(a)  No health maintenance organization, or representative of a health maintenance organization, may cause or knowingly permit the use of advertising that is untrue or misleading, solicitation that is untrue or misleading, or any form of evidence of coverage that is deceptive. For the purposes of this chapter:

(1)  A statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect that is or may be significant to an enrollee of, or a person considering enrollment with, a health maintenance organization;

(2)  A statement or item of information shall be deemed to be misleading, whether or not it may be literally untrue, if, in the total context in which the statement is made or the item of information is communicated, the statement or item of information may be reasonably understood by a reasonable person, not possessing special knowledge regarding healthcare coverage, as indicating any benefit or advantage or the absence of any exclusion, limitation, or disadvantage of possible significance to an enrollee of, or a person considering enrollment in, a health maintenance organization, if the benefit or advantage or absence of limitation, exclusion, or disadvantage does not in fact exist; and

(3)  An evidence of coverage shall be deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography, format, and language, shall be such as to cause a reasonable person, not possessing special knowledge regarding health maintenance organizations and evidences of coverage for them, to expect benefits, services, charges, or other advantages that the evidence of coverage does not provide or that the health maintenance organization issuing the evidence of coverage does not regularly make available for enrollees covered under the evidence of coverage.

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Terms Used In Rhode Island General Laws 27-41-14

  • Contract: A legal written agreement that becomes binding when signed.
  • Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
  • 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
  • Enrollee: means an individual who has been enrolled in a health maintenance organization. See Rhode Island General Laws 27-41-2
  • Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
  • Evidence of coverage: means any certificate, agreement, or contract issued to an enrollee setting out the coverage to which the enrollee is entitled. 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

  • Liabilities: The aggregate of all debts and other legal obligations of a particular person or legal entity.
  • person: may be construed to extend to and include co-partnerships and bodies corporate and politic. See Rhode Island General Laws 43-3-6
  • Physician: includes a podiatrist as defined in chapter 29 of Title 5. 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)  Section 42-62-12 and regulations pursuant to that section and chapter 29 of this title, relating to unfair competition and practices, shall be construed to apply to health maintenance organizations and evidences of coverage except to the extent that the director of business regulation determines that the nature of health maintenance organizations, and evidences of coverage, render those sections clearly inappropriate.

(c)  An enrollee may not be canceled or nonrenewed except for reasons stated in the rules of the health maintenance organization applicable to all enrollees, for the failure to pay the charge for coverage, or for the other reasons as may be approved by the director of business regulation.

(d)  No health maintenance organization, unless licensed as an insurer, may use in its name, contracts, or literature any of the words “insurance,” “casualty,” “surety,” or “mutual,” or any words descriptive of the insurance, casualty, or surety business or deceptively similar to the name or description of any insurance or surety corporation doing business in this state.

(e)  No person, unless in possession of a valid license as a health maintenance organization pursuant to the laws of this state, shall hold itself out as a health maintenance organization or HMO or shall do business as a health maintenance organization or HMO in the state of Rhode Island, and no person shall do business in this state under a name deceptively similar to the name of any health maintenance organization possessing a valid license pursuant to this chapter.

(f)  No health maintenance organization shall fail to contract with any provider who is licensed by this state to provide the services delineated in § 27-41-2(20)(i) solely because that provider is a podiatrist as defined in chapter 29 of Title 5.

(g)  Except as provided in § 27-41-13(i), no contract between a health maintenance organization and a physician for the provision of services to patients may require that the physician indemnify or hold harmless the health maintenance organization for any expenses and liabilities, including without limitation, judgments, settlements, attorneys’ fees, court costs, and any associated charges, incurred in connection with any claim or action brought against the plan based on the health maintenance organization’s management decisions or utilization review provisions for any patient.

History of Section.
P.L. 1983, ch. 225, § 2; P.L. 1985, ch. 170, § 1; P.L. 1987, ch. 107, § 2; P.L. 1996, ch. 309, § 1; P.L. 2023, ch. 395, art. 1, § 14, effective December 31, 2023.