230 R.I. Code R. 230-RICR-20-30-10.13

Current through December 3, 2024

Section 230-RICR-20-30-10.13 - Wellness Health Benefit Plan-The HEALTHpact Plan

A. Requirement to offer. Carriers that actively market health benefit plans to small employers in Rhode Island shall offer to those employers a wellness health benefit plan that meets the requirements of § 10.13 of this Part and complies with all other requirements of the Act and this regulation. Nothing in the Act or this regulation prohibits the sale of health benefit plans that differ from the wellness health benefit plans provided for in § 10.13 of this Part.

B. Effective date. Unless a carrier has received a waiver from the health insurance commissioner, all carriers that actively market health benefit plans to small employers in Rhode Island shall offer a wellness health benefit plan to small employers.

C. HEALTHpact. The wellness health benefit plan shall be referred to as the "HEALTHpact" plan.

D. Requirements of the HEALTHpact plan.

1. In general.

a. The HEALTHpact plan shall have two levels of benefits: Advantage and Basic.

b. Requirements for Advantage-level benefits are dependent on the member's age.

(1) Members (including dependents) who are eighteen years of age or over at the time of enrollment or renewal are classified as "adult members" and are subject to the requirements for adult members.

(2) Members who are between the ages of twelve and seventeen years of age at the time of enrollment or renewal are considered "adolescent members" and are subject to the requirements for adolescent members.

(3) Members who a under the age of twelve at the time of enrollment or renewal are considered "child members" and are subject to the requirements for child members.

c. The premium rates for the Advantage-level and Basic-level plans shall be the same, with Advantage-level members paying less for medical care, including but not limited to:

(1) lower copays for physician visits;

(2) lower coinsurance for specific procedures;

(3) lower annual deductibles; and

(4) lower out-of-pocket maximums.

d. Members who do not complete the requirements for Advantage-level benefits will receive Basic-level benefits. All members of a family must complete the Advantage-level requirements specified in § 10.13(D)(2) of this Part in order for the family to be eligible to receive Advantage-level benefits.

2. Different yearly requirements.

a. Requirements for Advantage-level benefits increase on a yearly basis over a period of two years.

b. Year-one Advantage-level benefits are tied to the following requirements:

(1) for adult members, completion of the requirements set out in § 10.13(D)(3)(a) of this Part no later than twenty-one days prior to enrollment;

(2) for adolescent members, completion of the requirements set out in § 10.13(D)(3)(c) of this Part no later than twenty-one days prior to enrollment; and

(3) for child members, completion of the requirements set out in § 10.13(D)(3)(e) of this Part no later than twenty-one days prior to enrollment.

c. Year-two Advantage-level benefits apply to year two and subsequent years, and are tied to the following requirements:

(1) for adult members, compliance with the requirements set out in § 10.13(D)(3)(b) of this Part no later than two hundred and forty days (eight months) from the date of enrollment;

(2) for adolescent members, compliance with the requirements set out in § 10.13(D)(3)(d) of this Part no later than two hundred and forty days (eight months) from the date of enrollment; and

(3) for child members, compliance with the requirements set out in § 10.13(D)(3)(f) of this Part no later than two hundred and forty days (eight months) from the date of enrollment.

3. Advantage-level requirements.

a. Each adult member must comply with specified wellness requirements for year-one Advantage-level benefits. These requirements include:

(1) selection of a primary care physician (PCP);

(2) completion and submission of a Personal Health Assessment (PHA); and

(3) completion and submission of a HEALTHpact pledge.

(4) A HEALTHpact pledge may be completed by an adult on behalf of all family members.

b. Each adult member must comply with specified wellness requirements for year-two Advantage-level benefits. These requirements include:

(1) completion and submission of a PCP Checklist;

(2) completion and submission of a Participation Commitment Form (PCF), which specifies participation in a smoking cessation program, if necessary, and participation in a weight loss or weight management program, if necessary;

(3) participation in a disease management program (or programs), when identified for such a program (or programs) by the carrier; and

(4) participation in a case management program (or programs), when identified for such a program (or programs) by the carrier.

c. Each adolescent member must comply with specified wellness requirements for year-one Advantage-level benefits. These requirements include:

(1) selection of a PCP; and

(2) completion and submission of a HEALTHpact pledge, unless a pledge is completed on behalf of an adolescent pursuant to § 10.13(D)(3)(a) of this Part.

d. Each adolescent member must comply with specified wellness requirements for year-two Advantage-level benefits. These requirements include:

(1) completion and submission of a PCP Checklist;

(2) participation in a disease management program (or programs), when identified for such a program (or programs) by the carrier; and

(3) participation in a case management program (or programs), when identified for such a program (or programs) by the carrier.

e. Each child member must comply with specified wellness requirements for year-one Advantage-level benefits. These requirements include:

(1) selection of a PCP.

f. Each child member must comply with specified wellness requirements for year-two Advantage-level benefits. These requirements include:

(1) participation in a disease management program (or programs), when identified for such a program (or programs) by the carrier; and

(2) participation in a case management program (or programs), when identified for such a program (or programs) by the carrier.

