SECTION 1. Chapter 23-4.1 of the General Laws entitled "Emergency Medical Transportation Services" is hereby amended by adding thereto the following section: 23-4.1-3.1. Mobile integrated healthcare community paramedicine program.
(a) The department of health, in collaboration of the ambulance service coordinating advisory board, shall administer a mobile integrated healthcare community paramedicine program (the” program”), as defined in § 27-18-1.1, § 27-19-1, § 27-20-1, and § 27-41-2, and shall promulgate any rules, regulations, standing orders, protocols, and procedures necessary and proper for the efficient administration and enforcement of this section. The requirements of this section shall only apply to emergency medical services agencies as defined in chapters 18, 19, 20, and 41 of title 27, who apply for and receive approval from the department of health to provide such services. The scope of the program shall address and incorporate ambulance services which are in- network (“INN”) ground ambulance services, out-of-network (“OON”) ground ambulance services, INN and OON community-based healthcare services, and INN and OON mobile integrated health community paramedicine programs approved by the department of health.
(b) Provided, an OON ground ambulance service participating in the program shall be subject to all state and federal prohibitions on surprise medical billing for their services.
SECTION 2. Sections 27-18-1.1 and 27-18-69 of the General Laws in Chapter 27-18 entitled "Accident and Sickness Insurance Policies" are hereby amended to read as follows: 27-18-1.1. Definitions. As used in this chapter:
(1) “Adverse benefit determination” means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of an individual’s eligibility to participate in a plan or to receive coverage under a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate. The term also includes a rescission of coverage determination.
(2) “Affordable Care Act” means the federal Patient Protection and Affordable Care Act of 2010, as amended by the federal Health Care and Education Reconciliation Act of 2010, and federal regulations adopted thereunder.
(3) "Ambulance" means any publicly or privately owned vehicle, designed, constructed, equipped, and operated for emergency medical treatment and/or transportation of persons who are sick or injured. (3)(4) “Commissioner” or “health insurance commissioner” means that individual appointed pursuant to § 42-14.5-1.
(5) "Emergency medical services" or "EMS agencies" means the practitioners, ambulance vehicles, and ambulance service entities licensed in accordance with chapter 4.1 of title 23 to provide emergency medical care, transportation, and prevention care to mitigate loss of life or exacerbation of illness or injury including, but not limited to, EMS responding to the 911 system established pursuant to the provisions of § 39-21.1-2.
(6) "Emergency medical services practitioner" means an individual who is licensed in accordance with state laws and regulations to perform emergency medical care and preventive care to mitigate loss of life or exacerbation of illness or injury, including emergency medical technicians, advanced emergency medical technicians, advanced emergency medical technicians cardiac, and paramedics. (4)(7) “Essential health benefits” shall have the meaning set forth in section 1302(b) of the federal Affordable Care Act [42 U.S.C. § 18022]. (5)(8) “Grandfathered health plan” means any group health plan or health insurance coverage subject to 42 U.S.C. § 18011.
(9) "Ground ambulance services" means those services provided by an ambulance service licensed to operate in Rhode Island in accordance with § 23-4.1-6. The term excludes air and water ambulance services and ambulance services provided outside of Rhode Island. (6)(10) “Group health insurance coverage” means, in connection with a group health plan, health insurance coverage offered in connection with such plan. (7)(11) “Group health plan” means an employee welfare benefit plan, as defined in 29 U.S.C. § 1002(1), to the extent that the plan provides health benefits to employees or their dependents directly or through insurance, reimbursement, or otherwise. (8)(12) “Health benefits” or “covered benefits” means coverage or benefits for the diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body including coverage or benefits for transportation primarily for and essential thereto, and including medical services as defined in § 27-19-17. (9)(13) “Healthcare facility” means an institution providing healthcare services or a healthcare setting, including, but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory, and imaging centers, and rehabilitation and other therapeutic health settings. (10)(14) “Healthcare professional” means a physician or other healthcare practitioner licensed, accredited, or certified to perform specified healthcare services consistent with state law. (11)(15) “Healthcare provider” or “provider” means a healthcare professional or a healthcare facility. (12)(16) “Healthcare services” means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. (13)(17) “Health insurance carrier” means a person, firm, corporation, or other entity subject to the jurisdiction of the commissioner under this chapter. Such term does not include a group health plan. (14)(18) “Health plan” or “health benefit plan” means health insurance coverage and a group health plan, including coverage provided through an association plan if it covers Rhode Island residents. Except to the extent specifically provided by the federal Affordable Care Act, the term “health plan” shall not include a group health plan to the extent state regulation of the health plan is preempted under section 514 [29 U.S.C. § 1144] of the federal Employee Retirement Income Security Act of 1974. The term also shall not include: (A)(i) Coverage only for accident, or disability income insurance, or any combination thereof.
