Title 27, Title 27 Title 27

With the exception of investments made in accordance with § 27-41-5(a)(1) and (a)(2) and § 27-41-5(b), the investable funds of a health maintenance organization may be invested in the following investments and any other investments that the director authorizes by regulation: (1)(…

(a) Unless otherwise provided, each health maintenance organization shall deposit with the general treasurer of the state of Rhode Island securities having a market value at all times of at least the amount set forth in this section, which are to be held for the benefit and prote…

Before the director issues a certificate of authority in accordance with § 27-41-4 of this act, an applicant seeking to establish or operate a health maintenance organization shall have the greater of: (1) The amount of capital required for a health organization under chapter 4.7…

(a) A health maintenance organization shall maintain minimum net worth equal to the greater of two million five hundred thousand dollars ($2,500,000) or the amount necessary to maintain capital required pursuant to chapter 4.7 of this title. (b) The amount in subsection (a) may b…

(a) The director may waive any of the net worth or total adjusted capital requirements, or both, as set forth in § 27-41-13.1 or § 27-41-13.2, whenever satisfied that the health maintenance organization has sufficient net worth or total adjusted capital, or both, and an adequate …

(a) No health maintenance organization, or representative of a health maintenance organization, may cause or knowingly permit the use of advertising that is untrue or misleading, solicitation that is untrue or misleading, or any form of evidence of coverage that is deceptive. For…

No health maintenance organization shall refuse to contract with or compensate for covered services an otherwise eligible healthcare provider solely because the provider has in good faith communicated with one or more of his or her current, former, or prospective patients regardi…

An insurance company licensed in this state may either directly or through a subsidiary or affiliate organize and operate a health maintenance organization under the provisions of this chapter. Notwithstanding any other law that may be inconsistent with this section, any two (2) …

(a) The director of business regulation may make an examination of the affairs of any health maintenance organization and the providers with whom the organization has contracts, agreements, or other arrangements pursuant to its healthcare plan as often as is reasonably necessary …

(a) The director may suspend or revoke any license issued to a health maintenance organization under this chapter if the director finds that any of the following conditions exist: (1) The health maintenance organization is operating significantly in contravention of its basic org…

(a) Any rehabilitation, liquidation, or conservation of a health maintenance organization shall be deemed to be the rehabilitation, liquidation, or conservation of an insurance company and shall be conducted under the supervision of the director of business regulation pursuant to…

(a) Whenever the director determines that the financial condition of a health maintenance organization is such that its continued operation must be hazardous to its enrollees, creditors, or the general public, or that it has violated any provision of this chapter, the director ma…

The director of business regulation and the director of health shall, after notice and hearing, promulgate reasonable rules and regulations that are necessary or proper to carry out the provisions of this chapter. Those rules and regulations shall be subject to review in accordan…

As used in this chapter: (1) “Adverse benefit determination” means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide …

(a) When the director of business regulation has cause to believe that grounds for the denial of an application for a license exist, or that grounds for the suspension or revocation of a license exist, the director shall notify the health maintenance organization and the director…

(a) The director of business regulation may, in lieu of the suspension or revocation of a license under § 27-41-17, levy an administrative penalty in an amount not less than five hundred dollars ($500) nor more than fifty thousand dollars ($50,000), if reasonable notice in writin…

(a) Except as otherwise provided in this chapter, provisions of chapters 19, 20, 20.1, and 20.2 of this title shall not be applicable to any health maintenance organization granted a license under this chapter. This provision shall not apply to an insurer or hospital or medical s…

The provisions of chapter 2 of title 38, relating to access to public records, shall apply to all applications, filings, and reports required under this chapter. Annual and quarterly financial statements shall be treated as public documents.

The director of health, in carrying out his or her obligations under §§ 27-41-4(a)(2), 27-41-16(b), and 27-41-17(b), may contract with qualified persons to make recommendations concerning the determinations required to be made by the director. Those recommendations may be accepte…

Except to the extent superseded by chapter 64 of this title, all of the provisions of chapter 35 of this title apply to corporations organized or licensed pursuant to this chapter.

No enrollee is liable to any provider for charges for covered health services, except for amounts due for copayments, when provided or made available to enrolled participants by a licensed health maintenance organization during a period in which premiums were paid by or on behalf…

For health benefit contracts issued, renewed, or delivered in this state the following shall apply: (1) The amount of copayments for physician office visits and hospital emergency room visits shall be printed on the subscriber identification cards issued to the insured. (2) A sch…

(a)(1) In accordance with regulations promulgated by the director of the department of business regulation: (i) Each employer that during any calendar quarter employed an average number of employees of not less than twenty-five (25), and (ii) The state and each political subdivis…

No provision of this chapter shall derogate from the common law or statutory authority of the attorney general nor shall any provision be construed as a limitation on the common law or statutory authority of the attorney general, including the authority to investigate at any time…