E. Eligibility. Determination of Advantage-level versus Basic-level eligibility will be made by the carrier. Members will only move from one level of benefits to another (e.g., Advantage to Basic) on:

1. the first day of the month following enrollment in the event the PHA is incomplete; or

2. the enrollment anniversary date.

F. Forms and Documents.

1. The enrollment package shall include the following forms and documents related to year-one Advantage-level eligibility:

a. a year-one Advantage-level eligibility instruction sheet and checklist that substantially conforms to the model set out in Appendix C issued in a bulletin promulgated for that purpose;

b. a HEALTHpact pledge form that substantially conforms to the model set out in Appendix D issued in a bulletin promulgated for that purpose.

c. a form for selecting a PCP; and

d. a PHA form.

2. Carriers may develop and use their own PHA forms. The commissioner may, in consultation with the carriers, develop a standard PHA form for use with HEALTHpact plans.

3. The forms and documents related to year-one Advantage-level eligibility shall be grouped together or otherwise conspicuously arranged so that members can readily identify all documents and forms necessary for eligibility for year-one Advantage-level benefits.

4. The enrollment package shall include the following forms and documents related to year-two Advantage-level eligibility:

a. a year-two Advantage-level eligibility instruction sheet and checklist that substantially conforms to the model set out in Appendix E issued in a bulletin promulgated for that purpose;

b. PCP checklists that substantially conform to the models issued in a bulletin promulgated for that purpose;

c. a sample Body Mass Index (BMI) chart that includes a statement that the sample BMI chart is for informational purposes only and that members should rely on their PCP rather than the sample BMI chart to determine their own BMI;

d. statement that defines "smoke" or "smoking" as use of a tobacco product within the six-month period prior to the completion of the PCP checklist; and

e. an PCF that substantially conforms to the model set out in Appendix I issued in a bulletin promulgated for that purpose.

5. The forms and documents related to year-two Advantage-level eligibility shall be grouped together or otherwise conspicuously arranged so that members can readily identify all documents and forms necessary for eligibility for year-two Advantage-level benefits.

6. Written copies of the forms and documents required by § 10.13(F) of this Part shall be made available to members upon request at no charge and shall, if possible, also be available on the carrier's website. Members shall also be informed that a photocopy of these form and documents, where possible, may be filled out and submitted to the carrier.

G. Rates.

1. The commissioner shall set an average annualized individual premium rate for the HEALTHpact plan to be less than ten percent of the average annual statewide wage, as reported by the Rhode Island department of labor and training, in their report entitled "Quarterly Census of Rhode Island Employment and Wages." In the event that this report is no longer available, or the commissioner determines that it is no longer appropriate for the determination of maximum annualized premium, an alternative method shall be adopted by the commissioner by regulation. The maximum annualized individual premium rate shall be determined no later than August 1st of each year, to be applied to the subsequent calendar year premium rates.

2. Carriers must offer a HEALTHpact plan at a base community rate that is at or below the rate established pursuant to § 10.13(G)(1) of this Part and consistent with the requirement of Section of this regulation. Each carrier must receive approval of its annual HEALTHpact plan base community rate from the commissioner. Carriers may make adjustments to their HEALTHpact plan base community rate in accordance with the Act and § 10.5 of this Part.

3. Carriers may increase their HEALTHpact plan base community rate throughout the year, but only as authorized by the commissioner.

H. Benefits to be offered.

1. The benefits to be provided in any HEALTHpact plan, by either new or renewal coverage commencing before October 1, 2008, shall be consistent with the guidance provided by the advisory committee established pursuant to R.I. Gen. Laws. § 27-50-10. This guidance is contained in the HEALTHpact plan requirements document, available from OHIC.

