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-20-30-4.3 - Definitions

Current through June 14, 2024
A. As used in this regulation:
1. "Affiliate" means the same as set out in
				  the first sentence of R.I. Gen. Laws §
											27-35-1(a). An
				  "affiliate" of, or an entity or person "affiliated" with, a specific entity or
				  person, is an entity or person who directly or indirectly through one or more
				  intermediaries controls, or is controlled by, or is under common control with,
				  the entity or person specified.
2.
				  "Aligned measure set" means any set of quality measures adopted by the
				  Commissioner pursuant to §
											4.10(D)(5)   of this Part. An Aligned Measure Set
				  shall consist of measures designated as 'Core Measures' and/or 'Menu Measures.'
				  Aligned Measure Sets are developed for specific provider contract types (e.g.,
				  primary care provider contracts, hospital contracts, Accountable Care
				  Organization (ACO, or Integrated System of Care) contracts.
3. "Commissioner" means the Health Insurance
				  Commissioner.
4. "Core measures"
				  means quality measures in an Aligned Measure Set that have been designated for
				  mandatory inclusion in applicable health care provider contracts that
				  incorporate quality measures into the payment terms (e.g., primary care
				  measures for primary care provider contracts).
5. "Demographic data" means self-reported
				  data on race, ethnicity, preferred language, sex assigned at birth, gender
				  identity, sexual orientation, and disability.
6. "Direct primary care expenses" means
				  payments by the Health Insurer directly to a primary care practice for:
a. Providing health care services, including
				  fee-for service payments, capitation payments, and payments under other
				  alternative, non-fee-for-service methodologies designed to provide incentives
				  for the efficient use of health services;
b. Achieving quality or cost performance
				  goals, including pay-for-performance payments and shared savings
				  distributions;
c. Infrastructure
				  development payments within the primary care practice, which the practice
				  cannot reasonably fund independently, in accordance with parameters and
				  criteria issued by order of the Commissioner, or upon request by a Health
				  Insurer and approval by the Commissioner:
(1)
				  That are designed to transform the practice into, and maintain the practice as
				  a Patient Centered Medical Home, and to prepare a practice to function within
				  an Integrated System of Care. Examples of acceptable spending under this
				  category include:
(AA) Making supplemental
				  payments to fund a practice-based and practice-paid care manager;
(BB) Funding the provision of care management
				  resources embedded in, but not paid for by, the primary care
				  practice;
(CC) Funding the purchase
				  by the practice of analytic software that enables primary care practices to
				  analyze patient quality and/or costs, such as software that tracks patient
				  costs in near-to-real time;
(DD)
				  Training of members of the primary care team in motivational interviewing or
				  other patient activation techniques; and
(EE) Funding the cost of the practice to link
				  to the health information exchange established by R.I. Gen. Laws Chapter
				  5-37.7;
(2) That promote
				  the appropriate integration of primary care and behavioral health care; for
				  example, funding behavioral health services not traditionally covered with a
				  discrete payment when provided in a primary care setting, such as substance
				  abuse or depression screening;
(3)
				  For shared services among small and independent primary care practices to
				  enable the practices to function as Patient-Centered Medical Homes. Acceptable
				  spending under this category:
(AA) must
				  directly enhance a Primary Care Practice's ability to support its patient
				  population, and
(BB) must provide,
				  reinforce or promote specific skills that Patient-Centered Medical Homes must
				  have to effectively operate using Patient-Centered Medical Home principles and
				  standards, or to participate in an Integrated System of Care that successfully
				  manages risk-bearing contracts. Examples of acceptable spending under this
				  category include:
(i) Funding the cost of a
				  clinical care manager who rotates through the practices;
(ii) Funding the cost of a practice data
				  analyst to provide data support and reports to the participating practices,
				  and
(iii) Funding the costs of a
				  pharmacist to help practices with medication reconciliation for poly-pharmacy
				  patients;
(4)
				  That promote community-based services to enable practices to function as
				  Patient Centered Medical Homes. Acceptable spending under this category:
(AA) must directly enhance a Primary Care
				  Practice's ability to support its patient population, and
(BB) must provide, reinforce or promote
				  specific skills that the Patient-Centered Medical Homes must have to
				  effectively operate using Patient-Centered Medical Home principles and
				  standards, or to participate in an Integrated System of Care that successfully
				  manages risk-bearing contracts. Acceptable spending under this category
				  includes funding multi-disciplinary care management teams to support Primary
				  Care Practice sites within a geographic region;
(5) Designed to increase the number of
				  primary care physicians practicing in RI, and approved by the Commissioner,
				  such as a medical school loan forgiveness program; and
(6) Any other direct primary care expense
				  that meets the parameters and criteria established in a bulletin issued by the
				  Commissioner, or that is requested by a Health Insurer and approved by the
				  Commissioner.
