Section 230-RICR-20-30-4.10 - Affordable Health Insurance - Affordability StandardsA. Health insurers with at least 10,000 covered lives under a health insurance plan issued, delivered, or renewed in Rhode Island shall comply with the delivery system and payment reform strategy requirements set forth in this § 4.10 of this Part. For purposes of this § 4.10 of this Part only, a health insurer shall not include a non-profit dental service corporation, or a non-profit optometric service corporation.B. Primary care and behavioral health care expenditure obligation. The purpose of § 4.10(B) of this Part is to ensure financial support for primary care providers and providers of behavioral health services in Rhode Island that will assist in achieving the goals of these Affordability Standards. 1. Primary care expenditures. a. Each health insurer's annual, actual Primary Care Expenses, including both Direct and Indirect Primary Care Expenses, shall be at least an amount calculated as 10.7% of its annual medical expenses for all insured lines of business. Of the health insurer's annual Primary Care Expense financial obligation, at least 9.7% of the calculated amount shall be for Direct Primary Care Expenses. Each health insurer's Indirect Primary Care Expenses shall include at least its proportionate share for the administrative expenses of the medical home initiative endorsed by R.I. Gen. Laws Chapter 42-14.6, and for its proportionate share of the expenses of the health information exchange established by R.I. Gen. Laws Chapter 5-37.7.b. Direct Primary Care Expenses shall be accounted for as medical expenses on the health insurer's annual financial statements. Indirect Primary Care Expenses shall be accounted for as administrative costs on the health insurer's annual financial statements. Indirect Primary Care Expenses may be deducted from the statement's administrative cost category as cost containment expenses, in accordance with federal Medical Loss Ratio calculation rules.c. In meeting its annual primary care spending obligations, a health insurer's insured covered lives shall not bear a financial burden greater than their fair share of expenses that benefit both insured covered lives, and non-insured covered lives whose health plans are administered by the health insurer.2. Behavioral health care expenditures. a. Each health insurer shall report its annual, actual expenditures on behavioral health care in a form and manner determined by the Commissioner.b. Behavioral health care expenditures shall be inclusive of claims-based expenditures where the claim includes a behavioral health condition as a principal diagnosis, inclusive of mental health and substance use disorder. Additionally, behavioral health care expenditures shall include non-claims-based expenditures, such as per member per month payments to support behavioral health care integration into primary care, pay for performance payments made to behavioral health care providers, and grants designed to address the behavioral health care needs of insured members. (1) Payments to support behavioral health care integration into primary care that are part of payments made to Integrated Systems of Care shall be allocated to behavioral health care based on a reasonable estimate of the portion of the payment that supports behavioral health care integration. Health insurers shall produce this estimate with guidance from their contracted Integrated Systems of Care, when necessary.(2) Grants designed to address the behavioral health care needs of insured members may be reported in full, without need to apportion the value of the grant to an insured member population, with the prior approval of the Commissioner.c. By January 1, 2025, each health insurer shall increase baseline per member per month expenditures on community-based behavioral health care for children and adolescents, age 0 - 18, to 200% of baseline expenditures and maintain the increase over time. Baseline expenditures shall be defined as payments incurred and paid in calendar year 2022.d. After January 1, 2025, health insurers that have annual per member per month expenditures on community-based behavioral health care for children and adolescents, age 0 - 18, that fall below the market average shall increase per member per month expenditures by an amount necessary to equal the market average. The market average will be determined by OHIC through analysis of the behavioral health care expenditure reports.C. Primary care practice transformation. The purpose of § 4.10(C) of this Part is to transform how primary care is delivered in Rhode Island and to ensure sustainable funding for advanced primary care, in order that the goals of these Affordability Standards can be achieved. While primary care practice transformation should not be considered an ultimate goal in itself, the Commissioner finds that it produces higher quality and potentially lower cost care and is a necessary foundation for the effective participation of practices in Integrated Systems of Care. One element of primary care transformation is the integration of behavioral health care into primary care practice. Integration is in the best interest of the public as it improves health status for those with behavioral health needs and may also result in more efficient use of health care resources. Further, behavioral health integration is a necessary and proper strategy to fulfill the Office's legislative mandate under R.I. Gen. Laws § 42-14.5-3, which directs insurers toward policies and practices that address the behavioral health needs of the public and greater integration of physical and behavioral health care delivery. 