§ 42-14.5-3 Powers and duties.[Contingent effective date; see notes under section 42-14.5-1].– The health insurance commissioner shall have the following powers and duties:
(a) To conduct quarterly public meetings throughout thestate, separate and distinct from rate hearings pursuant to § 42-62-13,regarding the rates, services and operations of insurers licensed to providehealth insurance in the state the effects of such rates, services andoperations on consumers, medical care providers, patients, and the marketenvironment in which such insurers operate and efforts to bring new healthinsurers into the Rhode Island market. Notice of not less than ten (10) days ofsaid hearing(s) shall go to the general assembly, the governor, the RhodeIsland Medical Society, the Hospital Association of Rhode Island, the directorof health, the attorney general and the chambers of commerce. Public noticeshall be posted on the department's web site and given in the newspaper ofgeneral circulation, and to any entity in writing requesting notice.
(b) To make recommendations to the governor and the house ofrepresentatives and senate finance committees regarding health care insuranceand the regulations, rates, services, administrative expenses, reserverequirements, and operations of insurers providing health insurance in thestate, and to prepare or comment on, upon the request of the governor, orchairpersons of the house or senate finance committees, draft legislation toimprove the regulation of health insurance. In making such recommendations, thecommissioner shall recognize that it is the intent of the legislature that themaximum disclosure be provided regarding the reasonableness of individualadministrative expenditures as well as total administrative costs. Thecommissioner shall also make recommendations on the levels of reservesincluding consideration of: targeted reserve levels; trends in the increase ordecrease of reserve levels; and insurer plans for distributing excess reserves.
(c) To establish a consumer/business/labor/medical advisorycouncil to obtain information and present concerns of consumers, business andmedical providers affected by health insurance decisions. The council shalldevelop proposals to allow the market for small business health insurance to beaffordable and fairer. The council shall be involved in the planning andconduct of the quarterly public meetings in accordance with subsection (a)above. The advisory council shall develop measures to inform small businessesof an insurance complaint process to ensure that small businesses thatexperience rate increases in a given year may request and receive a formalreview by the department. The advisory council shall assess views of the healthprovider community relative to insurance rates of reimbursement, billing andreimbursement procedures, and the insurers' role in promoting efficient andhigh quality health care. The advisory council shall issue an annual report offindings and recommendations to the governor and the general assembly andpresent their findings at hearings before the house and senate financecommittees. The advisory council is to be diverse in interests and shallinclude representatives of community consumer organizations; small businesses,other than those involved in the sale of insurance products; and hospital,medical, and other health provider organizations. Such representatives shall benominated by their respective organizations. The advisory council shall beco-chaired by the health insurance commissioner and a community consumerorganization or small business member to be elected by the full advisorycouncil.
(d) To establish and provide guidance and assistance to asubcommittee ("The Professional Provider-Health Plan Work Group") of theadvisory council created pursuant to subsection (c) above, composed of healthcare providers and Rhode Island licensed health plans. This subcommittee shallinclude in its annual report and presentation before the house and senatefinance committees the following information:
(i) A method whereby health plans shall disclose tocontracted providers the fee schedules used to provide payment to thoseproviders for services rendered to covered patients;
(ii) A standardized provider application and credentialsverification process, for the purpose of verifying professional qualificationsof participating health care providers;
(iii) The uniform health plan claim form utilized byparticipating providers;
(iv) Methods for health maintenance organizations as definedby § 27-41-1, and nonprofit hospital or medical service corporations asdefined by chapters 27-19 and 27-20, to make facility-specific data and othermedical service-specific data available in reasonably consistent formats topatients regarding quality and costs. This information would help consumersmake informed choices regarding the facilities and/or clinicians or physicianpractices at which to seek care. Among the items considered would be the uniquehealth services and other public goods provided by facilities and/or cliniciansor physician practices in establishing the most appropriate cost comparisons.
(v) All activities related to contractual disclosure toparticipating providers of the mechanisms for resolving health plan/providerdisputes; and
(vi) The uniform process being utilized for confirming inreal time patient insurance enrollment status, benefits coverage, includingco-pays and deductibles.