(ii) Coverage issued as a supplement to liability insurance.
(iii) Liability insurance, including general liability insurance and automobile liability insurance.
(iv) Workers’ compensation or similar insurance.
(v) Automobile medical payment insurance.
(vi) Credit-only insurance.
(vii) Coverage for on-site medical clinics.
(viii) Other similar insurance coverage, specified in federal regulations issued pursuant to Pub. L. No. 104-191, the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), under which benefits for medical care are secondary or incidental to other insurance benefits.
(B) The following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of the plan:
(i) Limited scope dental or vision benefits.
(ii) Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof.
(iii) Other excepted benefits specified in federal regulations issued pursuant to federal Pub. L. No. 104-191 (“HIPAA”).
(C) The following benefits if the benefits are provided under a separate policy, certificate, or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and the benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor:
(i) Coverage only for a specified disease or illness.
(ii) Hospital indemnity or other fixed indemnity insurance.
(D) The following if offered as a separate policy, certificate, or contract of insurance:
(i) Medicare supplement health insurance as defined under section 1882(g)(1) [42 U.S.C. § 1395ss] of the federal Social Security Act.
(ii) Coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)).
(iii) Similar supplemental coverage provided to coverage under a group health plan.
(19) "Mobile integrated healthcare community paramedicine program" means the provision of healthcare using patient-centered, mobile resources in the out-of-hospital environment pursuant to an EMS agency's plan approved by the department of health utilizing licensed emergency medical service practitioners working in collaboration with physicians, nurses, mid- level practitioners, community health teams and social, behavioral and substance use disorder specialists to address the unmet needs of individuals experiencing intermittent health care issues; provided that, only those emergency medical services (EMS) agencies who submit plans that meet the minimum requirements for participation set and approved by the department of health shall be eligible to participate in a mobile integrated healthcare/community paramedicine program. (15)(20) “Office of the health insurance commissioner” means the agency established under § 42-14.5-1. (16)(21) “Rescission” means a cancellation or discontinuance of coverage that has retroactive effect for reasons unrelated to timely payment of required premiums or contribution to costs of coverage. 27-18-69. Licensed ambulance service.
(a) No individual or group health insurance contract, plan, or policy delivered, issued for delivery, or renewed in this state on or after January 1, 2009, shall provide for a copayment for ground ambulance services in excess of fifty dollars ($50.00).
(b) As used in this section, the term “ground ambulance services” shall mean those services provided by an ambulance service licensed to operate in Rhode Island in accordance with § 23-4.1- 6. The term excludes air and water ambulance services and ambulance services provided outside of Rhode Island.
(c) This section Subsections (a) and (d) of this section shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by accident or both; and (9) Other limited benefit policies.
(d) Individual and group health insurance contracts, plans, and policies issued for delivery, or renewed in this state on or after January 1, 2027, shall provide coverage and reimbursement for ground ambulance services, as defined in § 27-18-1.1, equal to coverage and reimbursement rates provided by Medicare for the same medical services, and shall reimburse the emergency medical services provider staffed by emergency medical services practitioners, as defined in § 27-18-1.1, at the level of care provided, regardless of whether the patient is transported, such coverage and reimbursement shall be inclusive of the community-based healthcare services, to include mobile integrated health community paramedicine programs approved by the department of health; provided that, mobile integrated health community paramedicine programs services shall be performed by emergency medical services staffed by emergency medical practitioners. If the ground ambulance service provider participates in the carrier's network, the carrier shall cover and reimburse the ambulance service provider at the ambulance service provider's rate for the level of care provided, regardless of whether the patient is transported. This coverage and reimbursement shall also extend to ambulance services which are in-network (“INN”) ground ambulance services, out-of-network (“OON”) ground ambulance services, INN and OON community-based healthcare services, and INN and OON mobile integrated health community paramedicine programs approved by the department of health.
SECTION 3. Sections 27-19-1 and 27-19-60 of the General Laws in Chapter 27-19 entitled "Nonprofit Hospital Service Corporations" are hereby amended to read as follows: 27-19-1. Definitions. As used in this chapter:
(1) “Adverse benefit determination” means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of an individual’s eligibility to participate in a plan or to receive coverage under a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate. The term also includes a rescission of coverage determination.