1. Primary Care Practice Transformation & Patient Centered Medical Home Financial Support Model. a. Primary care practices which meet the requirements of a Patient-Centered Medical Home in § 4.3(A)(17) of this Part shall be deemed eligible for practice support payments.b. Health insurers shall fund primary care practices which have met the requirements of a Patient-Centered Medical Home in § 4.3(A)(17) of this Part in accordance with the following guidelines: (1) Primary care practices actively engaged in first-time transformation activity, or practices which have completed transformation activity, but which have not met the requirements outlined in § 4.3(A)(17) of this Part, shall receive both infrastructure and care management per member per month (PMPM) payments. The care management PMPM payment shall support development and maintenance of a care management function within the practice site.(2) Primary care practices that have completed transformation activity and which have met the requirements in § 4.3(A)(17) of this Part shall receive a care management PMPM payment and have an opportunity to earn a performance bonus.(3) Health insurers shall not impose a minimum attribution threshold for making care management PMPM or infrastructure payments to a Patient Centered Medical Home.(4) The monetary levels of practice support payments shall be independently determined by the health insurer and the primary care practices. If the primary care practice is part of an Integrated System of Care, the health insurer may make the PMPM payment to the Integrated System of Care, provided the Integrated System of Care is contractually obligated to use the PMPM payment to finance care management services at the primary care practice earning the payment.2. Behavioral Health Care Integration. The goal of § 4.10(C)(2) of this Part is to improve the efficiency, quality, and accessibility of behavioral health care in primary care settings. Behavioral health care is an important dimension of Rhode Island's health care system and refers to services for mental health and substance use diagnosis and treatment. In order to reach the goal of affordability and access through a well-integrated health care delivery system, the Commissioner finds that specific health insurer actions are required to support the integration of behavioral health care into primary care settings. a. Health insurers shall take such actions as necessary to decrease administrative barriers to patient access to integrated services in primary care practices by doing the following: (1) Financial barriers. By January 1, 2021, health insurers shall eliminate copayments for patients who have a behavioral health visit with an in-network behavioral health provider on the same day and in the same location as a primary care visit at a Qualifying Integrated Behavioral Health Primary Care Practice as defined in § 4.3(A)(21) of this Part.(2) Billing and Coding Policies. Health insurers shall adopt policies for Health and Behavior Assessment/Intervention (HABI) codes that are no more restrictive than Current Procedural Terminology (CPT) Coding Guidelines for HABI codes.(3) Out-of-pocket costs for Behavioral Health Screening. Health insurers shall adopt policies for the most common preventive behavioral health screenings in primary care that are no more restrictive than current applicable federal law and regulations for preventive services. For administrative simplification purposes, the Commissioner may issue interpretive guidance on strategies to align screening codes across health insurers and publish them, along with any supporting documentation, on the OHIC website.b. The Commissioner shall determine which practices are Qualifying Integrated Behavioral Health Primary Care Practices by November 30, 2020, and annually thereafter. The Commissioner shall issue guidelines on any time limitations for practices to qualify under §§ 4.3(A)(21)(a) and (b) of this Part.D. Payment reform. The purpose of § 4.10(D) of this Part is to improve the affordability and quality of health care through the implementation of alternative payment models. Alternative payment models are provider contracting practices that are designed to align provider financial incentives with the efficient use of health care resources and encourage the proactive management of the health needs of their patient populations. Furthermore, the Commissioner finds that provider contracting practices that incentivize the efficient use of health care resources and which invest in the capacity of health care providers to manage population health are essential to support the care transformation agenda articulated in § 4.10(C) of this Part and to meet OHIC's legislative mandate to direct health insurers toward policies and practices that address the behavioral health needs of the public and greater integration of physical and behavioral health care delivery. 