Rhode Island Code of Regulations
Title 230 - Department of Business Regulation
Chapter 20 - Insurance
Subchapter 30 - Health Insurance
Part 4 - Powers and Duties of the Office of the Health Insurance Commissioner
Section 230-RICR-20-30-4.3 - Definitions
Universal Citation: 230 RI Code of Rules 20 30 4.3
Current through September 18, 2024
A. As used in this regulation:
1. "Affiliate" means the same as set out in
the first sentence of R.I. Gen. Laws §
27-35-1(a). An
"affiliate" of, or an entity or person "affiliated" with, a specific entity or
person, is an entity or person who directly or indirectly through one or more
intermediaries controls, or is controlled by, or is under common control with,
the entity or person specified.
2.
"Aligned measure set" means any set of quality measures adopted by the
Commissioner pursuant to §
4.10(D)(5) of this Part. An Aligned Measure Set
shall consist of measures designated as 'Core Measures' and/or 'Menu Measures.'
Aligned Measure Sets are developed for specific provider contract types (e.g.,
primary care provider contracts, hospital contracts, Accountable Care
Organization (ACO, or Integrated System of Care) contracts.
3. "Commissioner" means the Health Insurance
Commissioner.
4. "Core measures"
means quality measures in an Aligned Measure Set that have been designated for
mandatory inclusion in applicable health care provider contracts that
incorporate quality measures into the payment terms (e.g., primary care
measures for primary care provider contracts).
5. "Demographic data" means self-reported
data on race, ethnicity, preferred language, sex assigned at birth, gender
identity, sexual orientation, and disability.
6. "Direct primary care expenses" means
payments by the Health Insurer directly to a primary care practice for:
a. Providing health care services, including
fee-for service payments, capitation payments, and payments under other
alternative, non-fee-for-service methodologies designed to provide incentives
for the efficient use of health services;
b. Achieving quality or cost performance
goals, including pay-for-performance payments and shared savings
distributions;
c. Infrastructure
development payments within the primary care practice, which the practice
cannot reasonably fund independently, in accordance with parameters and
criteria issued by order of the Commissioner, or upon request by a Health
Insurer and approval by the Commissioner:
(1)
That are designed to transform the practice into, and maintain the practice as
a Patient Centered Medical Home, and to prepare a practice to function within
an Integrated System of Care. Examples of acceptable spending under this
category include:
(AA) Making supplemental
payments to fund a practice-based and practice-paid care manager;
(BB) Funding the provision of care management
resources embedded in, but not paid for by, the primary care
practice;
(CC) Funding the purchase
by the practice of analytic software that enables primary care practices to
analyze patient quality and/or costs, such as software that tracks patient
costs in near-to-real time;
(DD)
Training of members of the primary care team in motivational interviewing or
other patient activation techniques; and
(EE) Funding the cost of the practice to link
to the health information exchange established by R.I. Gen. Laws Chapter
5-37.7;
(2) That promote
the appropriate integration of primary care and behavioral health care; for
example, funding behavioral health services not traditionally covered with a
discrete payment when provided in a primary care setting, such as substance
abuse or depression screening;
(3)
For shared services among small and independent primary care practices to
enable the practices to function as Patient-Centered Medical Homes. Acceptable
spending under this category:
(AA) must
directly enhance a Primary Care Practice's ability to support its patient
population, and
(BB) must provide,
reinforce or promote specific skills that Patient-Centered Medical Homes must
have to effectively operate using Patient-Centered Medical Home principles and
standards, or to participate in an Integrated System of Care that successfully
manages risk-bearing contracts. Examples of acceptable spending under this
category include:
(i) Funding the cost of a
clinical care manager who rotates through the practices;
(ii) Funding the cost of a practice data
analyst to provide data support and reports to the participating practices,
and
(iii) Funding the costs of a
pharmacist to help practices with medication reconciliation for poly-pharmacy
patients;
(4)
That promote community-based services to enable practices to function as
Patient Centered Medical Homes. Acceptable spending under this category:
(AA) must directly enhance a Primary Care
Practice's ability to support its patient population, and
(BB) must provide, reinforce or promote
specific skills that the Patient-Centered Medical Homes must have to
effectively operate using Patient-Centered Medical Home principles and
standards, or to participate in an Integrated System of Care that successfully
manages risk-bearing contracts. Acceptable spending under this category
includes funding multi-disciplinary care management teams to support Primary
Care Practice sites within a geographic region;
(5) Designed to increase the number of
primary care physicians practicing in RI, and approved by the Commissioner,
such as a medical school loan forgiveness program; and
(6) Any other direct primary care expense
that meets the parameters and criteria established in a bulletin issued by the
Commissioner, or that is requested by a Health Insurer and approved by the
Commissioner.