(2) “Affordable Care Act” means the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119, as amended by the federal Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029, and federal regulations adopted thereunder.
(3) "Ambulance" means any publicly or privately owned vehicle, designed, constructed, equipped, and operated for emergency medical treatment and/or transportation of persons who are sick or injured. (3)(4) “Commissioner” or “health insurance commissioner” means that individual appointed pursuant to § 42-14.5-1. (4)(5) “Contracting hospital” means an eligible hospital that has contracted with a nonprofit hospital service corporation to render hospital care to subscribers to the nonprofit hospital service plan operated by the corporation. (5)(6) “Eligible hospital” is one that is maintained either by the state or by any of its political subdivisions or by a corporation organized for hospital purposes under the laws of this state or of any other state or of the United States, that is designated as an eligible hospital by a majority of the directors of the nonprofit hospital service corporation.
(7) "Emergency medical services" or "EMS agencies" means the practitioners, ambulance vehicles, and ambulance service entities licensed in accordance with chapter 4.1 of title 23 to provide emergency medical care, transportation, and prevention care to mitigate loss of life or exacerbation of illness or injury including, but not limited to, EMS responding to the 911 system established pursuant to the provisions of § 39-21.1-2.
(8) "Emergency medical services practitioner" means an individual who is licensed in accordance with state laws and regulations to perform emergency medical care and preventive care to mitigate loss of life or exacerbation of illness or injury, including emergency medical technicians, advanced emergency medical technicians, advanced emergency medical technicians cardiac, and paramedics. (6)(9) “Essential health benefits” shall have the meaning set forth in section 1302(b) of the federal Patient Protection and Affordable Care Act [42 U.S.C. § 18022(b)]. (7)(10) “Grandfathered health plan” means any group health plan or health insurance coverage subject to 42 U.S.C. § 18011.
(11) "Ground ambulances services" means those services provided by an ambulance service licensed to operate in Rhode Island in accordance with § 23-4.1-6. The term excludes air and water ambulance services and ambulance services provided outside of Rhode Island. (8)(12) “Group health insurance coverage” means, in connection with a group health plan, health insurance coverage offered in connection with the plan. (9)(13) “Group health plan” means an employee welfare benefit plan, as defined in 29 U.S.C. § 1002(1), to the extent that the plan provides health benefits to employees or their dependents directly or through insurance, reimbursement, or otherwise. (10)(14) “Health benefits” or “covered benefits” means coverage or benefits for the diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body including coverage or benefits for transportation primarily for and essential thereto, and including medical services as defined in § 27-19-17. (11)(15) “Healthcare facility” means an institution providing healthcare services or a healthcare setting, including but not limited to: hospitals and other licensed inpatient centers; ambulatory surgical or treatment centers; skilled nursing centers; residential treatment centers; diagnostic, laboratory, and imaging centers; and rehabilitation and other therapeutic health settings. (12)(16) “Healthcare professional” means a physician or other healthcare practitioner licensed, accredited, or certified to perform specified healthcare services consistent with state law. (13)(17) “Healthcare provider” or “provider” means a healthcare professional or a healthcare facility. (14)(18) “Healthcare services” means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. (15)(19) “Health insurance carrier” means a person, firm, corporation, or other entity subject to the jurisdiction of the commissioner under this chapter, and includes nonprofit hospital service corporations. Such term does not include a group health plan. The use of this term shall not be construed to subject a nonprofit hospital service corporation to the insurance laws of this state other than as set forth in § 27-19-2. (16)(20) “Health plan” or “health benefit plan” means health insurance coverage and a group health plan, including coverage provided through an association plan if it covers Rhode Island residents. Except to the extent specifically provided by the federal Patient Protection and Affordable Care Act, the term “health plan” shall not include a group health plan to the extent state regulation of the health plan is preempted under section 514 of the federal Employee Retirement Income Security Act of 1974 [29 U.S.C. § 1144]. The term also shall not include: (A)(i) Coverage only for accident, or disability income insurance, or any combination thereof.
(ii) Coverage issued as a supplement to liability insurance.
(iii) Liability insurance, including general liability insurance and automobile liability insurance.
(iv) Workers’ compensation or similar insurance.
(v) Automobile medical payment insurance.
(vi) Credit-only insurance.
(vii) Coverage for on-site medical clinics.
(viii) Other similar insurance coverage, specified in federal regulations issued pursuant to the federal Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, 110 Stat. 1936 (“HIPAA”), under which benefits for medical care are secondary or incidental to other insurance benefits.
(B) The following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of the plan:
(i) Limited scope dental or vision benefits.
(ii) Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof.
