230 R.I. Code R. 230-RICR-20-30-9.9

Current through December 3, 2024

Section 230-RICR-20-30-9.9 - Provider Contracting and Due Process

A. The health care entity must include the following in its network provider contracts:

1. A provision protecting beneficiaries to include:

a. Ensuring the beneficiary is held harmless from any financial liability beyond in-network cost shares attributable to the failure of a referring network provider to adhere to the referral process, including by failing to submit the required network plan's referral documents according to the health care entity requirements when there is evidence that the beneficiary sought and received a referral from the network provider. This section is not applicable in cases where the beneficiary has self-referred.

b. That in no event, including but not limited to non-payment by the health care entity or intermediary, insolvency of the health care entity or one of its delegates or breach of the health care entity's agreement with a network plan provider, shall the network plan provider bill, charge, collect a deposit from, or seek compensation, remuneration or reimbursement from a beneficiary to include but not limited to facility or administrative fees added to a beneficiary for covered services by the provider; and

c. That no beneficiary shall be liable to any provider for charges for covered benefits, except for the amounts due for co-payments, deductibles and/or coinsurance, when provided or made available to enrolled participants by a licensed health maintenance organization, as that term is defined in R.I. Gen. Laws § 27-41-2(t), during a period in which premiums were paid by or on behalf of the enrollee.

2. Language to describe that in the event of a provider contract termination:

a. The beneficiary is held harmless for covered benefits except for amounts due for co-payments, coinsurance, and deductibles, for the duration of an active course of treatment or up to one year, whichever is earlier, subject to all the terms and conditions of the terminated provider contract, unless the provider is able to safely transition the patient to a network provider; and

b. For this period of active treatment, the beneficiary shall only be responsible for in-network cost shares provided for under the beneficiaries' coverage documents and not otherwise prohibited by state or federal laws or regulations.

B. In the event a health care entity or network plan modifies a professional provider contract the health care entity shall comply with the following:

1. A health care entity or network plan may materially modify the terms of a participating agreement it maintains with a professional provider only if it disseminates, in writing, by mail or by electronic means to the professional provider, the contents of the proposed modification and an explanation, in non-technical terms, of the modification's impact and any change or modification meets all requirements herein.

2. The entity or network plan shall give the professional provider an opportunity to amend or terminate the contract within sixty (60) calendar days of receipt of the notice of a contractual modification.

3. Any termination of a professional provider contract made as a result of a modification shall be effective fifteen (15) calendar days from the mailing of a written notice of termination by a professional provider to the health care entity.

4. The termination due to a modification in a professional provider contract shall not affect the method of payment or reduce the amount of reimbursement to the provider by the health care entity for any beneficiary in active treatment for an acute medical condition at the time the beneficiary's provider terminates until the active course of treatment is concluded or, if earlier, one year after the termination.

C. For all adverse decisions resulting in a change of professional provider privileges or a change in the terms of a provider contract, health care entities shall afford due process that includes, without limitation, the following:

1. Option for a voluntarily waiver by the professional provider;

2. Written notification by the health care entity to the affected professional provider(s) of the proposed action(s) and the reasons for the proposed action(s);

3. Meaningful opportunity for the provider to contest the proposed action(s);

4. An appeals process that has reasonable time limits for the resolution of the appeal; and

5. That all due process decisions are made by an objective, unbiased, and qualified individual or group.

D. A health care entity shall not refuse to contract with or compensate for covered services an otherwise eligible participating or non-participating provider solely because that provider has, in good faith, communicated with one or more or his/her patients regarding the provisions, terms, or requirements of the health care entity's network plan at it relates to the needs of a patient.

E. A health care entity shall not exclude a professional provider of covered services from participation in its network plans solely based on the professional provider's:

1. Degree or license as applicable under state law; or

2. Lack of affiliation with, or admitting privileges at, a hospital, if that lack of affiliation is due solely to provider's type of license.

3. Discussion with a beneficiary specific treatment options or for advocating to the health care entity treatment options for a beneficiary.

F. A health care entity shall not discriminate against providers when establishing its provider networks or when establishing provider network tiers using, but not limited to, the following selection criteria:

1. The provider treats a substantial number of patients who require expensive or uncompensated care; or

2. Are located in geographic areas that contain population or providers presenting a risk of higher than average utilization.

G. Health care entities shall not be allowed to include clauses in a provider's contract that allow for the health care entity's termination of the contract "without cause"; provided however, "cause" shall include lack of need due to economic considerations.

H. A health care entity or network plan shall not include a most-favored-rate clause in a provider contract.

230 R.I. Code R. 230-RICR-20-30-9.9

Adopted effective 12/16/2018