Rhode Island General Laws 27-41-8. Evidence of coverage and charges for healthcare services
(a) Every enrollee residing in this state is entitled to evidence of coverage for the payment and for the provision of healthcare services under a health maintenance organization. The health maintenance organization shall issue that evidence of coverage.
Terms Used In Rhode Island General Laws 27-41-8
- Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
- 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
- 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) Any evidence of coverage issued by a health maintenance organization licensed under this chapter shall comply with the minimum standards protection of § 42-62-12 and regulations pursuant to that section.
(c) No schedule of charges, rates, or rating formulae for enrollee coverage for healthcare services, or amendment to any schedule, may be used by any health maintenance organization until a copy of that schedule, rate, or rating formula, or amendment to it, has been filed with and approved by the director under the provisions of § 42-62-13.
History of Section.
P.L. 1983, ch. 225, § 2.