1. Alternative payment models a. It is in the interest of the public to significantly reduce the use of fee-for-service payment as a payment methodology, in order to mitigate fee-for-service volume incentives which unreasonably and unnecessarily increase the overall cost of care, and to replace fee-for-service payment with alternative payment models that provide incentives for better quality and more efficient delivery of health services.b. Health insurers shall take such actions as necessary to have 50% of insured medical payments made through an alternative payment model by January 1, 2021, and annually thereafter. The Commissioner shall issue a policy and guidelines manual by January 1 of each year that specifies the types of payments and payment models which may be credited toward the 50% target.2. Population-based contracts a. It is in the interest of the public to encourage population-based contracting, and specifically, to direct the evolution of population-based contracts toward downside risk over time. Downside risk strengthens provider economic incentives to act as responsible stewards of scarce health care resources and to proactively manage the health needs of their patient populations. These practices are necessary to support the achievement of more affordable health insurance.b. This § 4.10(D)(2) of this Part applies to Population-Based Contracts between an Integrated System of Care and a health insurer which are entered into, renewed, or amended on or after July 1, 2020, or the effective date of this regulation, if earlier. Each health insurer shall comply with the requirements of this § 4.10(D)(2) of this Part.c. Health insurers shall take such actions as necessary to have 30% of Rhode Island resident commercial insured covered lives attributed to a risk-sharing contract or global capitation contract.d. Risk-sharing contracts with 10,000 or more attributed lives shall meet the Minimum Downside Risk requirements of § 4.10(D)(2)(d) of this Part. For the purposes of § 4.10(D)(2)(d), contracts with Physician-based Integrated Systems of Care may employ a risk exposure cap that is tied to the annual provider revenue from the health insurer under the contract or the total cost of care. Contracts with Integrated Systems of Care including Hospital Systems are to employ a total cost of care methodology. (1) For contracts with Integrated Systems of Care including Hospital Systems between 10,000 and 20,000 attributed commercial lives, health insurers shall employ a risk-sharing rate of at least 40%, and if applicable, a risk-exposure cap of at least 5% of the total cost of care and a minimum loss rate of no more than 3% of the total cost of care. For such contracts entered into, renewed, or amended on or after January 1, 2021, health insurers shall employ a risk-sharing rate of at least 50%, and if applicable, a risk-exposure cap of at least 6% and a minimum loss rate of no more than 3% of the total cost of care.(2) For contracts with Integrated Systems of Care including Hospital Systems with more than 20,000 attributed commercial lives, health insurers shall employ a risk-sharing rate of at least 40%, and if applicable, a risk-exposure cap of at least 5% of the total cost of care and a minimum loss rate of no more than 2% of the total cost of care. For such contracts entered into, renewed, or amended on or after January 1, 2021, health insurers shall employ a risk-sharing rate of at least 50%, and if applicable, a risk-exposure cap of at least 6% and a minimum loss rate of no more than 2% of the total cost of care.(3) For contracts with Physician-based Integrated Systems of Care between 10,000 and 20,000 attributed commercial lives, health insurers shall employ a risk-sharing rate of at least 40%, and if applicable, a risk-exposure cap of at least 7% of provider revenue or at least 2% of the total cost of care and a minimum loss rate of no more than 3% of the total cost of care. For such contracts entered into, renewed, or amended on or after January 1, 2021, health insurers shall employ a risk-sharing rate of at least 50%, and if applicable, a risk-exposure cap of at least 8% of provider revenue or at least 3% of the total cost of care and a minimum loss rate of no more than 3% of the total cost of care.(4) For contracts with Physician-based Integrated Systems of Care with more than 20,000 attributed commercial lives, health insurers shall employ a risk-sharing rate of at least 40%, and if applicable, a risk-exposure cap of at least 8% of provider revenue or at least 3% of the total cost of care and a minimum loss rate of no more than 2% of the total cost of care. For such contracts entered into, renewed, or amended on or after January 1, 2021, health insurers shall employ a risk-sharing rate of at least 50%, and if applicable, a risk-exposure cap of at least 8% of provider revenue or at least 3% of the total cost of care and a minimum loss rate of no more than 2% of the total cost of care.(5) The Minimum Downside Risk requirements above, while not applicable to risk-sharing contracts with fewer than 10,000 attributed commercial lives, should not be construed to preclude or discourage health insurers and providers from entering into risk-sharing contracts with fewer than 10,000 attributed lives. OHIC recommends health insurer and provider caution when doing so, however, in order to account for the decreased statistical certainty with attributed populations less than 10,000.