Rhode Island General Laws 27-41-76. Prohibition on annual and lifetime limits
(a) Annual limits.
(1) For plan or policy years beginning prior to January 1, 2014, for any individual, a health maintenance organization subject to the jurisdiction of the commissioner under this chapter may establish an annual limit on the dollar amount of benefits that are essential health benefits provided the restricted annual limit is not less than the following:
(i) For a plan or policy year beginning after September 22, 2011, but before September 23, 2012 — one million two hundred fifty thousand dollars ($1,250,000); and
(ii) For a plan or policy year beginning after September 22, 2012, but before January 1, 2014 — two million dollars ($2,000,000).
(2) For plan or policy years beginning on or after January 1, 2014, a health maintenance organization shall not establish any annual limit on the dollar amount of essential health benefits for any individual, except:
(i) A health flexible spending arrangement, as defined in 26 U.S.C. § 106(c)(2), a medical savings account, as defined in 26 U.S.C. § 220, and a health savings account, as defined in 26 U.S.C. § 223, are not subject to the requirements of subsections (a)(1) and (a)(2) of this section.
(ii) The provisions of this subsection (a) shall not prevent a health maintenance organization from placing annual dollar limits for any individual on specific covered benefits that are not essential health benefits to the extent that such limits are otherwise permitted under applicable federal law or the laws and regulations of this state.
(3) In determining whether an individual has received benefits that meet or exceed the allowable limits, as provided in subsection (a)(1) of this section, a health maintenance organization shall take into account only essential health benefits.
Terms Used In Rhode Island General Laws 27-41-76
- Affordable Care Act: means the federal Patient Protection and Affordable Care Act, Pub. See Rhode Island General Laws 27-41-2
- covered benefits: means coverage or benefits for the diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body including coverage or benefits for transportation primarily for and essential thereto, and including medical services as defined in §?27-19-17. See Rhode Island General Laws 27-41-2
- Group health plan: means an employee welfare benefit plan as defined in Rhode Island General Laws 27-41-2
- Health insurance carrier: means a person, firm, corporation, or other entity subject to the jurisdiction of the commissioner under this chapter, and includes a health maintenance organization. See Rhode Island General Laws 27-41-2
- health insurance commissioner: means that individual appointed pursuant to §?42-14. 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
- Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
(b) Lifetime limits.
(1) A health insurance carrier and health benefit plan offering group or individual health insurance coverage shall not establish a lifetime limit on the dollar value of essential health benefits for any individual.
(2) Notwithstanding subsection (b)(1), a health insurance carrier and health benefit plan is not prohibited from placing lifetime dollar limits for any individual on specific covered benefits that are not essential health benefits in accordance with federal laws and regulations.
(c)(1) The provisions of this section relating to lifetime limits apply to any health maintenance organization or health insurance carrier providing coverage under an individual or group health plan, including grandfathered health plans.
(2) The provisions of this section relating to annual limits apply to any health maintenance organization or health insurance carrier providing coverage under a group health plan, including grandfathered health plans, but the prohibition and limits on annual limits do not apply to grandfathered health plans providing individual health insurance coverage.
(d) This section shall not apply to a plan or to policy years prior to January 1, 2014, for which the Secretary of the U.S. Department of Health and Human Services issued a waiver pursuant to 45 C.F.R. § 147.126(d)(3). This section also shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by accident or both; and (9) Other limited benefit policies.
(e) If the commissioner of the office of the health insurance commissioner determines that the corresponding provision of the federal Patient Protection and Affordable Care Act has been declared invalid by a final judgment of the federal judicial branch or has been repealed by an act of Congress, on the date of the commissioner’s determination this section shall have its effectiveness suspended indefinitely, and the commissioner shall take no action to enforce this section. Nothing in this subsection shall be construed to limit the authority of the commissioner to regulate health insurance under existing state law.
History of Section.
P.L. 2012, ch. 256, § 10; P.L. 2012, ch. 262, § 10.