Rhode Island General Laws 27-41-16. Examination
(a) The director of business regulation may make an examination of the affairs of any health maintenance organization and the providers with whom the organization has contracts, agreements, or other arrangements pursuant to its healthcare plan as often as is reasonably necessary for the protection of the interests of the people of this state. The examination shall be performed and the associated costs shall be borne by the company in accordance with all the provisions of chapter 13.1 of this title.
Terms Used In Rhode Island General Laws 27-41-16
- Director: means the director of the department of business regulation or his or her duly appointed agents. See Rhode Island General Laws 27-41-2
- Health maintenance organization: means a single public or private organization that:
(i) Provides or makes available to enrolled participants healthcare services, including at least the following basic healthcare services: usual physician services, hospitalization, laboratory, x-ray, emergency, and preventive services, and out-of-area coverage, and the services of licensed midwives;
(ii) Is compensated, except for copayments, for the provision of the basic healthcare services listed in subsection (20)(i) of this section to enrolled participants on a predetermined periodic rate basis;
(iii)(A) Provides physicians' services primarily:
(I) Directly through physicians who are either employees or partners of the organization; or
(II) Through arrangements with individual physicians or one or more groups of physicians organized on a group practice or individual practice basis;
(B) "Health maintenance organization" does not include prepaid plans offered by entities regulated under chapter 1, 2, 19, or 20 of this title that do not meet the criteria above and do not purport to be health maintenance organizations; and
(iv) Provides the services of licensed midwives primarily:
(A) Directly through licensed midwives who are either employees or partners of the organization; or
(B) Through arrangements with individual licensed midwives or one or more groups of licensed midwives organized on a group practice or individual practice basis. See Rhode Island General Laws 27-41-2
- Healthcare services: means any services included in the furnishing to any individual of medical, podiatric, or dental care, or hospitalization, or incident to the furnishing of that care or hospitalization, and the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability. See Rhode Island General Laws 27-41-2
- provider: means a healthcare professional or a healthcare facility. See Rhode Island General Laws 27-41-2
(b) The director of health may make an examination concerning the quality of healthcare services of any health maintenance organization and the providers with whom the organization has contracts, agreements, or other arrangements as often as is reasonably necessary for the protection of the interests of the people of this state.
(c) Each health maintenance organization shall establish and maintain on an ongoing basis a quality assurance program that involves the assessment of all quality assurance activities conducted in the provision of its healthcare services to its subscribers, which shall include no less than:
(1) Assessment of health outcomes;
(2) Ongoing review of health services by physicians and other health professionals; and
(3) Utilization and systematic data collection.
(d) Every health maintenance organization and provider shall submit its books and records to those examinations and in every way facilitate them. For the purpose of examinations, the director of business regulation and the director of health may administer oaths to, and examine, the officers and agents of the health maintenance organization and the principals of their providers concerning their business.
(e) The expenses of examinations under this section shall be assessed against the organization being examined and remitted to the director of the department for whom the examination is being conducted. The total cost of those examinations, whether made by the director of business regulation or by the director of health, shall be borne by the examined health maintenance organizations and shall be in the same amount as provided for in § 27-13-1, and shall be paid to the director of the department conducting the examination for deposit as general revenues. That assessment shall be in addition to any taxes and fees payable to the state. In instances where the examination is performed by outside accountants, the expenses of the examination shall be borne by the examined health maintenance organization.
(f) In lieu of any state examination, the director of business regulation or the director of health may accept the report of an examination made by the director of business regulation or the director of health of another state.
History of Section.
P.L. 1983, ch. 225, § 2; P.L. 1992, ch. 133, art. 24, § 1; P.L. 1994, ch. 404, § 13; P.L. 1995, ch. 370, art. 40, § 88; P.L. 2023, ch. 395, art. 1, § 14, effective December 31, 2023.