PROVIDENCE – The Office of Health Insurance Commissioner has finalized its regulation of health insurance network plans following its assumption of jurisdiction over them from the Department of Health in January.
Public comment on the regulation, posted to the R.I. Department of Business Regulation, closed Oct. 5. OHIC has been supervising the plans since the state Health Care Accessibility and Quality Assurance Act switched jurisdiction for health insurance network plans to the agency in 2017, effective Jan. 1, 2018, according to Cory King, principal policy planner for OHIC.
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The new regulation stipulates the following requirements, among others:
- Before making a formulary change to a network plan involving medications, medication tiering or cost sharing, health care companies must provide 30 calendar days’ notice to prescribers of the affected medications and adversely affected beneficiaries must be given 30 calendar days’ notice before the effective date of change.
- Maintain an on-going monitoring process to assure a provider network for each network plan provides sufficient scope and access in a timely manner without reasonable delay.
- Beneficiaries must have access to emergency services 24 hours a day, seven days a week.
- Establish a process to appeal a denial of access to out-of-network providers and additional cost charges imposed beyond in-network coverage.
- Quarterly monitoring of the network plan’s network adequacy.
- Ensure a beneficiary is held harmless from financial liability beyond in-network cost shares attributable to the failure of a referring network provider to adhere to the referral process by failing to submit referral documents (not including self-referrals).
Rob Borkowski is a PBN staff writer. He can be reached at Borkowski@PBN.com.