No insurance company organized as a stock or mutual corporation that merges or consolidates with, acquires ownership or control or possession of twenty percent (20%) or greater of the operating assets of, or acquires control of a nonprofit hospital service corporation organized u…

Notwithstanding any of the provisions of this chapter, except for §§ 27-41-5, 27-41-26, 27-41-35, and 27-41-37 which shall apply to all licensed health maintenance organizations including health maintenance organizations licensed pursuant to chapter 17 of title 23, nothing contai…

If any section, term, or provision of this chapter shall be adjudged invalid for any reason, that judgment shall not affect, impair, or invalidate any other section, term, or provision of this chapter, but the remaining sections, terms, and provisions shall be and remain in full …

(a) A health maintenance organization shall provide a summary of benefits and coverage explanation and definitions to policyholders and others required by, and at the times and in the format required by, the federal regulations adopted under section 2715 of the Public Health Serv…

(a) A health maintenance organization shall file all policy forms and rates used by it in the state with the commissioner, including the forms of any rider, endorsement, application blank, and other matter generally used or incorporated by reference in its policies or contracts o…

(a)(1) Notwithstanding chapter 5.1 of title 7, sections 27-2-22, 27-19-4, 27-20-4, 27-20.1-2, and 27-20.2-2, or any other law of this state to the contrary, any public or private organization may apply to the director of business regulation for and obtain a license to establish a…

(a) Subscribers to any health maintenance organization plan shall be afforded coverage under that plan for mammograms and pap smears, in accordance with guidelines established by the American Cancer Society. (b) Notwithstanding the provisions of this chapter, subscribers to any h…

(a) Every individual or group hospital or medical services plan contract delivered, issued for delivery, or renewed in this state shall provide coverage for a forty-eight-hour (48) time period in a hospital after a vaginal birth, and ninety-six (96) hours after a cesarean section…

A mammogram eligible for reimbursement under § 27-41-30 shall be reimbursed only if the facility in which the mammogram has been taken and processed, and the licensed physician interpreting the mammogram both meet state-approved quality assurance standards for taking, processing,…

A pap smear eligible for reimbursement under § 27-41-30 shall be reimbursed only if the laboratory in which the pap smear is processed is licensed by the department of health specifically to perform cervical cytology, or is accredited by the American Society of Cytology, or is ac…

(a) Any health maintenance organization service contract plan or policy delivered, issued for delivery, or renewed in this state, except a contract providing supplemental coverage to Medicare or other governmental programs, that includes pregnancy-related benefits, shall provide …

(a) Notwithstanding any other provisions of law, each domestic HMO shall be charged an assessment to partially support the activities of the division of insurance in the department of business regulation. (b) Each domestic HMO assessment shall be determined in accordance with the…

(a) In the event of an insolvency of a health maintenance organization, upon order of the director, all other carriers that participated in the enrollment process with the insolvent health maintenance organization at a group’s last regular enrollment period shall offer the group’…

Every health maintenance organization plan contract delivered, issued for delivery, or renewed in this state shall provide coverage for the services of licensed midwives in accordance with each health maintenance organization’s respective principles and mechanisms of reimbursemen…

No health maintenance organization subject to the provisions of this chapter shall discontinue reimbursement for or providing services for covered healthcare services of chronic disabilities, unless the patient has exhausted benefits to which he or she is entitled under the basic…

No health maintenance organization that provides coverage for prescription drugs under a group plan master contract delivered, issued for delivery, or renewed in this state may require any person covered under the contract to obtain prescription drugs from a mail order pharmacy a…

(a) An individual or group health insurance plan or policy delivered, issued for delivery, or renewed in this state on or after January 1, 2017, providing prescription drug coverage in the state, must permit and apply a prorated daily cost-sharing rate to covered prescriptions fo…

(a) Definitions. As used herein: (1) “Maximum-allowable cost” or “MAC” means the maximum amount that a pharmacy benefits manager will reimburse toward the cost of a drug; (2) “Nationally available” means that there is an adequate supply available from regional or national wholesa…

(a) The general assembly makes the following findings: (1) In 2015, an estimated six hundred thirty-five thousand (635,000) Rhode Island residents had at least one chronic disease, and an estimated two hundred forty-nine thousand (249,000) residents had two (2) or more chronic di…

(a) As used in this section, (1) “Clinician-administered drug” means an outpatient infused prescription drug other than a vaccine that: (i) Cannot reasonably be self-administered by the patient to whom the drug is prescribed or by a non-clinician individual assisting the patient …

(a) Every individual or group policy or contract delivered, issued for delivery, or renewed by a health maintenance organization in this state shall provide coverage for the services of certified registered nurse practitioners, practicing collaboratively, and psychiatric and ment…

(a)(1) Upon receipt of an application for issuance of a license, the director shall transmit copies of the application and accompanying documents to the director of health. (2) The director of health shall determine whether the applicant for a license, with respect to healthcare …