7. "Examination" means the same as set out in
R.I. Gen. Laws §
27-13.1-1
et
seq.
8. "Health insurance"
means "health insurance coverage," as defined in R.I. Gen. Laws §§
27-18.5-2 and
27-18.6-2, "health benefit plan,"
as defined in R.I. Gen. Laws §
27-50-3 and a "medical supplement
policy," as defined in R.I. Gen. Laws §
27-18.2-1 or coverage similar to a
Medicare supplement policy that is issued to an employer to cover
retirees.
9. "Global capitation
contract" means a Population-Based Contract with an Integrated System of Care
that:
a. holds the Integrated System of Care
responsible for providing or arranging for all, or substantially all of the
covered services provided to the Health Insurer's defined group of members in
return for a monthly payment that is inclusive of the total, or near total
costs of such covered services based on a negotiated percentage of the Health
Insurer's premium or based on a negotiated fixed per member per month payment,
and
b. incorporates incentives
and/or penalties for performance relative to quality targets.
10. "Health insurer" means any
entity subject to the insurance laws and regulations of this state, or subject
to the jurisdiction of the Commissioner, that contracts or offers to contract
to provide, deliver, arrange for, pay for, or reimburse any of the costs of
health care services, including, without limitation, an insurance company
offering accident and sickness insurance, a health maintenance organization, a
non-profit hospital service corporation, a non-profit medical service
corporation, a non-profit dental service corporation, a non-profit optometric
service corporation, a domestic insurance company subject R.I. Gen. Laws
Chapter 27-1 that offers or provides health insurance coverage in the state and
a foreign insurance company subject to R.I. Gen. Laws Chapter 27-2 that offers
or provides health insurance coverage in the state.
11. "Holding company system" means the same
as set out in R.I. Gen. Laws §
27-35-1
et
seq.
12. "Indirect primary
care expenses" means payments by the Health Insurer to support and strengthen
the capacity of a primary care practice to function as a medical home, and to
successfully manage risk-bearing contracts, but which do not qualify as Direct
Primary Care Expenses. Indirect Primary Care Expenses may include a proper
allocation, proportionate to the benefit accruing to the Primary Care Practice,
of Health Insurer investments in data, analytics, and population-health and
disease registries for Primary Care Practices without the foreseeable ability
to make and manage such infrastructure investments, but which do not qualify as
acceptable Direct Primary Care Spending, in accordance with parameters and
criteria issued in a bulletin issued by the Commissioner, or upon request by a
Health Insurer and approved by the Commissioner. Such payments shall include
financial support, in an amount approved by the Commissioner, for the
administrative expenses of the medical home initiative endorsed by R.I. Gen.
Laws Chapter 42-14.6, and for the health information exchange established by
R.I. Gen. Laws Chapter 5-37.7.
13.
"Integrated system of care", sometimes referred to as an Accountable Care
Organization, means one or more business entities consisting of physicians,
other clinicians, hospitals and/or other providers that together provide care
and share accountability for the cost and quality of care for a population of
patients, and that enters into a Population-Based Contract, such as a Shared
Savings Contract or Risk Sharing Contract or Global Capitation Contract, with
one or more Health Insurers to care for a defined group of patients.
14. "Low-value care" most often refers to
medical services, including tests and procedures, that should not be performed
given their potential for harm or the existence of comparably effective and
often less expensive alternatives.
15. "Menu measures" means quality measures
within an Aligned Measure Set that are included in applicable health care
provider contracts that incorporate quality measures into the payment terms
when such inclusion occurs at the mutual agreement of the Health Insurer and
contracted health care provider.
16. "Minimum loss rate" means a defined
percentage of the total cost of care, or annual provider revenue from the
insurer under a population-based contract, which must be met or exceeded before
actual losses are incurred by the provider. Losses may accrue on a "first
dollar" basis once the "minimum loss rate" is breached.
