230 R.I. Code R. 230-RICR-20-30-4.6

Current through December 3, 2024

Section 230-RICR-20-30-4.6 - Protecting the Interests of Consumers

A. The interests of the consumers of health insurance, including individuals, groups and employers, must be protected.

B. The provisions of this regulation do not require the Commissioner to act as an advocate on behalf of a particular health insurance consumer. Instead, while the Commissioner will endeavor to address individual consumer complaints as they arise, the OHIC Purposes Statute requires the OHIC to protect the interests of health insurance consumers, including individuals, groups and employers, on a system-wide basis.

C. Whenever the Commissioner determines that one of the circumstances in §§ 4.6(C)(1) through (3) of this Part exist, the Commissioner shall, in addition to exercising any duty or power authorized or required by R.I. Gen. Laws Titles 27 or 42 related specifically to the protection of the interests of the consumers of health insurance, act to protect the interests of consumers of health insurance when exercising any other power or duty of the Office, including, but not limited to, approving or denying any request or application; approving, denying or modifying any requested rate; approving or rejecting any forms, trend factors, or other filings; issuing any order, decision or ruling; initiating any proceeding, hearing, examination, or inquiry; or taking any other action authorized or required by statute or regulation.

1. The interests of the state's health insurance consumers are, or are likely to be, adversely affected by any policy, practice, action or inaction of a health insurer;

2. The approval or denial by the Commissioner of any regulatory request, application or filing made by a health insurer could adversely affect the interests of the state's health insurance consumers; or

3. Any other circumstances exist such that the interests of the state's health insurance consumers may be adversely affected.

D. When making a determination as described in § 4.6(C) of this Part or when acting to protect the interests of the state's health insurance consumers, the Commissioner may consider and/or act upon the following consumer interest issues, either singly or in combination of two or more:

1. The privacy and security of consumer health information;

2. The efforts by a health insurer to ensure that consumers are able to

a. Read and understand the terms and scope of the health insurance coverage documents issued or provided by the health insurer and

b. Make fully informed choices about the health insurance coverage provided by the health insurer;

3. The effectiveness of a health insurer's consumer appeal and complaint procedures.;

4. The efforts by a health insurer to ensure that consumers have ready access to claims information;

5. The efforts by a health insurer to increase the effectiveness of its communications with its insureds, including, but not limited to, communications related to the insureds' financial responsibilities;

6. That the benefits in health insurance coverage documents issued or provided by a health insurer are consistent with state laws;

7. That the benefits delivered by a health insurer are consistent with those guaranteed by the health insurance coverage documents issued or provided by the health insurer; and

8. The steps taken by a health insurer to enhance the affordability of its products, as described in § 4.9 of this Part.

E. The factors enumerated in § 4.6(D) of this Part shall not be construed as limiting the Commissioner from making a finding that other consumer protection issues not specifically enumerated in § 4.6(D) of this Part are necessary or desirable factors upon which the Commissioner may act to protect the interests of consumers of health insurance.

230 R.I. Code R. 230-RICR-20-30-4.6

Amended effective 12/4/2018
Amended effective 6/25/2020
Amended effective 8/20/2023