(6) None of the requirements of this § 4.10(D)(2)(d) of this Part shall be construed to preclude contracts with greater degrees of provider risk assumption with health insurers including fee for service, capitation and global capitation contracts.e. A health insurer shall not enter into a Risk Sharing Contract or a Global Capitation contract unless the health insurer has determined, in accordance with standard operating procedures filed and approved by the Commissioner, that the provider organization entering into the contract has the operational and financial capacity and resources needed to assume clinical and financial responsibility for the provision of covered services to members attributable to the provider organization. At the reasonable request of the provider organization, the health insurer shall maintain the confidentiality of information which the health insurer requests to make its determination. The health insurer shall periodically review the provider organization's continuing ability to assume such responsibilities. The health insurer shall maintain contingency plans in the event the provider organization is unable to sustain its ability to manage its responsibilities. The foregoing shall not be construed to permit the transfer of insurance risk or the transfer of delegation of the health insurer's regulatory obligations.f. Population-Based Contracts shall include a provision that agrees on a budget for each contract year. Review and prior approval by the Office of the Health Insurance Commissioner shall be required if any annual increase in the total cost of care for services reimbursed under the contract, after risk adjustment, exceeds the US All Urban Consumer All Items Less Food and Energy CPI ("CPI-Urban") percentage increase (reported by the Commissioner by October 1 of each year, in accordance with the method set forth in § 4.10(D)(6)(i) of this Part). Such percentage increase shall be plus 1.5%.g. Should any Integrated System of Care have had three immediately prior years of average historical risk-adjusted total cost of care per capita spending for the provider's attributed patient population that was significantly below the health insurer's risk-adjusted commercially insured average (statistically significant at p <= .05 and excluding the provider from the calculated average), the health insurer may prospectively adjust that provider's budget upward by up to, but not more than, 2% of the provider's unadjusted expected per capita spending. The adjusted budget shall never exceed the health insurer's projected risk-adjusted commercially insured average spending. Only Integration Systems of Care with risk-sharing contracts shall qualify for the upward budget adjustment.h. Population-based Contracts shall not carve out behavioral health or prescription drug claims experience from the provider budget. Population-based Contracts may include a methodology to reflect the member-months for which the health insurer covers pharmacy and/or behavioral health claims.i. Population-Based Contracts shall include terms that relinquish the right of any party to contest the public release, by state officials or the parties to the contract, of the provisions of the contract demonstrating compliance with the requirements of § 4.10(D)(2) of this Part; provided that the health insurer or other affected party may request the Commissioner to maintain specific contract terms or portions thereof as confidential, if properly supported with legal and factual analysis justifying the claim of confidentiality.3. Primary care alternative payment models a. The development and implementation of alternative payment models for primary care providers is necessary to support primary care practice transformation. The implementation of alternative payment models for primary care also represents a necessary strategy to fulfill OHIC's legislative mandate to direct health insurers toward policies and practices that address the behavioral health needs of the public and greater integration of physical and behavioral health care delivery.b. Health insurers shall develop and implement a prospectively paid alternative payment model for primary care. Health insurers are encouraged to align their primary care alternative payment model with the State of Rhode Island Office of the Health Insurance Commissioner Primary Care Alternative Payment Model Work Group Consensus Model published on August 9, 2017.c. For primary care practices recognized as a Qualifying Integrated Behavioral Health Primary Care Practice under § 4.3(A)(21) of this Part, Health Insurers shall develop and implement a prospectively paid alternative payment model for primary care that compensates practices for the primary care and behavioral health services delivered by the site.d. Health insurers shall take such actions as necessary to achieve the following primary care alternative payment model contracting targets.(1) At least 20% of insured Rhode Island resident covered lives shall be attributed to a primary care alternative payment model by the end of 2024.(2) At least 35% of insured Rhode Island resident covered lives shall be attributed to a primary care alternative payment model by the end of 2025.(3) At least 45% of insured Rhode Island resident covered lives shall be attributed to a primary care alternative payment model by the end of 2026.