(iii) Other excepted benefits specified in federal regulations issued pursuant to the federal Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, 110 Stat. 1936 (“HIPAA”).
(C) The following benefits if the benefits are provided under a separate policy, certificate, or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and the benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor:
(i) Coverage only for a specified disease or illness.
(ii) Hospital indemnity or other fixed indemnity insurance.
(D) The following if offered as a separate policy, certificate, or contract of insurance:
(i) Medicare supplement health insurance as defined under section 1882(g)(1) of the federal Social Security Act [42 U.S.C. § 1395ss].
(ii) Coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)).
(iii) Similar supplemental coverage provided to coverage under a group health plan.
(21) "Mobile integrated healthcare community paramedicine program" means the provision of healthcare using patient-centered, mobile resources in the out-of-hospital environment pursuant to an EMS agency's plan approved by the department of health utilizing licensed emergency medical service practitioners working in collaboration with physicians, nurses, mid- level practitioners, community health teams and social, behavioral and substance use disorder specialists to address the unmet needs of individuals experiencing intermittent health care issues; provided that, only those emergency medical services (EMS) agencies who submit plans that meet the minimum requirements for participation set and approved by the department of health shall be eligible to participate in a mobile integrated healthcare/community paramedicine program. (17)(22) “Nonprofit hospital service corporation” means any corporation organized pursuant to this chapter for the purpose of establishing, maintaining, and operating a nonprofit hospital service plan. (18)(23) “Nonprofit hospital service plan” means a plan by which specified hospital care is to be provided to subscribers to the plan by a contracting hospital. (19)(24) “Office of the health insurance commissioner” means the agency established under § 42-14.5-1. (20)(25) “Rescission” means a cancellation or discontinuance of coverage that has retroactive effect for reasons unrelated to timely payment of required premiums or contribution to costs of coverage. (21)(26) “Subscribers” mean those persons, whether or not residents of this state, who have contracted with a nonprofit hospital service corporation for hospital care pursuant to a nonprofit hospital service plan operated by the corporation. 27-19-60. Licensed ambulance service.
(a) No individual or group health insurance contract, plan, or policy delivered, issued for delivery, or renewed in this state on or after January 1, 2009, shall provide for a copayment for ground ambulance services in excess of fifty dollars ($50.00).
(b) As used in this section, the term “ground ambulance services” shall mean those services provided by an ambulance service licensed to operate in Rhode Island in accordance with § 23-4.1- 6. The term excludes air and water ambulance services and ambulance services provided outside of Rhode Island.
(c) This section Subsections (a) and (d) of this section shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by accident, or both; and (9) Other limited benefit policies.
(d) Individual and group health insurance contracts, plans, and policies issued for delivery, or renewed in this state on or after January 1, 2027, shall provide coverage and reimbursement for ground ambulance services, as defined in § 27-19-1, equal to coverage and reimbursement rates provided by Medicare for the same medical services, and shall reimburse the emergency medical services provider staffed by emergency medical services practitioners, as defined in § 27-19-1, at the level of care provided, regardless of whether the patient is transported, such coverage and reimbursement shall be inclusive of the community-based healthcare services, to include mobile integrated health community paramedicine programs approved by the department of health; provided that, mobile integrated health community paramedicine programs services shall be performed by emergency medical services staffed by emergency medical practitioners. If the ground ambulance service provider participates in the carrier's network, the carrier shall cover and reimburse the ambulance service provider at the ambulance service provider's rate for the level of care provided, regardless of whether the patient is transported. This coverage and reimbursement shall also extend to ambulance services which are in- network (“INN”) ground ambulance services, out-of-network (“OON”) ground ambulance services, INN and OON community-based healthcare services, and INN and OON mobile integrated health community paramedicine programs approved by the department of health.
SECTION 4. Sections 27-20-1 and 27-20-55 of the General Laws in Chapter 27-20 entitled "Nonprofit Medical Service Corporations" are hereby amended to read as follows: 27-20-1. Definitions. As used in this chapter:
(1) “Adverse benefit determination” means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of an individual’s eligibility to participate in a plan or to receive coverage under a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate. The term also includes a rescission of coverage determination.
(2) “Affordable Care Act” means the federal Patient Protection and Affordable Care Act, as amended by the federal Health Care and Education Reconciliation Act of 2010, and federal regulations adopted thereunder.