(vii) Information related to temporary credentialing ofproviders seeking to participate in the plan's network and the impact of saidactivity on health plan accreditation;
(viii) The feasibility of regular contract renegotiationsbetween plans and the providers in their networks.
(ix) Efforts conducted related to reviewing impact of silentPPOs on physician practices.
(e) To enforce the provisions of Title 27 and Title 42 as setforth in § 42-14-5(d).
(f) To provide analysis of the Rhode Island Affordable HealthPlan Reinsurance Fund. The fund shall be used to effectuate the provisions of§§ 27-18.5-8 and 27-50-17.
(g) To analyze the impact of changing the rating guidelinesand/or merging the individual health insurance market as defined in chapter27-18.5 and the small employer health insurance market as defined in chapter27-50 in accordance with the following:
(i) The analysis shall forecast the likely rate increasesrequired to effect the changes recommended pursuant to the preceding subsection(g) in the direct pay market and small employer health insurance market overthe next five (5) years, based on the current rating structure, and currentproducts.
(ii) The analysis shall include examining the impact ofmerging the individual and small employer markets on premiums charged toindividuals and small employer groups.
(iii) The analysis shall include examining the impact onrates in each of the individual and small employer health insurance markets andthe number of insureds in the context of possible changes to the ratingguidelines used for small employer groups, including: community ratingprinciples; expanding small employer rate bonds beyond the current range;increasing the employer group size in the small group market; and/or addingrating factors for broker and/or tobacco use.
(iv) The analysis shall include examining the adequacy ofcurrent statutory and regulatory oversight of the rating process and factorsemployed by the participants in the proposed new merged market.
(v) The analysis shall include assessment of possiblereinsurance mechanisms and/or federal high-risk pool structures and funding tosupport the health insurance market in Rhode Island by reducing the risk ofadverse selection and the incremental insurance premiums charged for this risk,and/or by making health insurance affordable for a selected at-risk population.
(vi) The health insurance commissioner shall work with aninsurance market merger task force to assist with the analysis. The task forceshall be chaired by the health insurance commissioner and shall include, butnot be limited to, representatives of the general assembly, the businesscommunity, small employer carriers as defined in § 27-50-3, carriersoffering coverage in the individual market in Rhode Island, health insurancebrokers and members of the general public.
(vii) For the purposes of conducting this analysis, thecommissioner may contract with an outside organization with expertise in fiscalanalysis of the private insurance market. In conducting its study, theorganization shall, to the extent possible, obtain and use actual health plandata. Said data shall be subject to state and federal laws and regulationsgoverning confidentiality of health care and proprietary information.
(viii) The task force shall meet as necessary and includetheir findings in the annual report and the commissioner shall include theinformation in the annual presentation before the house and senate financecommittees.
§ 42-14.5-3 Powers and duties.[Contingent effective date; see notes under section 42-14.5-1].– The health insurance commissioner shall have the following powers and duties:
(a) To conduct quarterly public meetings throughout thestate, separate and distinct from rate hearings pursuant to § 42-62-13,regarding the rates, services and operations of insurers licensed to providehealth insurance in the state the effects of such rates, services andoperations on consumers, medical care providers, patients, and the marketenvironment in which such insurers operate and efforts to bring new healthinsurers into the Rhode Island market. Notice of not less than ten (10) days ofsaid hearing(s) shall go to the general assembly, the governor, the RhodeIsland Medical Society, the Hospital Association of Rhode Island, the directorof health, the attorney general and the chambers of commerce. Public noticeshall be posted on the department's web site and given in the newspaper ofgeneral circulation, and to any entity in writing requesting notice.
(b) To make recommendations to the governor and the house ofrepresentatives and senate finance committees regarding health care insuranceand the regulations, rates, services, administrative expenses, reserverequirements, and operations of insurers providing health insurance in thestate, and to prepare or comment on, upon the request of the governor, orchairpersons of the house or senate finance committees, draft legislation toimprove the regulation of health insurance. In making such recommendations, thecommissioner shall recognize that it is the intent of the legislature that themaximum disclosure be provided regarding the reasonableness of individualadministrative expenditures as well as total administrative costs. Thecommissioner shall also make recommendations on the levels of reservesincluding consideration of: targeted reserve levels; trends in the increase ordecrease of reserve levels; and insurer plans for distributing excess reserves.