(4) At least 60% of insured Rhode Island resident covered lives shall be attributed to a primary care alternative payment model by the end of 2027.e. The Commissioner shall periodically convene a working group to assess health insurer, provider and patient experience under these models.4. Specialist alternative payment models a. It is in the interest of the public to expand innovative alternative payment models to specialist physician practices to encourage more efficient use of health care resources, reduce unwarranted variation in episode treatment costs, and improve the quality of care through the reduction of potentially avoidable complications.b. Health insurers with 30,000 or more covered lives shall develop and implement new specialist alternative payment model contracts, and/or expand existing alternative payment model contracts with clinical professionals in the following specialties: (4) Behavioral health; and(5) Maternity, Endocrinology, or other clinical specialties selected by the health insurer.c. For each specialty, the health insurer shall develop or expand at least two contracts. The term "expand existing alternative payment model contracts" includes, but is not limited to, an expansion of a health insurer's existing contract such that more services (e.g., procedures, conditions) are included in the arrangement, or downside risk is introduced for the first time.d. Qualifying alternative payment models include limited scope of service budget models, including both prospectively paid and retrospectively reconciled models, and episode-based (bundled) payments.e. Health insurers shall meet this requirement according to the following schedule: by December 31, 2021: two specialties; by December 31, 2022: three specialties; by December 31, 2023: four specialties; by December 31, 2024: five specialties.5. Measure alignment a. The purpose of this § 4.10(D)(5) of this Part is to ensure consistency in the use of quality measures in contracts between health insurers and health care providers in Rhode Island, to reduce the administrative burden placed on providers by the unaligned use of quality measures across health insurers, to improve the quality of care by channeling clinical focus on core areas of health care delivery, to formally adopt Aligned Measure Sets to be used in contracts between health insurers and health care providers in Rhode Island, and to articulate a process for annually refining and updating the Aligned Measure Sets.b. § 4.10(D)(5) of this Part applies to contracts between health care providers, including primary care providers, specialists, hospitals, and Integrated Systems of Care and a health insurer which incorporate quality measures into the payment terms of the contract and are entered into, renewed, or amended on or after July 1, 2020, or the effective date of this regulation, if earlier.c. Health insurers shall adopt the Aligned Measure Sets for primary care, hospitals, Accountable Care Organizations (ACOs, otherwise known as Integrated Systems of Care as defined in § 4.3(A)(12) of this Part), maternity care, outpatient behavioral health and any other Aligned Measure Set developed pursuant to this § 4.10(D)(5) of this Part. (1) Health care provider contracts which incorporate quality measures into the payment terms shall include all measures designated as Core Measures in an Aligned Measure Set.(2) Health care provider contracts which incorporate quality measures into the payment terms shall not include measures beyond those designated as Core Measures in an Aligned Measure Set, with the exception of designated Menu Measures. Menu Measures may be incorporated into the payment terms of the contract at the mutual agreement of the health insurer and contracted health care provider.(3) In the event than an Aligned Measure Set does not include any Core Measures, health insurers shall limit selection of measures to Menu Measures.(4) Health insurers shall not incorporate a Core Measure into the terms of payment with a de minimis weight attached to the measure, such that performance on the Core Measure lacks meaningful financial implication for the provider.(5) A health insurer may petition the Commissioner to modify or waive one or more of the requirements of § 4.10(D)(5) of this Part. Any request to modify or waive one or more of the requirements must articulate a clear rationale supporting the waiver request and must demonstrate how the health insurer's request will advance the quality, accessibility, and/or affordability of health care services in Rhode Island.d. The Commissioner shall convene a Quality Measure Alignment and Review Committee (Committee) by August 1 each year. The Committee shall be charged with developing recommendations, for consideration by the Commissioner, that: (1) Propose modifications, if necessary, to existing Aligned Measure Sets to be used in contracts between health insurers and health care providers in Rhode Island.(2) When possible, prioritize measures that objectively track measurable health care outcomes over measures that track the performance of screenings or other processes.(3) Propose measures as Core Measures and Menu Measures.(4) Propose a work plan for the development of Aligned Measure Sets for additional professional health care provider specialties as determined necessary by the Commissioner.e. The Commissioner shall designate as members of the Committee individuals or organizations representing:(1) Relevant state agencies and programs, including the Office, the Medicaid program, the Rhode Island Department of Health, and the Department of Behavioral Health, Developmental Disabilities and Hospitals;(4) Health care providers;(6) Quality measure experts; and(7) Any other individual or organization that the Commissioner determines can bring value to the work of the Committee.f. OHIC will maintain a list of participating individuals or organizations with voting status. Each designated organization shall have one (1) vote and the designee must be present in order to vote.g. The recommendations, together with any stakeholder comments, shall be submitted to the Commissioner on or before October 1 of each year. Health insurers shall comply with the requirements adopted by the Commissioner.h. The Commissioner shall maintain the Aligned