230 R.I. Code R. 230-RICR-20-30-4.8

Current through October 15, 2024

Section 230-RICR-20-30-4.8 - Improving the Efficiency and Quality of Health Care Delivery and Increasing Access to Health Care Services

A. Consumers, providers, health insurers and the public generally have an interest in:

1. Improving the quality and efficiency of health care service delivery and outcomes in Rhode Island;

2. Viewing the health care system as a comprehensive entity; and

3. Encouraging and directing insurers towards policies that advance the welfare of the public through overall efficiency, improved health care quality, and appropriate access.

B. The government, consumers, employers, providers and health insurers all have a role to play in increasing access to health care services and improving the quality and efficiency of health care service delivery and outcomes in Rhode Island. Nevertheless, the state's health insurers, because of their prominent role in the financing of health care services, bear a greater burden with respect to improving the quality and efficiency of health care service delivery and outcomes in Rhode Island, treating the health care system as a comprehensive entity, and advancing the welfare of the public through overall efficiency, improved health care quality, and appropriate access. Furthermore, a balance must be struck between competition among the health insurers, which can result in benefits such as innovation, and collaboration, which can promote consumer and provider benefits such as standardization and simplification.

C. Whenever the Commissioner determines that any of the circumstances listed in §§ 4.8(C)(1) or (2) of this Part exist, the Commissioner shall, in addition to exercising any duty or power authorized or required by R.I. Gen. Laws Titles 27 or 42 related specifically to improving the efficiency and quality of health care delivery and increasing access to healthcare services, act to further the interests set out in § 4.8(C)(1)(a) of this Part when exercising any other power or duty of the Office, including, but not limited to, approving or denying any request or application; approving, denying or modifying any requested rate; approving or rejecting any forms, trend factors, or other filings; issuing any order, decision or ruling; initiating any proceeding, hearing, examination, or inquiry; or taking any other action authorized or required by statute or regulation.

1. The decision to approve or deny any regulatory request, application or filing made by a health insurer

a. Can be made in a manner that will

(1) Improve the quality and efficiency of health care service delivery and outcomes in Rhode Island;

(2) View the health care system as a comprehensive entity; or

(3) Encourage and direct insurers towards policies that advance the welfare of the public through overall efficiency, improved health care quality, and appropriate access; or

b. Should include conditions when feasible that will

(1) Promote increased quality and efficiency of health care service delivery and outcomes in Rhode Island;

(2) Incent health insurers to view the health care system as a comprehensive entity; or

(3) Encourage and direct insurers towards policies that advance the welfare of the public through overall efficiency, improved health care quality, and appropriate access; or

2. Any other circumstances exist such that regulatory action by the Commissioner with respect to a health insurer will likely improve the efficiency and quality of health care delivery and increase access to health care services.

D. When making a determination as described in § 4.8(C) of this Part or when acting to further the interests set out in § 4.8(A) of this Part, the Commissioner may consider and/or act upon the following, either singly or in combination of two or more:

1. Efforts by health insurers to develop benefit design and payment policies that:

a. Enhance the affordability of their products, as described in § 4.9 of this Part;

b. Encourage more efficient use of the state's existing health care resources;

c. Promote appropriate and cost effective acquisition of new health care technology and expansion of the existing health care infrastructure;

d. Advance the development and use of high quality health care services (e.g., centers of excellence); and

e. Prioritize the use of limited resources

2. Efforts by health insurers to promote the dissemination of information, increase consumer access to health care information, and encourage public policy dialog about increasing health care costs and solutions by:

a. Providing consumers' timely and user-friendly access to health care information related to the quality and cost of providers and health care services so that consumers can make well informed-decisions;

b. Encouraging public understanding, participation and dialog with respect to the rising costs of health care services, technologies, and pharmaceuticals; the role played by health insurance as both a financing mechanism for health care and as a hedge against financial risk for the consumers of health care; and potential solutions to the problems inherent in the health insurance market (e.g., market concentration, increasing costs, the growing population of uninsureds, market-driven changes to insurance products (such as the growth of high deductible plans) and segmentation of the insurance market due to state and federal laws); and

c. Providing consumers timely and user friendly access to administrative information, including information related to benefits; eligibility; claim processing and payment; financial responsibility, including deductible, coinsurance and copayment information; and complaint and appeal procedures.

3. Efforts by health insurers to promote collaboration among the state's health insurers to promote standardization of administrative practices and policy priorities, including

a. Participation in administrative standardization activities to increase efficiency and simplify practices; and

b. Efforts to develop standardized measurement and provider payment processes to promote the goals set out in this regulation.

4. Directing resources, including financial contributions, toward system-wide improvements in the state's health care system related to quality, access and efficiency, including providing support to local collaboratives, organizations and initiatives that promote quality, access and efficiency.

5. Participating in the development and implementation of public policy issues related to health, including

a. Collaborating with state and local health planning officials;

b. Participating in the legislative and regulatory processes; and

c. Engaging the public in policy debates and discussions.

E. The factors enumerated in § 4.8(D) of this Part shall not be construed as limiting the Commissioner from making a finding that other factors may be considered when acting to further the interests set out in § 4.8(A) of this Part.

230 R.I. Code R. 230-RICR-20-30-4.8

Amended effective 12/4/2018
Amended effective 6/25/2020
Amended effective 8/20/2023