(c) To establish a consumer/business/labor/medical advisorycouncil to obtain information and present concerns of consumers, business andmedical providers affected by health insurance decisions. The council shalldevelop proposals to allow the market for small business health insurance to beaffordable and fairer. The council shall be involved in the planning andconduct of the quarterly public meetings in accordance with subsection (a)above. The advisory council shall develop measures to inform small businessesof an insurance complaint process to ensure that small businesses thatexperience rate increases in a given year may request and receive a formalreview by the department. The advisory council shall assess views of the healthprovider community relative to insurance rates of reimbursement, billing andreimbursement procedures, and the insurers' role in promoting efficient andhigh quality health care. The advisory council shall issue an annual report offindings and recommendations to the governor and the general assembly andpresent their findings at hearings before the house and senate financecommittees. The advisory council is to be diverse in interests and shallinclude representatives of community consumer organizations; small businesses,other than those involved in the sale of insurance products; and hospital,medical, and other health provider organizations. Such representatives shall benominated by their respective organizations. The advisory council shall beco-chaired by the health insurance commissioner and a community consumerorganization or small business member to be elected by the full advisorycouncil.
(d) To establish and provide guidance and assistance to asubcommittee ("The Professional Provider-Health Plan Work Group") of theadvisory council created pursuant to subsection (c) above, composed of healthcare providers and Rhode Island licensed health plans. This subcommittee shallinclude in its annual report and presentation before the house and senatefinance committees the following information:
(i) A method whereby health plans shall disclose tocontracted providers the fee schedules used to provide payment to thoseproviders for services rendered to covered patients;
(ii) A standardized provider application and credentialsverification process, for the purpose of verifying professional qualificationsof participating health care providers;
(iii) The uniform health plan claim form utilized byparticipating providers;
(iv) Methods for health maintenance organizations as definedby § 27-41-1, and nonprofit hospital or medical service corporations asdefined by chapters 27-19 and 27-20, to make facility-specific data and othermedical service-specific data available in reasonably consistent formats topatients regarding quality and costs. This information would help consumersmake informed choices regarding the facilities and/or clinicians or physicianpractices at which to seek care. Among the items considered would be the uniquehealth services and other public goods provided by facilities and/or cliniciansor physician practices in establishing the most appropriate cost comparisons.
(v) All activities related to contractual disclosure toparticipating providers of the mechanisms for resolving health plan/providerdisputes; and
(vi) The uniform process being utilized for confirming inreal time patient insurance enrollment status, benefits coverage, includingco-pays and deductibles.
(vii) Information related to temporary credentialing ofproviders seeking to participate in the plan's network and the impact of saidactivity on health plan accreditation;
(viii) The feasibility of regular contract renegotiationsbetween plans and the providers in their networks.
(ix) Efforts conducted related to reviewing impact of silentPPOs on physician practices.
(e) To enforce the provisions of Title 27 and Title 42 as setforth in § 42-14-5(d).
(f) To provide analysis of the Rhode Island Affordable HealthPlan Reinsurance Fund. The fund shall be used to effectuate the provisions of§§ 27-18.5-8 and 27-50-17.
(g) To analyze the impact of changing the rating guidelinesand/or merging the individual health insurance market as defined in chapter27-18.5 and the small employer health insurance market as defined in chapter27-50 in accordance with the following:
(i) The analysis shall forecast the likely rate increasesrequired to effect the changes recommended pursuant to the preceding subsection(g) in the direct pay market and small employer health insurance market overthe next five (5) years, based on the current rating structure, and currentproducts.
(ii) The analysis shall include examining the impact ofmerging the individual and small employer markets on premiums charged toindividuals and small employer groups.
(iii) The analysis shall include examining the impact onrates in each of the individual and small employer health insurance markets andthe number of insureds in the context of possible changes to the ratingguidelines used for small employer groups, including: community ratingprinciples; expanding small employer rate bonds beyond the current range;increasing the employer group size in the small group market; and/or addingrating factors for broker and/or tobacco use.