Measure Sets and publish them, along with any supporting documentation and interpretive guidance, on the OHIC website.6. Hospital contractsa. Each health insurer shall include in its hospital contracts the terms required by § 4.10(D)(6) of this Part.b. This § 4.10(D)(6) of this Part shall apply to contracts between a health insurer and a hospital licensed in Rhode Island which are entered into, renewed, or amended on or after July 1, 2023, or the effective date of this regulation, if earlier. To ensure compliance with § 4.10(D)(6) in the event of any hospital conversions pursuant to R.I. Gen. Laws Chapter 23-17.14, the health insurer shall, in terms of contracting, treat the contract of the successor hospital or entity as a continuation of the contract of the predecessor hospital or entity with whom the health insurer had contracted.c. Hospital contracts shall utilize unit-of-service payment methodologies for both inpatient and outpatient services that realign payment to provide incentives for efficient use of health services, and are derived from nationally utilized payment practices other than fee-for-service. Nothing in this requirement prevents contract terms that provide additional or stronger payment incentives toward quality and efficiency such as performance bonuses, bundled payments, global payments, or case rates.d. Hospital contracts shall include a quality incentive program.(1) The quality incentive program shall include payment for attaining or exceeding mutually agreed-to, sufficiently challenging performance levels for all Core Measures within the Aligned Measure Set for hospitals. For measures beyond the Core Measures the health insurer shall limit selection of measures to those listed as Menu Measures in the Aligned Measures Set for hospitals.(2) The measures, performance levels, payment levels, and payment mechanisms must be articulated in the contract.(3) Quality incentive payments will not be due and payable until the quality incentive measure targets have been met or otherwise achieved by the hospital. A health insurer may make interim payments in the event that interim quality performance targets have been met; provided that the interim payments are commensurate with the achievement of the interim targets; and provided further that if the annual quality performance targets have not been achieved, the hospital shall be required to remit unearned interim payments back to the health insurer. A health insurer may also make prospective payments without consideration of performance, provided that if the annual quality performance targets have not been achieved, the hospital shall be required to remit unearned prospective payments back to the health insurer. Earned quality incentive payments shall become part of base payment rates.e. Hospital contracts shall include a provision that agrees on rates, and quality incentive payments for each contract year, such that review and prior approval by the Office of the Health Insurance Commissioner shall be required if either: (1) The average rate increase, including estimated quality incentive payments, is greater than the US All Urban Consumer All Items Less Food and Energy CPI ("CPI-Urban") percentage increase (reported by the Commissioner by October 1 each year, in accordance with the method set forth in § 4.10(D)(6)(i) of this Part). Such percentage increase shall be plus 1%, or(2) Less than twenty-five percent (25%) of the average rate increase is for expected quality incentive payments.f. Hospitals which have been paid by a health insurer at less than the median commercial payments made to all Rhode Island acute care hospitals for inpatient services, including inpatient behavioral health services, in the health insurer's provider network, as determined by the health insurer summing all of its inpatient payments (numerator) and dividing that by a sum of all DRG case weights (denominator) to provide a case-mix-adjusted discharge payment rate for each hospital for inpatient services, shall receive an equal percentage increase in payment for each inpatient service until the hospital's average payment per case-mix-adjusted DRG for inpatient services is equal to the median. At the time of the calculation, the health insurer shall utilize the most recent 12-months of claims data for which the health insurer's Rhode Island hospital claim runout is at least 95% complete. The increase in payment rates shall not be construed as an ongoing price floor. The increase in payment rates shall be contractually contingent on the following: (1) At the conclusion of three years after the first increase in payments, or at the mutual agreement of the health insurer and hospital to establish a shorter time period, the hospital shall attain performance no different or better than the national benchmark for Clostridium difficile (C. diff) intestinal infections, Central line-associated bloodstream infections (CLABSI), and the rate of readmission after discharge from hospital (hospital-wide) as published on the Medicare.gov Hospital Compare website;(2) At the mutual agreement of the health insurer and hospital, alternative quality measures and performance targets may be employed as a substitute for the quality measures and performance targets specified in § 4.10(D)(6)(f)(1). If the parties cannot agree to an alternative set of quality measures, then the quality measures and performance targets in § 4.10(D)(6)(f)(1) shall be used.