17. "Patient-centered medical home" means:
a. A Primary Care Practice recognized by the
collaborative initiative endorsed by R.I. Gen. Laws Chapter 42-14.6,
or
b. A Primary Care Practice
recognized by a national accreditation body, or
c. A Primary Care Practice designated by
contract between a Health Insurer and a primary care practice, or between a
Health Insurer and an Integrated System of Care in which the Primary Care
Practice is participating. A contractually designated Primary Care Practice
must meet pre-determined quality and efficiency criteria and practice
performance standards, which are approved by the Commissioner, for improved
care management and coordination that are at least as rigorous as those of the
collaborative initiative endorsed by R.I. Gen. Laws Chapter 42-14.6. For the
purposes of this definition a primary care practice that participates in a
primary care alternative payment model and participates in an integrated system
of care will be deemed to have met the requirements of a patient-centered
medical home, and
d. A Primary Care
Practice which has demonstrated development and implementation of meaningful
cost management strategies and clinical quality performance attainment and/or
improvement. The requirements for meaningful cost management strategies and for
clinical quality performance attainment and/or improvement, and the measures
for assessing performance, shall be determined annually by the
Commissioner.
18.
"Population-based contract" means a provider reimbursement contract with an
Integrated System of Care that uses a reimbursement methodology that is
inclusive of the total, or near total medical costs of an identified,
covered-lives population. A Population-Based Contract may be a Shared Savings
Contract, or a Risk Sharing Contract, or a Global Capitation Contract. A
primary care or specialty service capitation reimbursement contract shall not
be considered a Population-Based Contract for purposes of this Part. A
Population-Based Contract may not transfer insurance risk or any health
insurance regulatory obligations. A Health Insurer may request clarification
from the Commissioner as to whether its proposed contract constitutes the
transfer of insurance risk.
19.
"Primary care alternative payment model" means a payment model that relies on
prospective payment to a primary care practice or a primary care provider for a
defined set of primary care services (including office evaluation and
management services) in addition to any amounts paid to support care management
and infrastructure of the primary care practice. It may also include a model
that includes additional services in the alternative payment methodology, such
as integrated behavioral health.
20. "Primary care practice" means the
practice of a physician, medical practice, or other medical provider considered
by the insured subscriber or dependent to be his or her usual source of care.
Designation of a primary care provider shall be limited to providers within the
following practice type: Family Practice, Geriatrics, Internal Medicine and
Pediatrics; and providers with the following professional credentials: Doctors
of Medicine and Osteopathy, Nurse Practitioners, and Physicians' Assistants;
except that specialty medical providers, including behavioral health providers,
may be designated as a primary care provider if the specialist is paid for
primary care services on a primary care provider fee schedule, and
contractually agrees to accept the responsibilities of a primary care
provider.
21. "Qualifying
Integrated Behavioral Health Primary Care Practice" means:
a. A patient-centered medical home practice
that is recognized by a national accreditation body (such as NCQA) as an
integrated behavioral health practice, or
b. A patient-centered medical home practice
that participated in and successfully completed, or is currently participating
in, an integrated behavioral health program under the oversight of the
collaborative initiative endorsed by R.I. Gen. Laws Chapter 42-14.6. Such
practices must be recognized as an integrated behavioral health practice by a
national accreditation body (such as NCQA) or meet integrated behavioral health
standards developed by the Care Transformation Collaborative of Rhode Island,
or
c. A patient centered-medical
home practice that completes a qualifying behavioral health integration
self-assessment tool approved by the Commissioner and develops an action plan
for improving its level of integration. Such practices must be recognized as an
integrated behavioral health practice by a national accreditation body (such as
NCQA) or meet integrated behavioral health standards developed by the Care
Transformation Collaborative of Rhode Island.
22. "Risk exposure cap" means a cap on the
losses which may be incurred by the provider under the contract, expressed as a
percentage of the total cost of care or the annual provider revenue from the
insurer under the population-based contract.
23. "Risk sharing contract" means a
Population-Based Contract that:
a. Holds the
provider financially responsible for a negotiated portion of costs that exceed
a predetermined population-based budget, in exchange for provider eligibility
for a portion of any savings generated below the predetermined budget,
and
b. Incorporates incentives
and/or penalties for performance relative to quality targets.
24. "Risk sharing rate" means the
percentage of total losses shared by the provider with the insurer under the
contract after the application of any minimum loss rate.
25. "Shared savings contract" means a
Population-Based Contract that:
a. Allows the
provider to share in a portion of any savings generated below a predetermined
population-based budget, and
b.
Incorporates incentives and/or penalties for performance relative to quality
targets.
Disclaimer: These regulations may not be the most recent version. Rhode Island may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
