OHIC REGULATION 2 – POWERS AND DUTIES OF THE OFFICE OF THE HEALTH INSURANCE COMMISSIONER

Regulation Authority:

R.I. Gen. Laws §§ 42-14.5-1 et seq., 42-14-5, 42-14-17 and 42-35-1 et seq.

Purpose and Reason:

The Proposed Amendments delete a portion of Section 9, and replace it with a new Section 10 “Affordability Standards”, designed to accomplish the following: 1. Primary Care Spend. The financial obligations of health insurers to support primary care providers are defined in terms of direct primary care spending, and in terms of indirect primary care spending. 2. Primary Care Practice Transformation. Goals and targets for the development of Patient-Centered Medical Homes are established, as well as health insurers’ obligations to support the achievement of those goals and targets. 3. Payment Reform. The revised Standards propose to promote the affordability of health insurance by: o Setting targets for population-based contracts with health care providers. o Increasing alternative payment mechanisms. o Codifying OHIC’s existing hospital contracting conditions, while revising the index against which annual hospital rate increases are measured. o Establishing budget targets for integrated systems of care. 4. Implementing provisions. Standards and procedures needed to implement the revised Affordability Standards are established. The Proposed Amendments in Section 11 codify in regulation the Administrative Simplification Task Force established by RI Gen. Laws section 42-14.5-3(h), and implement the following administrative standards: 1. Retroactive terminations. 2. Coordination of benefits. 3. Appeal of “timely filing” denials. 4. Medical Records management. The Proposed Amendments in Section 12 regarding price transparency codify in regulation the existing obligation of health insurers to disclose the prices of health services and products to consumers and referring physicians. The remainder of the Proposed Amendments are changes to grammar and form.