Rhode Island law requires extensive disclosures to consumers on access, coverage and other issues
Rhode Island Consumer Laws
September 30, 1997
Rhode Island is about to implement some of the most aggressive and extensive requirements on disclosing information to consumers about how their health plans work. A new law requires that carriers make disclosures about policies and procedures in a standardized and consumer-friendly format that is intended to encourage comparison.
Under the state’s Health Care Accessibility and Quality Assurance Act of 1996, plans will be required to disclose their policies on referrals, prior authorizations, coverage of experimental treatments and emergency care access as well as financial and other information (see list).
"Our biggest issue was that it (printed information) wouldn’t be so big it would be of no use to anybody," said Brian Jordan, a lobbyist and spokesman for Blue Cross & Blue Shield of Rhode Island, who adds that the costs of printing and mailing is a major concern for the insurer.
After lengthy discussions with consumer groups and insurers, state officials have developed a strategy for how best to make this extensive and technical information comprehensible to consumers.
Consumers get guide
All consumers in the state will receive a consumer guide, which includes information common to all plans and which can be mass-produced. The guide, to be distributed in October, contains a glossary of terms such as "formulary" and "pre-existing condition" and summarizes the state’s utilization review law which allows for external appeals of decisions. Plans may share the cost of printing the guide based on their enrollment, said one state official.
Disclosures specific to the plans, such as their policies on reimbursing and accessing emergency care, will be presented in a standardized question-and-answer format that are to be distributed later.
For example, a question on accessing emergency care reads: "What if I have an emergency? An emergency is a problem that needs to be seen by a provider "right-away" to prevent permanent damage or death. Here’s what this Health Plan wants you to do when you have an emergency health care problem, at home or out of state." A box below the question provides space for the plan to respond. About eight pages long, the standardized disclosure form also will include a standardized table called "covered services at-a-glance" that will allow consumers to make quick comparisons on coverage.
The plans’ disclosures first will have to be filed with the state as part of a new certification process. Plans need to apply for certification by Jan. 1. If the "disclosure doesn’t square with policy, the public has recourse," said Linda Johnson, chief of the Office of Managed Care at the Department of Health. A discrepancy between the public filing and actual policies would generate an inquiry, she said. Under the new certification process, plans also will have to meet requirements for quality assurance and access.
Robert Marshall, assistant director for community affairs, Office of the Director, at the Department of Health, said the state has decided to delay some of the disclosures under the law such as the requirement that consumers receive information about medical loss ratios and revenues and expenses for each plan; that they receive information about plan spending on physician, hospital, pharmacy and mental health and substance abuse; and that they also receive statistics on complaint, adverse decisions and prior authorization.
"We thought it would be a better implementation of the law to break it up into components," he said.
"What we have decided to do is to collect the information for a year and analyze it to determine what’s the best way to disclose the information to consumers," Dr. Marshall said. He said officials want to ensure the quality of the data before releasing it to the public.
A continuing challenge was finding the "balance between being useful and helpful but not providing too much information," said Mr. Jordan. Another issue, he said , is that plans are being asked to provide information they consider proprietary such as quarterly enrollment information on the age and sex of subscribers.
"I in no way mean this to sound patronizing to our subscribers, but if you walked into a Burger King in Cranston, RI, I doubt anyone would be interested in this information," he said.
Contact Ms. Johnson at 401-277-6015, Dr. Marshall at 401-277-2231
New disclosure requirements for Rhode Island health plans
Plans are required to disclose:
• right to seek second opinion and reimbursement policy;
• appeals process for utilization review (with address and phone number of health plan and state agency for complaints);
• criteria used to authorize treatment;
• referral policies and limitations on reimbursement;
• prior authorization procedures as well as other review
requirements, including concurrent review,retrospective review;
• policies for accessing emergency treatment and reimbursement policies;
• schedule of revenues and expenses; direct service ratios;
• plan spending on health services, including physician, hospital, pharmacy, substance abuse and mental health;
• financial arrangements for capitated or other risk-sharing arrangements;
• plan complaint, adverse decision and prior authorization
statistics, annually. Ratios of :
—complaints to covered persons;
—adverse decisions to complaints;
—prior authorizations denied to requests;
—ratio of successful appeals to total appeals.
Rhode Island law requires extensive disclosures to consumers on access, coverage and other issues
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