TITLE 27

Insurance

CHAPTER 27-41

Health Maintenance Organizations

SECTION 27-41-2



   § 27-41-2  Definitions. –

As used in this chapter:



   (a) "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 or make payment that is based on

a determination of a an individual's eligibility to participate in a plan or to

receive coverage under a plan, and including, with respect to group health

plans, a denial, reduction, or termination of, or a failure to provide or make

payment (in whole or in part) for, a benefit resulting from the application of

any utilization review, as well as a failure to cover an item or service for

which benefits are otherwise provided because it is determined to be

experimental or investigational or not medically necessary or appropriate. The

term also includes a rescission of coverage determination.



   (b) "Affordable Care Act" means the federal Patient

Protection and Affordable Care act of 2010, as amended by the federal Health

Care and Education Reconciliation Act of 2010, and federal regulations adopted

thereunder;



   (c) "Commissioner" or "health insurance commissioner" means

that individual appointed pursuant to § 42-14.5-1 of the general laws.



   (d) "Covered health services" means the services that a

health maintenance organization contracts with enrollees and enrolled groups to

provide or make available to an enrolled participant.



   (e) "Director" means the director of the department of

business regulation or his or her duly appointed agents.



   (f) "Employee" means any person who has entered into the

employment of or works under a contract of service or apprenticeship with any

employer. It shall not include a person who has been employed for less than

thirty (30) days by his or her employer, nor shall it include a person who

works less than an average of thirty (30) hours per week. For the purposes of

this chapter, the term "employee" means a person employed by an "employer" as

defined in subsection (d) of this section. Except as otherwise provided in this

chapter the terms "employee" and "employer" are to be defined according to the

rules and regulations of the department of labor and training.



   (g) "Employer" means any person, partnership, association,

trust, estate, or corporation, whether foreign or domestic, or the legal

representative, trustee in bankruptcy, receiver, or trustee of a receiver, or

the legal representative of a deceased person, including the state of Rhode

Island and each city and town in the state, which has in its employ one or more

individuals during any calendar year. For the purposes of this section, the

term "employer" refers only to an employer with persons employed within the

state of Rhode Island.



   (h) "Enrollee" means an individual who has been enrolled in a

health maintenance organization.



   (i) "Essential health benefits" shall have the meaning set

forth in section 1302(b) of the federal Affordable Care Act.



   (j) "Evidence of coverage" means any certificate, agreement,

or contract issued to an enrollee setting out the coverage to which the

enrollee is entitled.



   (k) "Grandfathered health plan" means any group health plan

or health insurance coverage subject to 42 USC § 18011.



   (l) "Group health insurance coverage" means, in connection

with a group health plan, health insurance coverage offered in connection with

such plan.



   (m) "Group health plan" means an employee welfare benefit

plan as defined in 29 USC § 1002(1), to the extent that the plan provides

health benefits to employees or their dependents directly or through insurance,

reimbursement, or otherwise.



   (n) "Health benefits" or "covered benefits" means coverage or

benefits for the diagnosis, cure, mitigation, treatment, or prevention of

disease, or amounts paid for the purpose of affecting any structure or function

of the body including coverage or benefits for transportation primarily for and

essential thereto, and including medical services as defined in R.I. Gen. Laws

§ 27-19-17;



   (o) "Health care facility" means an institution providing

health care services or a health care setting, including but not limited to

hospitals and other licensed inpatient centers, ambulatory surgical or

treatment centers, skilled nursing centers, residential treatment centers,

diagnostic, laboratory and imaging centers, and rehabilitation and other

therapeutic health settings.



   (p) "Health care professional" means a physician or other

health care practitioner licensed, accredited or certified to perform specified

health care services consistent with state law.



   (q) "Health care provider" or "provider" means a health care

professional or a health care facility.



   (r) "Health care services" means any services included in the

furnishing to any individual of medical, podiatric, or dental care, or

hospitalization, or incident to the furnishing of that care or hospitalization,

and the furnishing to any person of any and all other services for the purpose

of preventing, alleviating, curing, or healing human illness, injury, or

physical disability.



   (s) "Health insurance carrier" means a person, firm,

corporation or other entity subject to the jurisdiction of the commissioner

under this chapter, and includes a health maintenance organization. Such term

does not include a group health plan.



   (t) "Health maintenance organization" means a single public

or private organization which:



   (1) Provides or makes available to enrolled participants

health care services, including at least the following basic health care

services: usual physician services, hospitalization, laboratory, x-ray,

emergency, and preventive services, and out of area coverage, and the services

of licensed midwives;



   (2) Is compensated, except for copayments, for the provision

of the basic health care services listed in subdivision (1) of this subsection

to enrolled participants on a predetermined periodic rate basis; and



   (3)(i) Provides physicians' services primarily:



   (A) Directly through physicians who are either employees or

partners of the organization; or



   (B) Through arrangements with individual physicians or one or

more groups of physicians organized on a group practice or individual practice

basis;



   (ii) "Health maintenance organization" does not include

prepaid plans offered by entities regulated under chapter 1, 2, 19, or 20 of

this title that do not meet the criteria above and do not purport to be health

maintenance organizations;



   (4) Provides the services of licensed midwives primarily:



   (i) Directly through licensed midwives who are either

employees or partners of the organization; or



   (ii) Through arrangements with individual licensed midwives

or one or more groups of licensed midwives organized on a group practice or

individual practice basis.



   (u) "Licensed midwife" means any midwife licensed pursuant to

§ 23-13-9.



   (v) "Material modification" means only systemic changes to

the information filed under § 27-41-3.



   (w) "Net worth", for the purposes of this chapter, means the

excess of total admitted assets over total liabilities.



   (x) "Office of the health insurance commissioner" means the

agency established under § 42-14.5-1 of the general laws.



   (y) "Physician" includes podiatrist as defined in chapter 29

of title 5.



   (z) "Private organization" means a legal corporation with a

policy making and governing body.



   (aa) "Provider" means any physician, hospital, licensed

midwife, or other person who is licensed or authorized in this state to furnish

health care services.



   (bb) "Public organization" means an instrumentality of

government.



   (cc) "Rescission" means a cancellation or discontinuance of

coverage that has retroactive effect for reasons unrelated to timely payment of

required premiums or contribution to costs of coverage.



   (dd) "Risk based capital ("RBC') instructions" means the risk

based capital report including risk based capital instructions adopted by the

National Association of Insurance Commissioners ("NAIC"), as these risk based

capital instructions are amended by the NAIC in accordance with the procedures

adopted by the NAIC.



   (ee) "Total adjusted capital" means the sum of:



   (1) A health maintenance organization's statutory capital and

surplus (i.e. net worth) as determined in accordance with the statutory

accounting applicable to the annual financial statements required to be filed

under § 27-41-9; and



   (2) Any other items, if any, that the RBC instructions

provide.



   (ff) "Uncovered expenditures" means the costs of health care

services that are covered by a health maintenance organization, but that are

not guaranteed, insured, or assumed by a person or organization other than the

health maintenance organization. Expenditures to a provider that agrees not to

bill enrollees under any circumstances are excluded from this definition.



History of Section.

(P.L. 1983, ch. 225, § 2; P.L. 1987, ch. 107, § 1; P.L. 1990, ch.

168, § 3; P.L. 1995, ch. 334, § 1; P.L. 1999, ch. 254, § 1; P.L.

2002, ch. 292, § 85; P.L. 2012, ch. 256, § 9; P.L. 2012, ch. 262,

§ 9.)