Rhode Island Health Insurance Enforcement and Consumer Protections Grant Award

Cycle I Grant Application Summary

Rhode Island Grantee: Rhode Island Department of Business Regulation

Award Date: October 31, 2016

Total Award: $1,090,263.35

Baseline Award: $476,998

Selected Market Reforms Amount: $540,000

Workload Award Amount: $73,265.35

• Section 2707- The Rhode Island Department of Business Regulation will review plan designs for potential discriminatory practices in not covering services for a particular group of conditions/diseases or for sub-groups of individuals. Rhode Island will request and review health insurance issuer claims data on selected chronic diseases and health conditions as well as on high-cost medical conditions. In addition, if applicable, The Department of Business Regulation will work to incorporate data from the All Payer Claims Database into this review. Finally, Rhode Island will conduct a review of existing tools used to identify discriminatory formulary design, including examining existing CMS tools, to enhance its review process.

• Section 2713 - Current reviews have uncovered potential conflict as to what and how an issuer assures no cost-share coverage for preventive services listed in the United States Preventive Service Task Force (USPSTF) recommendations. In addition to the USPSTF recommendations, the Rhode Island Department of Business Regulation will address potential conflicts regarding the effects of deductibles on preventive services. Rhode Island will determine the status of current health insurance issuer coverage as well as best practices around preventive medicine in order to better define what the USPTF considers to be preventive.

• Section 2719 - The Rhode Island Department of Business Regulation will work to align its internal and external appeals processes with the Affordable Care Act (ACA) and National Association of Insurance Commissioners (NAIC) standards and will require the most protective standard where there are differences.

• Section 2726 - Rhode Island will enhance and continue its review of parity in Behavioral Health disorder benefits. The Rhode Island Department of Business Regulation will focus on determining qualitative and quantitative disparities in the Behavioral Health arena, in addition to verifying and validating health insurance issuer parity analyses.