Rhode Island General Laws 27-41-35. Enrollment period in the event of insolvency
(a) In the event of an insolvency of a health maintenance organization, upon order of the director, all other carriers that participated in the enrollment process with the insolvent health maintenance organization at a group’s last regular enrollment period shall offer the group’s enrollees of the insolvent health maintenance organization a thirty-day (30) enrollment period commencing upon the date of insolvency. Each carrier shall offer the enrollees of the insolvent health maintenance organization the same coverage and rates that it had offered to the enrollees of the group at its last regular enrollment period.
Terms Used In Rhode Island General Laws 27-41-35
- 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
(b) If no other carrier had been offered to some groups enrolled in the insolvent health maintenance organization, or if the director determines that the other health benefit plan(s) lack(s) sufficient healthcare delivery resources to ensure that healthcare services will be available and accessible to all of the group enrollees of the insolvent health maintenance organization, then the director shall allocate equitably the insolvent health maintenance organization’s group contracts for the groups among all health maintenance organizations that operate within a portion of the insolvent health maintenance organization’s service area, taking into consideration the healthcare delivery resources of each health maintenance organization. If the director determines that no health maintenance organization has sufficient resources to ensure that healthcare services will be available and accessible to some groups enrolled in the insolvent health maintenance organization, then the director shall allocate equitably the insolvent health maintenance organization’s contracts for the groups among the other carriers as he or she deems appropriate. Each health maintenance organization, or other carrier, to which a group or groups are so allocated, shall offer the group or groups the health maintenance organization’s or other carrier’s existing coverage that is most similar to each group’s coverage with the insolvent health maintenance organization at rates determined in accordance with the successor health maintenance organization’s or other carrier’s existing rating methodology.
(c) The director shall also allocate equitably the insolvent health maintenance organization’s nongroup enrollees that are unable to obtain other coverage among all health maintenance organizations that operate within a portion of the insolvent health maintenance organization’s service area, taking into consideration the healthcare delivery resources of each health maintenance organization. If the director determines that no health maintenance organization has sufficient resources to ensure that healthcare services will be available and accessible to some nongroup enrollees of the insolvent health maintenance organization, then the director shall allocate equitably the insolvent health maintenance organization’s contracts for the nongroup enrollees among the other carriers as he or she deems appropriate. Each health maintenance organization or other carrier to which nongroup enrollees are allocated shall offer the nongroup enrollees the health maintenance organization’s or other carrier’s existing coverage for individual or conversion coverage as determined by his or her type of coverage in the insolvent health maintenance organization at rates determined in accordance with the successor health maintenance organization’s or other carrier’s existing rating methodology. Successor health maintenance organizations or other carriers that do not offer direct nongroup enrollment may aggregate all of the allocated nongroup enrollees into one group for rating and coverage purposes.
History of Section.
P.L. 1990, ch. 161, § 2.