in this Part. This shall be submitted through a
				  certification, recertification and material change process determined by the
				  Commissioner, including as set forth in this Part.
B. A review agent operating in Rhode Island
				  shall provide evidence of adherence to the following:
1. That it shall not conduct benefit
				  determination reviews in the state unless the Commissioner has granted the
				  review agent a certificate pursuant to the Act and this Part;
2. Individuals shall not be required to hold
				  a separate review agent certification under the Act or this Part when acting as
				  either an employee of, an affiliate of, a contractor for, or otherwise acting
				  on behalf of a certified review agent, however, the review agent shall be
				  responsible for these individuals in the same manner that the review agent is
				  responsible for its delegates under the Act and this Part;
3. Submission of a recertification
				  application every two (2) years in form and content consistent with
				  instructions issued by the Office for that purpose;
4. Notification and explanation to the Office
				  at least thirty (30) calendar days prior to implementation of any systemic
				  change to any of the certified review agent's operations to include the
				  information on file with the Office;
5. Upon a determination by the Office that a
				  systemic change constitutes a material change, shall file an application
				  consistent with instructions and requests for information issued by the Office
				  for that purpose; and
6. A systemic
				  change determined by the Office to be a material change shall not be
				  implemented until receipt of written approval for the material change by the
				  Office.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 14 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-14.5 - Delegate Requirements

Current through June 14, 2024
A. An agency must
				  provide evidence to the Office of current state certification under the Act for
				  each of its delegates, if any, to which the agency has delegated activity in
				  accordance with this Part.
B. Each
				  agency must maintain regular and meaningful oversight of each of its delegates
				  to ensure every such delegate is in compliance with the Act's requirements,
				  including but not limited to the following:
1. For any portion of the agency activity
				  that is delegated, in part or whole, the agency shall be responsible for
				  oversight and be held accountable for all activity delegated and for any
				  non-compliance of its delegate with the Act and this Part.
2. Should the Commissioner determine that any
				  delegated activity is non-compliant with this Part or other state and/or
				  federal laws, the agency may be required by the Commissioner to re-assume or
				  reassign the performance of the activity delegated.
3. The agency shall ensure through its
				  delegation agreement or contract that it and the Office will have direct access
				  to all the information held by the delegate that in its or the Office's
				  determination could contribute to determining compliance with the Act and this
				  Part as well as all other applicable state and federal laws and
				  regulations.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 14 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-14.7 - Internal Appeal and Reconsideration Requirements

Current through June 14, 2024
A. All internal appeal and reconsideration
				  requirements shall follow procedures in accordance with R.I. Gen. Laws §
										27-18.9-7 and this Part.
B. All review agents shall conform and
				  evidence to the Commissioner the following for the internal appeal of
				  administrative and non-administrative (utilization review) adverse benefit
				  determinations:
1. The review agent shall
				  maintain and make available a written description of its appeal procedures by
				  which the claimant may seek review of determinations not to authorize health
				  care services.
2. The process
				  established by each review agent shall include a reasonable time period within
				  which an appeal must be filed to be considered and that time period shall not
				  be less than one hundred eighty (180) calendar days after receipt of the
				  adverse benefit determination notice.
3. During the appeal, a review agent may
				  utilize a reconsideration process acceptable to the Commissioner in assessing
				  an adverse benefit determination. A reconsideration process for utilization
				  review benefit determinations must also comply with the requirements set forth
				  in §
											14.7(C)   of this Part.
4.
				  The review agent shall notify the claimant of the reconsideration or internal
				  appeal determination consistent with the form and content requirements set
				  forth in R.I. Gen. Laws §
											27-18.9-6(b) and
				  §
											14.6(E)   of this Part, as appropriate.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 14 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-14.8 - External Appeal of Non-Administrative Benefit Determinations Requirements