7. "Examination" means the same as set out in
				  R.I. Gen. Laws §
											27-13.1-1
et
				  seq
.
8. "Health insurance"
				  means "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.
9. "Global capitation
				  contract" means a Population-Based Contract with an Integrated System of Care
				  that:
a. holds the Integrated System of Care
				  responsible for providing or arranging for all, or substantially all of the
				  covered services provided to the Health Insurer's defined group of members in
				  return for a monthly payment that is inclusive of the total, or near total
				  costs of such covered services based on a negotiated percentage of the Health
				  Insurer's premium or based on a negotiated fixed per member per month payment,
				  and
b. incorporates incentives
				  and/or penalties for performance relative to quality targets.
10. "Health insurer" means any
				  entity subject to the insurance laws and regulations of this state, or subject
				  to the jurisdiction of the 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, a health maintenance organization, a
				  non-profit hospital service corporation, a non-profit medical service
				  corporation, a non-profit dental service corporation, a non-profit optometric
				  service corporation, a domestic insurance company subject R.I. Gen. Laws
				  Chapter 27-1 that offers or provides health insurance coverage in the state and
				  a foreign insurance company subject to R.I. Gen. Laws Chapter 27-2 that offers
				  or provides health insurance coverage in the state.
11. "Holding company system" means the same
				  as set out in R.I. Gen. Laws §
											27-35-1
et
				  seq
.
12. "Indirect primary
				  care expenses" means payments by the Health Insurer to support and strengthen
				  the capacity of a primary care practice to function as a medical home, and to
				  successfully manage risk-bearing contracts, but which do not qualify as Direct
				  Primary Care Expenses. Indirect Primary Care Expenses may include a proper
				  allocation, proportionate to the benefit accruing to the Primary Care Practice,
				  of Health Insurer investments in data, analytics, and population-health and
				  disease registries for Primary Care Practices without the foreseeable ability
				  to make and manage such infrastructure investments, but which do not qualify as
				  acceptable Direct Primary Care Spending, in accordance with parameters and
				  criteria issued in a bulletin issued by the Commissioner, or upon request by a
				  Health Insurer and approved by the Commissioner. Such payments shall include
				  financial support, in an amount approved by the Commissioner, for the
				  administrative expenses of the medical home initiative endorsed by R.I. Gen.
				  Laws Chapter 42-14.6, and for the health information exchange established by
				  R.I. Gen. Laws Chapter 5-37.7.
13.
				  "Integrated system of care", sometimes referred to as an Accountable Care
				  Organization, means one or more business entities consisting of physicians,
				  other clinicians, hospitals and/or other providers that together provide care
				  and share accountability for the cost and quality of care for a population of
				  patients, and that enters into a Population-Based Contract, such as a Shared
				  Savings Contract or Risk Sharing Contract or Global Capitation Contract, with
				  one or more Health Insurers to care for a defined group of patients.
14. "Low-value care" most often refers to
				  medical services, including tests and procedures, that should not be performed
				  given their potential for harm or the existence of comparably effective and
				  often less expensive alternatives.
15. "Menu measures" means quality measures
				  within an Aligned Measure Set that are included in applicable health care
				  provider contracts that incorporate quality measures into the payment terms
				  when such inclusion occurs at the mutual agreement of the Health Insurer and
				  contracted health care provider.
16. "Minimum loss rate" means a defined
				  percentage of the total cost of care, or annual provider revenue from the
				  insurer under a population-based contract, which must be met or exceeded before
				  actual losses are incurred by the provider. Losses may accrue on a "first
				  dollar" basis once the "minimum loss rate" is breached.