(iv) The analysis shall include examining the adequacy ofcurrent statutory and regulatory oversight of the rating process and factorsemployed by the participants in the proposed new merged market.
(v) The analysis shall include assessment of possiblereinsurance mechanisms and/or federal high-risk pool structures and funding tosupport the health insurance market in Rhode Island by reducing the risk ofadverse selection and the incremental insurance premiums charged for this risk,and/or by making health insurance affordable for a selected at-risk population.
(vi) The health insurance commissioner shall work with aninsurance market merger task force to assist with the analysis. The task forceshall be chaired by the health insurance commissioner and shall include, butnot be limited to, representatives of the general assembly, the businesscommunity, small employer carriers as defined in § 27-50-3, carriersoffering coverage in the individual market in Rhode Island, health insurancebrokers and members of the general public.
(vii) For the purposes of conducting this analysis, thecommissioner may contract with an outside organization with expertise in fiscalanalysis of the private insurance market. In conducting its study, theorganization shall, to the extent possible, obtain and use actual health plandata. Said data shall be subject to state and federal laws and regulationsgoverning confidentiality of health care and proprietary information.
(viii) The task force shall meet as necessary and includetheir findings in the annual report and the commissioner shall include theinformation in the annual presentation before the house and senate financecommittees.
§ 42-14.5-3 Powers and duties.[Contingent effective date; see notes under section 42-14.5-1].– The health insurance commissioner shall have the following powers and duties:
(a) To conduct quarterly public meetings throughout thestate, separate and distinct from rate hearings pursuant to § 42-62-13,regarding the rates, services and operations of insurers licensed to providehealth insurance in the state the effects of such rates, services andoperations on consumers, medical care providers, patients, and the marketenvironment in which such insurers operate and efforts to bring new healthinsurers into the Rhode Island market. Notice of not less than ten (10) days ofsaid hearing(s) shall go to the general assembly, the governor, the RhodeIsland Medical Society, the Hospital Association of Rhode Island, the directorof health, the attorney general and the chambers of commerce. Public noticeshall be posted on the department's web site and given in the newspaper ofgeneral circulation, and to any entity in writing requesting notice.
(b) To make recommendations to the governor and the house ofrepresentatives and senate finance committees regarding health care insuranceand the regulations, rates, services, administrative expenses, reserverequirements, and operations of insurers providing health insurance in thestate, and to prepare or comment on, upon the request of the governor, orchairpersons of the house or senate finance committees, draft legislation toimprove the regulation of health insurance. In making such recommendations, thecommissioner shall recognize that it is the intent of the legislature that themaximum disclosure be provided regarding the reasonableness of individualadministrative expenditures as well as total administrative costs. Thecommissioner shall also make recommendations on the levels of reservesincluding consideration of: targeted reserve levels; trends in the increase ordecrease of reserve levels; and insurer plans for distributing excess reserves.
(c) To establish a consumer/business/labor/medical advisorycouncil to obtain information and present concerns of consumers, business andmedical providers affected by health insurance decisions. The council shalldevelop proposals to allow the market for small business health insurance to beaffordable and fairer. The council shall be involved in the planning andconduct of the quarterly public meetings in accordance with subsection (a)above. The advisory council shall develop measures to inform small businessesof an insurance complaint process to ensure that small businesses thatexperience rate increases in a given year may request and receive a formalreview by the department. The advisory council shall assess views of the healthprovider community relative to insurance rates of reimbursement, billing andreimbursement procedures, and the insurers' role in promoting efficient andhigh quality health care. The advisory council shall issue an annual report offindings and recommendations to the governor and the general assembly andpresent their findings at hearings before the house and senate financecommittees. The advisory council is to be diverse in interests and shallinclude representatives of community consumer organizations; small businesses,other than those involved in the sale of insurance products; and hospital,medical, and other health provider organizations. Such representatives shall benominated by their respective organizations. The advisory council shall beco-chaired by the health insurance commissioner and a community consumerorganization or small business member to be elected by the full advisorycouncil.