Current through June 14, 2024
A. In the cases
				  where the utilization review adverse benefit determination or the final
				  internal level of appeal to reverse a utilization review adverse benefit
				  determination is unsuccessful, the health care entity or review agent shall
				  provide for an external appeal by an independent review organization (IRO)
				  approved by the Commissioner and ensure that the external appeal complies with
				  all applicable laws, regulations, and the Office's instructions.
B. In order to seek an external appeal;
1. The claimant must have exhausted the
				  internal appeal process; and
2. The
				  claimant is deemed to have exhausted the internal appeal process when the
				  review agent or health care entity fails to strictly adhere to all benefit
				  determination and appeal processes with respect to a claim; or
3. The claimant has applied for expedited
				  external review at the same time as applying for expedited internal
				  review.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 14 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-14.9 - Reporting

Current through June 14, 2024
A. Each agency shall compile and maintain
				  reports in form and content consistent with instructions issued as a bulletin
				  by the Office for that purpose and these reports shall:
1. Include but not be limited to a report
				  that includes all utilization review benefit determinations made by the agency
				  and its delegates (if applicable), broken down by categories set forth by the
				  Office, which categories may change from time to time at the discretion of the
				  Commissioner; and
2. Be filed with
				  the Office according to the Office's instructions, no more frequently than
				  quarterly.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 14 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-14.10 - Waiver of Requirements

Current through June 14, 2024
A. The Office shall
				  waive the requirements of the Act or this Part only when the Commissioner has
				  determined a conflict exists with those activities of a review agent that are
				  conducted pursuant to contracts with the state or the federal government or
				  those activities under other state or federal jurisdictions.
B. The Office shall waive de minimus activity
				  as determined by the Commissioner.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 14 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-14.11 - Variance Requirements

Current through June 14, 2024
Statutory variances are governed by R.I. Gen. Laws §
										27-18.9-12.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 14 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-14.12 - Denial, Suspension, or Revocation of Certification

Current through June 14, 2024
Denial, suspension, or revocation or certification is
					 governed by R.I. Gen. Laws §
										27-18.9-13.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 14 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-14.13 - Penalties and Enforcement

Current through June 14, 2024
Penalties and enforcement are governed by R.I. Gen. Laws
					 §
										27-18.9-14.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 14 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-14.14 - Severability

Current through June 14, 2024
If any section, clause, provision or application of the Act
					 or this Part shall be held either unconstitutional or ineffective in whole or
					 in part, to the extent that it is not unconstitutional or ineffective, it shall
					 be valid and effective, and no other section, clause, provision or application
					 shall on account thereof be termed invalid or ineffective.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 15 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-15.1 - Authority

Current through June 14, 2024
This Part is promulgated pursuant to R.I. Gen. Laws
					 §§
										42-14.5-1 et seq., 42-14-5,
					 42-14-17, 27-18-8, 27-18-8.4, 27-19-6, 27-20-6, 27-41-29.2, and
					 42.62-12(b)(4).
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 15 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-15.2 - Purpose and Scope

Current through June 14, 2024
A. The purpose of
				  this Part is:
1. To establish procedures for
				  the filing of health insurance plan rates, rating, formulas, rating manuals,
				  and forms with the Office of the Health Insurance Commissioner by health
				  insurance issuers;
2. To establish
				  standards for the approval or disapproval of health insurance plan forms;
				  and
3. To establish standards for
				  the approval, disapproval or modification of health insurance plan rates,
				  rating formulas, and rating manuals.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 15 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-15.4 - Filing of Health Insurance Plan Forms

