230 R.I. Code R. 230-RICR-20-30-9.6

Current through December 3, 2024

Section 230-RICR-20-30-9.6 - Network Plan General Requirements

A. For each network plan the health care entity must maintain and submit to the Office its most current grievance and complaint process that adheres to and includes the following minimal requirements:

1. Written processes whereby the beneficiary, a beneficiary's authorized representatives, or health care providers may seek resolution of complaints and other matters of which the health care entity has received oral or written notice;

2. Reasonable timeframes for the resolution of beneficiary, authorized representative of beneficiary, and provider complaints, grievances inquiries of not more than thirty (30) calendar days from the date the health care entity receives the oral or written notice unless granted an extension by the Commissioner;

3. At a minimum, an annual communication from the applicable health care entity to the network plan's beneficiaries and providers that explains the grievance and complaint process for the applicable network plan(s) and provides guidance for distinguishing between a complaint/grievance and a benefit determination appeal and the rights associated with each; and

4. Internal monitoring of complaints and grievances and reporting to the Office on categories of complaints in form and content consistent with instructions issued by the Office for that purpose.

B. As to each network plan, a health care entity shall be required to submit to the Office a mechanism designed to ensure beneficiaries and providers, including local providers participating in the network plans, provide meaningful input into the plan's health care polices, including without limitation:

1. A process to evidence that beneficiary and provider input is reasonably assessed for use by the health care entity; and

2. A process that ensures that issues brought to the attention of the health care entity regarding its network plans via the entity's complaint processes are regularly considered and addressed by the health care entity in the context of developing, reviewing and evaluating each network plan's health care policies.

C. For each network plan, health care entities must evidence to the Office its adherence to the following formulary requirements:

1. Network plan providers shall have input to formulary development;

2. "Formulary changes" include but are not limited to the following:

a. Medications covered on the formulary;

b. Medication tiering; and

c. Cost sharing.

3. Prior to making any formulary changes for a network plan, a health care entity must provide at least thirty (30) calendar days direct notice to prescribers of the affected medications and adversely affected beneficiaries must be given at least thirty (30) calendar days direct notice prior to effective date of change;

4. All formulary change notifications to beneficiaries must include the following:

a. The familiar name of the medication(s);

b. A description of the change being made in easy to understand language; and

c. An explanation of the formulary exception process, in accordance with R.I. Gen. Laws Chapter 27-18.9, in easy to understand language; and

D. To the extent a network plan has requirements relating to referrals, the network plan and or health care entity must institute and maintain a procedure for providers to make and authorize in-network referrals, which procedure shall include, without limitation:

1. A reasonable process for communicating the referral process to its beneficiaries in a manner that is easily understood; and

2. An administrative appeal process for denials for failure to obtain a referral consistent with R.I. Gen. Laws Chapter 27-18.9.

E. Each health care entity shall develop, implement and maintain a quality assurance program that: includes the health care entity's oversight of all activities, whether or not delegated, subject to the Act and these regulations; that includes a process to regularly evaluate and determine whether its activities are being performed in a manner that maintains the quality of services delivered to its beneficiaries; and that assures that these activities do not adversely affect the delivery of covered services.

F. Each health care entity shall evidence to the Offices its compliance with state and federal behavioral health parity statutes and any applicable regulations.

G. Each health care entity shall cooperate with all compliance reviews and investigations conducted by the Office which may include but not be limited to the following:

1. A review by the Office of the certified health care entity's operations as often as the Commissioner in his or her sole discretion deems appropriate to determine whether a health care entity may be in violation of the Act and these regulations.

230 R.I. Code R. 230-RICR-20-30-9.6

Adopted effective 12/16/2018