(3) The contract contains a provision for recovery of monies paid to the hospital by the health insurer pursuant to this § 4.10(D)(6)(f) of this Part should the hospital fail to achieve the quality targets defined in § 4.10(D)(6)(f)(1) of this Part. Such provision shall be subject to audit by the Commissioner.g. Hospital contracts shall include terms that define the parties' mutual obligations for greater administrative efficiencies, such as improvements in claims and eligibility verification processes, and identify commitments on the part of each, and that require the parties to actively participate in the Commissioner's Administrative Simplification Work Group.h. Hospital contracts shall include terms that relinquish the right of either party to contest the public release, by state officials or the parties to the contract of the provisions of the contract demonstrating compliance with the requirements of this § 4.10(D)(6) of this Part; provided that the health insurer or other affected party may request the Commissioner to maintain specific contract terms or portions thereof as confidential, if properly supported with legal and factual analysis justifying the claim of confidentiality.i. The US All Urban Consumer All Items Less Food and Energy CPI ("CPI-Urban") percentage increase to be reported according to the Standard Method by the Commissioner shall be equal to the 12-month percent change in the CPI-Urban published by the United States Bureau of Labor Statistics in September of each year. The September report will reference the 12-month percent change from August of the prior year to August of the report year. Due to significant epidemiological or macroeconomic events the Commissioner may elect to utilize a different method of determining the value of the CPI-Urban Should the Commissioner elect to utilize a different method than the Standard Method, the Commissioner shall announce his or her intention of doing so by August 1 and allow for thirty days of public comment on the proposed method prior to issuing a final decision. If the Commissioner ultimately elects to utilize a different method than the Standard Method, any entity that submitted a public comment and is aggrieved by the Commissioner's determination may challenge the determination through all available methods of appeal.7. Nothing in §§ 4.10(D)(2) or (6) of this Part is intended to require that the health insurer must contract with all hospitals and providers licensed in Rhode Island. Consistent with statutes administered by OHIC, health insurers must demonstrate the adequacy of their hospital and provider network.8. Professional provider contracts a. The purpose of § 4.10(D)(8) of this Part is to ensure that health insurer contracts with professional providers include terms that allow for the release of contracts, in whole or in part, to OHIC for purposes of monitoring professional provider fee schedule increases, substantiating unit cost trend data filed as part of the health insurer's rate filing, or assessing compliance with state laws and regulations adopted pursuant to Titles 27 or 42 in which the Commissioner holds jurisdiction. This § 4.10(D)(8) of this Part shall apply to contracts between a health insurer and a professional provider or provider group in Rhode Island which are entered into, renewed, or amended on or after January 1, 2024.b. Professional provider contracts shall include terms that relinquish the right of either party to contest the release of the contract, or parts thereof, to OHIC; provided that the health insurer or other affected party may request that OHIC maintain specific contract terms or portions thereof as confidential, if properly supported with legal and factual analysis justifying the claim of confidentiality.E. Health equity 1. By July 1, 2026, health insurers are required to obtain NCQA Health Equity Accreditation in support of making progress toward eliminating health disparities, improving health outcomes, and reducing overall health care cost growth.2. Demographic data collection principles a. Health insurers are required to systematically collect, maintain, protect, and report on demographic data. When collecting, maintaining, and reporting demographic data, health insurers shall aim to align their practices with established national standards where possible.b. Health insurers are required to utilize industry-wide best practice for demographic data in terms of data collection strategies and survey language that has been consumer-tested and is widely recognized for increased accuracy and responsiveness.c. The disclosure of demographic data by prospective members and members to health insurers must always be voluntary and based on self-identification or disclosure and be accompanied by detailed reasoning for why demographic data is being requested and that it will support efforts to provide equitable care.d. To the extent that health insurers use staff to collect and/or analyze demographic data, health insurers shall develop and implement trainings on how to ask questions about the demographic data, including training on how to maintain privacy of this sensitive information.3. Demographic data use principlesa. Health insurers shall strictly adhere to any and all existing federal and/or state prohibitions or restrictions on the collection and/or reporting of demographic data.b. Health insurers shall apply Health Insurance Portability and Accountability Act of 1996 protections to demographic data and treat demographic data as protected health information.c. Health insurers shall strictly adhere to any and all existing federal and/or state requirements