Current through June 14, 2024
A. No
				  health insurance plan shall be offered, issued, delivered or renewed to any
				  person or entity in this state, nor shall a certificate or other evidence of
				  coverage of a health insurance plan defined in §
										15.3(A)(6)(b)   of this Part
				  be offered, issued, delivered or renewed unless all forms used in connection
				  with the health insurance plan, including but not limited to any application,
				  rider, endorsement, certificate of coverage, policy, subscriber contract, or
				  group master contract, have been filed in a complete manner with the Office,
				  and the filing has been approved by the Commissioner.
1. Individual and small group market plans
				  (including Qualified Health Plans sold on the Exchange) proposed to be
				  effective between January 1 and December 31 of each calendar year shall be
				  filed with the Commissioner on the date set annually by the Commissioner unless
				  a waiver of such filing deadline is approved by the Commissioner.
2. The Commissioner shall notify the Issuer
				  when the filing is deemed complete. Nothing in §
											15.4(A)(2)   of this Part is
				  intended to limit the obligation of Issuers to provide information relating to
				  the filing requested by the Commissioner after the filing is deemed
				  complete.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 15 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-15.5 - Filing of Health Insurance Plan Rates, Rating Formulas, and Rate Manuals - General

Current through June 14, 2024
A. No health
				  insurance plan shall be offered, issued, delivered or renewed to any person or
				  entity in this state unless the rates, the rating formula, and the rate manual
				  used in connection with the plan have been filed in a complete manner with the
				  Office, and the filing has been approved by the Commissioner, or approved as
				  modified by the Commissioner; provided that with respect to small group health
				  insurance plans, issuers shall comply with the filing and maintenance of
				  records requirements of R.I. Gen. Laws §
										27-50-5(h).
1. Rates, rate factors, premiums, rating
				  formulas and rate manuals for individual and small group market plans
				  (including qualified health plans sold on the Exchange) proposed to be
				  effective between January 1 and December 31 of each calendar year shall be
				  filed with the Commissioner on the date set annually by the Commissioner unless
				  a waiver of such filing deadline is approved by the Commissioner. Rate factors
				  for large group market plans proposed to be effective between January 1and
				  December 31 of each calendar year shall be filed with the Commissioner on the
				  date set annually by the Commissioner.
2. A nonprofit health insurance issuer filing
				  rates, rate factors, premiums, rating formulas or rate manuals with respect to
				  health insurance plans in the individual market, and in the Medicare
				  supplemental insurance market shall provide a copy of such filings to the
				  Insurance Advocacy Unit of the Attorney General's Office, in accordance with
				  R.I. Gen. Laws §§
											27-19-6(b) and
				  27-20-6(b).
3. The Commissioner shall notify the Issuer
				  when the filing is deemed complete. Nothing in §
											15.5(A)(3)   of this Part is
				  intended to limit the obligation of Issuers to provide information relating to
				  the filing requested by the Commissioner after the filing is deemed
				  complete.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 15 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-15.6 - Filing of Health Insurance Plan Rates - Annual, All Market Filing in the Individual, Small Group, and Large Group Markets

Current through June 14, 2024
A. The
				  requirements of §
										15.6   of this Part shall apply to comprehensive hospital
				  and medical health insurance plan rate filings in the individual, small group,
				  and large group markets, in addition to the requirements of §
										15.5   of this
				  Part.
B. On the date prescribed by
				  the Commissioner, after at least 30 days' notice to affected health insurance
				  issuers, each health insurance issuer doing business in this state with at
				  least one percent of the covered lives in the insured market during the prior
				  calendar year shall file its proposed rates for health insurance plans offered,
				  issued or renewed during the succeeding calendar year for the individual, small
				  group, and large group markets, including rates for individual and SHOP
				  qualified health plans offered or proposed to be offered on the
				  Exchange.
C. In addition to the
				  filing instructions authorized by the Commissioner under §
										15.5(E)   of this
				  Part, the Commissioner's instructions for the annual, all market rate filing
				  may require:
1. A rate factor template
				  completed on the form prescribed by the Commissioner;
2. Evidence of compliance with the
				  affordability standards adopted by the Commissioner, in a manner prescribed by
				  the Commissioner; and
3. Such other
				  instructions as the Commissioner determines are necessary or desirable to
				  review the rate filing in accordance with statutory and regulatory
				  standards.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 15 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-15.7 - Commissioner's Review and Decision - Rates, Rating Formulas, and Rate Manuals