2. The benefits to be provided in any HEALTHpact plan, by either new or renewal coverage commencing on or after October 1, 2008, shall be consistent with the guidance provided by the commissioner in an annual HEALTHpact plan requirements document. The procedures for establishing the annual plan requirements document guidance, including timeframes for the approval process, shall be specified by the commissioner in an OHIC bulletin, to be issued no later than May 1 of each year.

I. Appeals. Carriers shall develop and consistently apply an appeal mechanism for a member dissatisfied with his or her Basic-level benefits determination. Carriers may satisfy this requirement through the use of existing appeal processes and procedures.

J. Marketing.

1. A small employer carrier shall actively market a HEALTHpact plan in accordance with R.I. Gen. Laws § 27-50-7(b). Prior to offering a HEALTHpact plan, a carrier shall provide the commissioner with a copy of the carrier's initial marketing plan for its HEALTHpact plan.

2. Except as provided by § 10.13(L) of this Part, a small employer carrier may not suspend the marketing or issuance of the HEALTHpact plan unless the carrier has good cause and has received the prior approval of the Commissioner.

3. Any producer authorized by a small employer carrier to market health benefit plans to small employers in this state shall also be authorized to market the HEALTHpact plan.

4. Carriers are free to use any name for the marketing of the HEALTHpact plan; however, a tagline identifying the wellness health benefit plan as a "HEALTHpact" plan shall be used by the carriers in all marketing materials related to the HEALTHpact plan. The insurers shall be free to name the HEALTHpact plan in accordance with its standard product naming process and conventions. Either the tagline or the logo shall appear on the health plan identification cards for the HEALTHpact plan in accordance with the style guide developed by the commissioner. The style guide is available from the OHIC and is posted on the OHIC website.

K. Dual option. The HEALTHpact plan must be offered on a dual option and sole replacement basis to all small group employers. "Offered" means at a minimum that every rate sheet from the insurer to a broker or a small group must include the HEALTHpact plan as an option. This requirement will be reevaluated in time for applications and renewals commencing no later than October 1, 2009. This dual option requirement will be reevaluated in terms of its impact on each carrier's HEALTHpact plan membership, loss ratio, and other relevant metrics.

L. Enrollment cap. Carriers may set an enrollment cap of no fewer than 5,000 HEALTHpact plan members. Once the cap is reached in a particular year, carriers may cease to offer the HEALTHpact plan for the remainder of the year. The cap may be reevaluated annually by the commissioner, with the first evaluation performed in time for applications and renewals commencing no later than October 1, 2009.

M. Time limits for participation requirements. The following timeline shall apply to all new and renewal applications for HEALTHpact plans:

1. Distribution of enrollment or renewal packages. Enrollment or renewal packages containing the information, documents and forms required by this regulation for HEALTHpact plans shall be provided to employers, either directly by the carrier or through a broker, no later than forty-five days prior to the employer's expected enrollment or renewal date, unless not practicable.

2. Completion and submission of year-one Advantage level eligibility requirements.

a. In order to meet the requirements set out in § 10.13(D)(2)(b) of this Part, members must forward to the carrier, either by mail (first class postage) or delivery (by hand or by a third-party) the pledges, PCP selection forms and PHAs, as required by § 10.13(D)(3)(a) of this Part (for adults), § 10.13(D)(3)(c) of this Part (for adolescents), or § 10.13(D)(3)(e) of this Part (for children), no later than twenty-one days prior to the enrollment date.

b. Members will meet the deadline required by § 10.13(D)(2)(b) of this Part if the forms, if mailed, are postmarked on or before the twenty-first day prior to the enrollment date, or if delivered, are received by the carrier before the close of business on or before the twenty-first day prior to enrollment date.

c. If the twenty-first day prior to enrollment date falls on a weekend or state or federal holiday, the deadline shall be extended by the carrier to the next business day.

3. Reminder card or letter. No later than one hundred and fifty days (five months) after enrollment, carriers shall send a reminder card or letter to members alerting members of the year-two Advantage-level requirements and deadlines.

4. Completion and submission of year-two Advantage level eligibility requirements. In order to be eligible for year-two Advantage-level benefits, members must:

a. Submit the PCP checklist no later than two hundred and forty days (eight months) after the enrollment date.

b. Participate in case management and/or disease management programs no later than two hundred and forty days (eight months) after the enrollment date, if:

(1) selected by the carrier for case management and/or disease management programs; and

(2) notified by the carrier of the case management and/or disease management programs no later than one hundred and eighty days (six months) after the enrollment date.