governing analysis and information sharing of demographic data.d. Legally and ethically acceptable use cases relative to the use of demographic data may include: (1) Evaluating algorithms or population health or performance related analytics used to assess member needs, evaluate performance, or assess key performance indicators, to identify and mitigate disparate impact or bias;(2) Analyzing claims, enrollment, and complaint data to better understand health care disparities or to evaluate the efficacy of programs intended to reduce health care disparities;(3) Provider network development and performance and coordination of care;(4) Service quality improvement; or(5) Assessing or planning to meet the need for health-related social services and supports, including trauma-informed care, and outreach to populations that have been marginalized, among other uses.4. Demographic data completeness goals a. By January 1, 2025, health insurers should obtain demographic data for at least 80% of their members, as specified by the Commissioner.F. Stakeholder input, waiver and modification 1. Stakeholder input plays a critical role in the formation of public policy. The transformation of the health care system, which is necessary to support improved system performance on cost and quality, is a dynamic task which relies on trust, collaboration, and open communication between stakeholders and policymakers.a. The Commissioner may convene a Payment and Care Delivery Advisory Committee as needed to obtain input on policies related to the Affordability Standards. The Committee shall be charged with considering and developing recommendations for necessary actions by the Commissioner to advance health care system performance and affordability. The Commissioner shall solicit input from members of the Committee on topics to address during the meetings.b. The Commissioner shall designate as members of the Committee individuals or organizations representing: (1) Relevant state agencies and programs, such as the Office of the Health Insurance Commissioner, the Medicaid program, the Department of Health, and the state employees' health benefit plan;(3) Integrated Systems of Care;(5) Health care providers, including behavioral health providers;(7) Employer purchasers of health insurance and health care services.c. In addition to topics concerning the improvement of health care system performance and affordability, the Commissioner shall solicit input on whether the Affordability Standards need to be modified: (1) To create or maintain an effective incentive for provider organizations to participate in care transformation, population-based contracts and alternative payment models; or(2) To account for unanticipated and profound macroeconomic events, or similarly significant changes in systemic utilization or costs that are beyond the ability of the health insurer to control, such that application of the any of the requirements of § 4.10 of this Part would be manifestly unfair.2. The Commissioner, upon petition by a health insurer for good cause shown, or in his or her discretion as necessary to carry out the purposes of the laws and regulations administered by the Office, may modify or waive one or more of the requirements of § 4.10 of this Part. Any such modifications shall be considered and made during the formal process of the Commissioner's review and approval of health insurance rates filed by the health insurer.3. A health insurer shall not be held accountable for a violation of the requirements of § 4.10 of this Part if the health insurer demonstrates to the satisfaction of the Commissioner that compliance with any of these requirements was not possible, notwithstanding the health insurer's good faith and reasonable efforts. The health insurer shall notify the Commissioner and request a waiver under § 4.10(F)(2) of this Part, if desired, as soon as any such circumstances arise. Failure by the health insurer to establish that good faith and reasonable efforts were undertaken shall result in penalties consistent with the Commissioner's authority under R.I. Gen. Laws Titles 27 and 42.G. Data collection and evaluation 1. Each health insurer shall submit to the Commissioner, in a format approved by the Commissioner, a Primary Care Spend Report, a Behavioral Health Care Spend Report, and a Payment Reform Report, including such data as is necessary to monitor and evaluate the provisions of § 4.10 of this Part.2. On or before October 1 and annually thereafter, the Office shall present to the Health Insurance Advisory Council a monitoring report describing the status of progress in implementing the Affordability Standards.3. Health insurers shall provide to the Office, in a timely manner and in the format requested by the Commissioner, such data as the Commissioner determines is necessary to evaluate the Affordability Standards and to monitor compliance with the Affordability Standards established in this § 4.10 of this Part. Such data may include any hospital or provider reimbursement contract, and any data relating to a hospital or provider's attainment of quality and other performance-based measures as specified in quality incentive programs referenced in §§ 4.10(D)(6)(d) and (e) of this Part.4. To the extent possible, the Office shall use the All Payer Claims Database authorized by R.I. Gen. Laws Chapter 23-17.17 to collect data required by § 4.10(G) of this Part.230 R.I. Code R. 230-RICR-20-30-4.10
Amended effective 12/4/2018
Amended effective 6/25/2020
Amended effective 8/20/2023