Current through June 14, 2024
A. The provisions of §
										15.7   of this Part
				  apply to rates, rating formulas, and rate manuals filed under §§
										15.5  and  15.6   of this Part.
B. The
				  Commissioner shall review the rate, rating formula, or rate manual filing and
				  approve the filing, propose to the health insurance issuer how the filing can
				  amended and approved, notice an administrative hearing, or take such other
				  actions separately or in combination as the Commissioner deems appropriate and
				  as authorized by law.
1. If the Commissioner
				  proposes amendments to the filing, the health insurance issuer shall be
				  provided with an opportunity to amend its filing in conformity with the
				  proposed amendments. If the health insurance issuer amends its filing in
				  conformity with the proposed amendments, the Commissioner shall approve the
				  filing.
2. If the health insurance
				  issuer does not amend its filing within the time period prescribed by the
				  Commissioner, the Commissioner shall notice an administrative hearing on the
				  filing.
3. Notwithstanding the
				  foregoing, after the Commissioner has determined a filing to be complete in
				  connection with an individual health insurance plan rate, rating formula, or
				  rate manual filing of a hospital or medical services corporation, including a
				  rate, rating formula, or rate manual of a hospital or medical services
				  corporation filed in connection with a qualified health plan, the Commissioner
				  shall conduct an administrative hearing.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 15 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-15.8 - Severability

Current through June 14, 2024
If any section, term, or provision of this Part 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 15 - Benefit Determination and Utilization Review › Section 230-RICR-20-30-15.9 - Construction

Current through June 14, 2024
A. This Part shall be liberally construed to
				  give full effect to the purposes stated in R.I. Gen. Laws §
										42-14.5-2.
B. This Part shall not be construed to limit
				  the powers granted the Commissioner by other provisions of law or
				  regulation.
C. This Part shall not
				  be construed to limit the powers of the Exchange to grant, withhold, revoke, or
				  reinstate final certification of qualified health plans in its discretion in
				  accordance with 45 C.F.R.
				  §
											155.1000 et seq., and subject to the
				  provisions of §§
										15.4(F)  and  15.5(F)   of this Part.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.1 - Purpose

Current through June 14, 2024
The purpose of this Part is to implement R.I. Gen. Laws
					 Chapter 27-34.2, to promote the public interest, to promote the availability of
					 long-term care insurance coverage, to protect applicants for long-term care
					 insurance, as defined, from unfair or deceptive sales or enrollment practices,
					 to facilitate public understanding and comparison of long-term care insurance
					 coverages, and to facilitate flexibility and innovation in the development of
					 long-term care insurance. This Part is not intended to interfere with the
					 qualification of long-term care policies or certificates as provided for in
					 Chapter 97, SEC. 7702B(b) of the U.S. Internal Revenue Code of 1986
					 (26 U.S.C. §
											7702B(b)), as added by the
					 Health Insurance Portability and Accountability Act of 1996,
					 Pub.L.
					 No. 104-191, as now constituted or later
					 amended.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.2 - Authority

Current through June 14, 2024
This Part is issued pursuant to the authority vested in the
					 Director under R.I. Gen. Laws §
										27-34.2-6(a).
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.3 - Applicability and Scope

Current through June 14, 2024
A. Except as
				  otherwise specifically provided, this Part applies to all long-term care
				  insurance as defined in R.I. Gen. Laws §
										27-34.2-4, including qualified
				  long-term care contracts subject to the requirements of Section  7702B(b)   of the
				  Internal Revenue Code of 1986 (26 U.S.C. §
											7702B(b)), as amended and
				  life insurance policies that accelerate benefits for long- term care delivered
				  or issued for delivery in this state on or after the effective date of the 2008
				  amendments to this Part by issuers, as defined in R.I. Gen. Laws §
										27-34.2-4.
B. Additionally, this Part is intended to
				  apply to policies having indemnity benefits that are triggered by activities of
				  daily living and sold as disability income insurance, if:
1. The benefits of the disability income
				  policy are dependent upon or vary in amount based on the receipt of long-term
				  care services;
2. The disability
				  income policy is advertised, marketed or offered as insurance for long-term
				  care services; or
3. Benefits under
				  the policy may commence after the policyholder has reached Social Security's
				  normal retirement age unless benefits are designed to replace lost income or
				  pay for specific expenses other than long-term care services.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.6 - Policy Practices and Provisions