(3) Members who are notified by the carrier of selection for case management and/or disease management programs after the deadline set out in § 10.13(M)(4)(b) ((2)) of this Part, must nevertheless participate in the case management and/or disease management programs, however, this participation shall not affect the member's year-two Advantage-level eligibility, but shall affect the member's year-three (and subsequent) Advantage-level eligibility.

c. Meet the requirements set out in § 10.13(D)(2)(b) of this Part.

(1) In order to meet the requirements set out in§ 10.13(D)(2)(c) of this Part, members must forward to the carrier, either by mail (first class postage) or delivery (by hand or by a third-party) the PCP checklists and PCFs, as required by § 10.13(D)(3)(b) of this Part (for adults) and § 10.13(D)(3)(d) of this Part (for adolescents), to the carrier no later than two hundred and forty days (eight months) after the enrollment date.

(2) Members will meet the requirements set out in § 10.13(D)(2)(c) of this Part if the forms, if mailed, are postmarked on or before the two hundred and fortieth day after the enrollment date, or if delivered, are received by the carrier before the close of business on or before the two hundred and fortieth day after the enrollment date.

(3) If the two hundred and fortieth day after the enrollment date falls on a weekend or state or federal holiday, the deadline shall be extended by the carrier to the next business day.

d. An example of the Advantage-level benefits timeline for adults with an October 1, 2007 enrollment date is as follows:

Number of days to/from enrollment	Action	Date
-45	Enrollment packages received by employer	8/17/2007
-21	Last day for employees to submit: (1) PCP selection form (2) Signed pledge (3) PHA form	9/10/2007
0	Enrollment date	10/1/2007
+150	Reminder card/letter sent by carrier for year-two Advantage-level requirements	2/28/2008
+180	Last day for carriers to notify subscribers of case management participation requirement in time to affect year-two Advantage eligibility	3/31/2008
+180	Last day for PCP office visit to fill out PCP Checklist	4/28/2008
+240	Last day for members to participate in CM and DM, if necessary, to affect year 2 Advantage eligibility.	5/28/2008
+240	Last submission of the following to carriers: (1) PCP checklist and (2) PCF.	5/28/2008

N. Non-renewal date enrollment. Employers may switch from an existing product to the HEALTHpact plan with the same carrier earlier than the employers scheduled renewal date, thereby changing their effective renewal date, at no penalty to the employer. Employers interested in purchasing the HEALTHpact plan but who are unable to complete the enrollment requirements within the required twenty-one days prior to their scheduled renewal date may extend their existing plan, unless the plan has been discontinued, for at least thirty days (one month) in order to allow sufficient time to complete the new enrollment requirements, at no penalty to the employer.

O. Network Requirements. Unless otherwise specified by the commissioner, the carriers shall develop a tiered network according to the deadlines § 10.13 of this Part, that is, at minimum, based on quality measures. Each carrier's tiered network structure must be implemented for all new and renewal HEALTHpact plan members no later than October 1, 2008. OHIC rating decisions for rates applicable to October 1, 2008 and later will assume compliance with this requirement. Draft tiered network proposals to be implemented on October 1, 2008 must be submitted to OHIC on or before September 1, 2007. A final tiered network proposal must be submitted to OHIC on or before March 1, 2008. OHIC decisions regarding carrier proposals will be determined on or before April 1, 2008. OHIC decisions regarding future revisions/phased implementation of network proposals (after October 1, 2008) will be made in response to the final carrier proposals.

P. Bulletins. The commissioner may issue bulletins for clarification or additional guidance on the HEALTHpact plan. Carriers may also request guidance from the commissioner in the form of a bulletin.

Q. Late enrollees (including added dependents).

1. Enrollees who are either:

a. offered participation in an employer's HEALTHpact plan less than twenty-one days prior to the enrollment date and who could not have completed the year-one Advantage-level requirements prior to twenty-one days before the enrollment date (e.g., because the employee had not yet been employed by the employer who offered the plan, the dependent had not yet been born, etc.); or

b. added to an employer's HEALTHpact plan after the enrollment datewill recieve year-one Advantage-level benefits, but must, at the time of enrollment, complete the standard requirements for year-one Advantage-level enrollees.

2. To be eligible for year-two Advantage level-benefits, late enrollees must comply with the same disease and case management requirements as all other enrollees.

R. Switching carriers. If an employer switches carriers after enrolling in the HEALTHpact plan, the new carrier may require the employer's enrollees to meet the Advantage-level benefits requirements that would have been required of those enrollees had the employer remained enrolled in the HEALTHpact plan through the previous carrier.

230 R.I. Code R. 230-RICR-20-30-10.13