230 R.I. Code R. 230-RICR-20-30-4.9

Current through December 3, 2024

Section 230-RICR-20-30-4.9 - Affordable Health Insurance - General

A. Consumers of health insurance have an interest in stable, predictable, affordable rates for high quality, cost efficient health insurance products. Achieving an economic environment in which health insurance is affordable will depend in part on improving the performance of the Rhode Island health care system as a whole, including but not limited to the following areas:

1. Improved primary care supply, measured by the total number of primary care providers, and by the percentage of physicians identified as primary care providers.

2. Improved integration of behavioral health services into the primary care delivery system to meet the physical and behavioral health needs of the public.

3. Reduced incidence of hospitalizations for ambulatory care-sensitive conditions, and of re-hospitalizations.

4. Reduced incidence of emergency room visits for ambulatory care-sensitive conditions.

5. Reduced provision of low-value care.

6. Reduced rates of premium increase for fully insured, commercial health insurance.

B. In discharging the duties of the Office, including but not limited to the Commissioner's decisions to approve, disapprove, modify or take any other action authorized by law with respect to a health insurer's filing of health insurance rates or rate formulas under the provisions of R.I. Gen. Laws Titles 27 or 42, the Commissioner may consider whether the health insurer's products are affordable, and whether the carrier has implemented effective strategies to enhance the affordability of its products.

C. In determining whether a carrier's health insurance products are affordable, the Commissioner may consider the following factors:

1. Trends, including:

a. Historical rates of trend for existing products;

b. National medical and health insurance trends (including Medicare trends);

c. Regional medical and health insurance trends; and

d. Inflation indices, such as the Consumer Price Index and the medical care component of the Consumer Price Index.

2. Price comparison to other market rates for similar products (including consideration of rate differentials, if any, between not-for-profit and for-profit insurers in other markets);

3. The ability of lower-income individuals to pay for health insurance;

4. Efforts of the health insurer to maintain close control over its administrative costs;

5. Implementation of effective strategies by the health insurer to enhance the affordability of its products; and

6. Any other relevant affordability factor, measurement or analysis determined by the Commissioner to be necessary or desirable to carry out the purposes of this Regulation.

D. In determining whether a health insurance carrier has implemented effective strategies to enhance the affordability of its products, the Commissioner may consider the following factors:

1. Whether the health insurer offers a spectrum of product choices to meet consumer needs.

2. Whether the health insurer offers products that address the underlying cost of health care by creating appropriate and effective incentives for consumers, employers, providers and the insurer itself. Such incentives shall be designed to promote efficiency in the following areas:

a. Creating a focus on primary care, integrated behavioral health care, prevention and wellness.

b. Establishing active management procedures for the chronically ill population.

c. Encouraging use of the least cost, most appropriate settings; this goal is meant to apply in the aggregate. Use of some higher cost providers and settings may in some instances result in better outcomes and should not be discouraged; and

d. Promoting use of evidence-based, quality care.

3. Whether the insurer employs delivery system reform and payment reform strategies to enhance cost effective utilization of appropriate services. Such delivery system reform and payment reform strategies for insurers with greater than 10,000 covered lives shall include, but not be limited to complying with the requirements of § 4.10 of this Part. Consideration may also be given to:

a. Whether the insurer supports product offerings with simple and cost-effective administrative processes for providers and consumers;

b. Whether the insurer addresses consumer need for cost information through increasing the availability of provider cost information and promoting public conversation on trade-offs and cost effects of medical choices; and

c. Whether the insurer allows for an appropriate contribution to surplus.

E. The following constraints on affordability efforts will be considered:

1. State and federal requirements (e.g., state mandates, federal laws).

2. Costs of medical services over which plans have limited control.

3. Health insurer solvency requirements.

4. The prevailing financing system in United States (i.e., the third-party payor system) and the resulting decrease in consumer price sensitivity.

230 R.I. Code R. 230-RICR-20-30-4.9

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