Current through June 14, 2024
A. Renewability.
				  The terms "guaranteed renewable" and "noncancellable" shall not be used in any
				  individual long-term care insurance policy without further explanatory language
				  in accordance with the disclosure requirements of §
										1.8   of this Part.
1. A policy issued to an individual shall not
				  contain renewal provisions other than "guaranteed renewable" or
				  "noncancellable."
2. The term
				  "guaranteed renewable" may be used only when the insured has the right to
				  continue the long-term care insurance in force by the timely payment of
				  premiums and when the issuer has no unilateral right to make any change in any
				  provision of the policy or rider while the insurance is in force, and cannot
				  decline to renew, except that rates may be revised by the issuer on a class
				  basis.
3. The term "noncancellable"
				  may be used only when the insured has the right to continue the long-term care
				  insurance in force by the timely payment of premiums during which period the
				  issuer has no right to unilaterally make any change in any provision of the
				  insurance or in the premium rate.
4. The term "level premium" may only be used
				  when the issuer does not have the right to change the premium.
5. In addition to the other requirements of
				  this subsection, a qualified long-term care insurance contract shall be
				  guaranteed renewable, within the meaning of Section  7702B(b)(1)(C)   of the
				  Internal Revenue Code of 1986 (26 U.S.C. §
												7702B(b)(1)(C)), as
				  amended.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.7 - Unintentional Lapse

Current through June 14, 2024
Provisions regarding Unintentional Lapse are contained in
					 R.I. Gen. Laws §
										27-34.2-12.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.8 - Required Disclosure Provisions

Current through June 14, 2024
A. Renewability.
				  Individual long-term care insurance policies shall contain a renewability
				  provision.
1. The provision shall be
				  appropriately captioned, shall appear on the first page of the policy, and
				  shall clearly state that the coverage is guaranteed renewable or
				  noncancellable. This provision shall not apply to policies which do not contain
				  a renewability provision and under which the right to nonrenew is reserved
				  solely to the policyholder.
2. A
				  long-term care insurance policy or certificate, other than one where the issuer
				  does not have the right to change the premium, shall include a statement that
				  premium rates may change.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.9 - Required Disclosure of Rating Practices to Consumers

Current through June 14, 2024
A. This section shall apply as follows:
1. Except as provided in §
											1.9(A)(2)   of
				  this Part, this section applies to any long-term care policy or certificate
				  issued in this state on or after December 1, 2008.
2. For certificates issued on or after the
				  effective date of this amended Part under a group long-term care insurance
				  policy as defined in R.I. Gen. Laws §
											27-34.2-4(4)(i),
				  which policy was in force at the time this amended Part became effective, the
				  provisions of this section shall apply on the policy anniversary following June
				  1, 2009.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.11 - Prohibition Against Post-Claims Underwriting

Current through June 14, 2024
A. All
				  applications for long-term care insurance policies or certificates except those
				  which are guaranteed issue shall contain clear and unambiguous questions
				  designed to ascertain the health condition of the applicant.
B. If an application for long-term care
				  insurance contains a question which asks whether the applicant has had
				  medication prescribed by a physician, it must also ask the applicant to list
				  the medication that has been prescribed.
1. If
				  the medications listed in such application were known by the issuer, or should
				  have been known at the time of application, to be directly related to a medical
				  condition for which coverage would otherwise be denied, then the policy or
				  certificate shall not be rescinded for that condition.