(d) To establish and provide guidance and assistance to asubcommittee ("The Professional Provider-Health Plan Work Group") of theadvisory council created pursuant to subsection (c) above, composed of healthcare providers and Rhode Island licensed health plans. This subcommittee shallinclude in its annual report and presentation before the house and senatefinance committees the following information:
(i) A method whereby health plans shall disclose tocontracted providers the fee schedules used to provide payment to thoseproviders for services rendered to covered patients;
(ii) A standardized provider application and credentialsverification process, for the purpose of verifying professional qualificationsof participating health care providers;
(iii) The uniform health plan claim form utilized byparticipating providers;
(iv) Methods for health maintenance organizations as definedby § 27-41-1, and nonprofit hospital or medical service corporations asdefined by chapters 27-19 and 27-20, to make facility-specific data and othermedical service-specific data available in reasonably consistent formats topatients regarding quality and costs. This information would help consumersmake informed choices regarding the facilities and/or clinicians or physicianpractices at which to seek care. Among the items considered would be the uniquehealth services and other public goods provided by facilities and/or cliniciansor physician practices in establishing the most appropriate cost comparisons.
(v) All activities related to contractual disclosure toparticipating providers of the mechanisms for resolving health plan/providerdisputes; and
(vi) The uniform process being utilized for confirming inreal time patient insurance enrollment status, benefits coverage, includingco-pays and deductibles.
(vii) Information related to temporary credentialing ofproviders seeking to participate in the plan's network and the impact of saidactivity on health plan accreditation;
(viii) The feasibility of regular contract renegotiationsbetween plans and the providers in their networks.
(ix) Efforts conducted related to reviewing impact of silentPPOs on physician practices.
(e) To enforce the provisions of Title 27 and Title 42 as setforth in § 42-14-5(d).
(f) To provide analysis of the Rhode Island Affordable HealthPlan Reinsurance Fund. The fund shall be used to effectuate the provisions of§§ 27-18.5-8 and 27-50-17.
(g) To analyze the impact of changing the rating guidelinesand/or merging the individual health insurance market as defined in chapter27-18.5 and the small employer health insurance market as defined in chapter27-50 in accordance with the following:
(i) The analysis shall forecast the likely rate increasesrequired to effect the changes recommended pursuant to the preceding subsection(g) in the direct pay market and small employer health insurance market overthe next five (5) years, based on the current rating structure, and currentproducts.
(ii) The analysis shall include examining the impact ofmerging the individual and small employer markets on premiums charged toindividuals and small employer groups.
(iii) The analysis shall include examining the impact onrates in each of the individual and small employer health insurance markets andthe number of insureds in the context of possible changes to the ratingguidelines used for small employer groups, including: community ratingprinciples; expanding small employer rate bonds beyond the current range;increasing the employer group size in the small group market; and/or addingrating factors for broker and/or tobacco use.
(iv) The analysis shall include examining the adequacy ofcurrent statutory and regulatory oversight of the rating process and factorsemployed by the participants in the proposed new merged market.
(v) The analysis shall include assessment of possiblereinsurance mechanisms and/or federal high-risk pool structures and funding tosupport the health insurance market in Rhode Island by reducing the risk ofadverse selection and the incremental insurance premiums charged for this risk,and/or by making health insurance affordable for a selected at-risk population.
(vi) The health insurance commissioner shall work with aninsurance market merger task force to assist with the analysis. The task forceshall be chaired by the health insurance commissioner and shall include, butnot be limited to, representatives of the general assembly, the businesscommunity, small employer carriers as defined in § 27-50-3, carriersoffering coverage in the individual market in Rhode Island, health insurancebrokers and members of the general public.
(vii) For the purposes of conducting this analysis, thecommissioner may contract with an outside organization with expertise in fiscalanalysis of the private insurance market. In conducting its study, theorganization shall, to the extent possible, obtain and use actual health plandata. Said data shall be subject to state and federal laws and regulationsgoverning confidentiality of health care and proprietary information.
(viii) The task force shall meet as necessary and includetheir findings in the annual report and the commissioner shall include theinformation in the annual presentation before the house and senate financecommittees.