17. "Patient-centered medical home" means:
a. A Primary Care Practice recognized by the
				  collaborative initiative endorsed by R.I. Gen. Laws Chapter 42-14.6,
				  or
b. A Primary Care Practice
				  recognized by a national accreditation body, or
c. A Primary Care Practice designated by
				  contract between a Health Insurer and a primary care practice, or between a
				  Health Insurer and an Integrated System of Care in which the Primary Care
				  Practice is participating. A contractually designated Primary Care Practice
				  must meet pre-determined quality and efficiency criteria and practice
				  performance standards, which are approved by the Commissioner, for improved
				  care management and coordination that are at least as rigorous as those of the
				  collaborative initiative endorsed by R.I. Gen. Laws Chapter 42-14.6. For the
				  purposes of this definition a primary care practice that participates in a
				  primary care alternative payment model and participates in an integrated system
				  of care will be deemed to have met the requirements of a patient-centered
				  medical home, and
d. A Primary Care
				  Practice which has demonstrated development and implementation of meaningful
				  cost management strategies and clinical quality performance attainment and/or
				  improvement. The requirements for meaningful cost management strategies and for
				  clinical quality performance attainment and/or improvement, and the measures
				  for assessing performance, shall be determined annually by the
				  Commissioner.
18.
				  "Population-based contract" means a provider reimbursement contract with an
				  Integrated System of Care that uses a reimbursement methodology that is
				  inclusive of the total, or near total medical costs of an identified,
				  covered-lives population. A Population-Based Contract may be a Shared Savings
				  Contract, or a Risk Sharing Contract, or a Global Capitation Contract. A
				  primary care or specialty service capitation reimbursement contract shall not
				  be considered a Population-Based Contract for purposes of this Part. A
				  Population-Based Contract may not transfer insurance risk or any health
				  insurance regulatory obligations. A Health Insurer may request clarification
				  from the Commissioner as to whether its proposed contract constitutes the
				  transfer of insurance risk.
19.
				  "Primary care alternative payment model" means a payment model that relies on
				  prospective payment to a primary care practice or a primary care provider for a
				  defined set of primary care services (including office evaluation and
				  management services) in addition to any amounts paid to support care management
				  and infrastructure of the primary care practice. It may also include a model
				  that includes additional services in the alternative payment methodology, such
				  as integrated behavioral health.
20. "Primary care practice" means the
				  practice of a physician, medical practice, or other medical provider considered
				  by the insured subscriber or dependent to be his or her usual source of care.
				  Designation of a primary care provider shall be limited to providers within the
				  following practice type: Family Practice, Geriatrics, Internal Medicine and
				  Pediatrics; and providers with the following professional credentials: Doctors
				  of Medicine and Osteopathy, Nurse Practitioners, and Physicians' Assistants;
				  except that specialty medical providers, including behavioral health providers,
				  may be designated as a primary care provider if the specialist is paid for
				  primary care services on a primary care provider fee schedule, and
				  contractually agrees to accept the responsibilities of a primary care
				  provider.
21. "Qualifying
				  Integrated Behavioral Health Primary Care Practice" means:
a. A patient-centered medical home practice
				  that is recognized by a national accreditation body (such as NCQA) as an
				  integrated behavioral health practice, or
b. A patient-centered medical home practice
				  that participated in and successfully completed, or is currently participating
				  in, an integrated behavioral health program under the oversight of the
				  collaborative initiative endorsed by R.I. Gen. Laws Chapter 42-14.6. Such
				  practices must be recognized as an integrated behavioral health practice by a
				  national accreditation body (such as NCQA) or meet integrated behavioral health
				  standards developed by the Care Transformation Collaborative of Rhode Island,
				  or
c. A patient centered-medical
				  home practice that completes a qualifying behavioral health integration
				  self-assessment tool approved by the Commissioner and develops an action plan
				  for improving its level of integration. Such practices must be recognized as an
				  integrated behavioral health practice by a national accreditation body (such as
				  NCQA) or meet integrated behavioral health standards developed by the Care
				  Transformation Collaborative of Rhode Island.
22. "Risk exposure cap" means a cap on the
				  losses which may be incurred by the provider under the contract, expressed as a
				  percentage of the total cost of care or the annual provider revenue from the
				  insurer under the population-based contract.
23. "Risk sharing contract" means a
				  Population-Based Contract that:
a. Holds the
				  provider financially responsible for a negotiated portion of costs that exceed
				  a predetermined population-based budget, in exchange for provider eligibility
				  for a portion of any savings generated below the predetermined budget,
				  and
b. Incorporates incentives
				  and/or penalties for performance relative to quality targets.
24. "Risk sharing rate" means the
				  percentage of total losses shared by the provider with the insurer under the
				  contract after the application of any minimum loss rate.
25. "Shared savings contract" means a
				  Population-Based Contract that:
a. Allows the
				  provider to share in a portion of any savings generated below a predetermined
				  population-based budget, and
b.
				  Incorporates incentives and/or penalties for performance relative to quality
				  targets.