(3) "Ambulance" means any publicly or privately owned vehicle, designed, constructed, equipped, and operated for emergency medical treatment and/or transportation of persons who are sick or injured. (3)(4) “Certified registered nurse practitioners” is an expanded role utilizing independent knowledge of physical assessment and management of health care and illnesses. The practice includes collaboration with other licensed healthcare professionals including, but not limited to, physicians, pharmacists, podiatrists, dentists, and nurses. (4)(5) “Commissioner” or “health insurance commissioner” means that individual appointed pursuant to § 42-14.5-1. (5)(6) “Counselor in mental health” means a person who has been licensed pursuant to § 5-63.2-9.
(7) "Emergency medical services" or "EMS agencies" means the practitioners, ambulance vehicles, and ambulance service entities licensed in accordance with chapter 4.1 of title 23 to provide emergency medical care, transportation, and prevention care to mitigate loss of life or exacerbation of illness or injury including, but not limited to, EMS responding to the 911 system established pursuant to the provisions of § 39-21.1-2.
(8) "Emergency medical services practitioner" means an individual who is licensed in accordance with state laws and regulations to perform emergency medical care and preventive care to mitigate loss of life or exacerbation of illness or injury, including emergency medical technicians, advanced emergency medical technicians, advanced emergency medical technicians cardiac, and paramedics. (6)(9) “Essential health benefits” shall have the meaning set forth in section 1302(b) of the federal Affordable Care Act [42 U.S.C. § 18022(b)]. (7)(10) “Grandfathered health plan” means any group health plan or health insurance coverage subject to 42 U.S.C. § 18011.
(11) "Ground ambulances services" means those services provided by an ambulance service licensed to operate in Rhode Island in accordance with § 23-4.1-6. The term excludes air and water ambulance services and ambulance services provided outside of Rhode Island. (8)(12) “Group health insurance coverage” means, in connection with a group health plan, health insurance coverage offered in connection with such plan. (9)(13) “Group health plan” means an employee welfare benefit plan as defined in 29 U.S.C. § 1002(1) to the extent that the plan provides health benefits to employees or their dependents directly or through insurance, reimbursement, or otherwise. (10)(14) “Health benefits” or “covered benefits” means coverage or benefits for the diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body including coverage or benefits for transportation primarily for and essential thereto, and including medical services as defined in § 27-19-17. (11)(15) “Healthcare facility” means an institution providing healthcare services or a healthcare setting, including but not limited to: hospitals and other licensed inpatient centers; ambulatory surgical or treatment centers; skilled nursing centers; residential treatment centers; diagnostic, laboratory, and imaging centers; and rehabilitation and other therapeutic health settings. (12)(16)“Healthcare professional” means a physician or other healthcare practitioner licensed, accredited, or certified to perform specified healthcare services consistent with state law. (13)(17) “Healthcare provider” or “provider” means a healthcare professional or a healthcare facility. (14)(18) “Healthcare services” means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. (15)(19) “Health insurance carrier” means a person, firm, corporation, or other entity subject to the jurisdiction of the commissioner under this chapter, and includes a nonprofit medical service corporation. Such term does not include a group health plan. (16)(20) “Health plan” or “health benefit plan” means health insurance coverage and a group health plan, including coverage provided through an association plan if it covers Rhode Island residents. Except to the extent specifically provided by the federal Affordable Care Act, the term “health plan” shall not include a group health plan to the extent state regulation of the health plan is preempted under section 514 of the federal Employee Retirement Income Security Act of 1974 [29 U.S.C. § 1144]. The term also shall not include: (A)(i) Coverage only for accident, or disability income insurance, or any combination thereof;
(ii) Coverage issued as a supplement to liability insurance;
(iii) Liability insurance, including general liability insurance and automobile liability insurance;
(iv) Workers’ compensation or similar insurance;
(v) Automobile medical payment insurance;
(vi) Credit-only insurance;
(vii) Coverage for on-site medical clinics; and
(viii) Other similar insurance coverage, specified in federal regulations issued pursuant to federal Pub. L. No. 104-191, the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), under which benefits for medical care are secondary or incidental to other insurance benefits.
(B) The following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of the plan:
(i) Limited scope dental or vision benefits;
(ii) Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; and
(iii) Other excepted benefits specified in federal regulations issued pursuant to federal Pub. L. No. 104-191 (“HIPAA”).
(C) The following benefits if the benefits are provided under a separate policy, certificate, or contract of insurance; there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor; and the benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor:
(i) Coverage only for a specified disease or illness; and
(ii) Hospital indemnity or other fixed indemnity insurance.
(D) The following if offered as a separate policy, certificate, or contract of insurance:
(i) Medicare supplement health insurance as defined under section 1882(g)(1) of the federal Social Security Act [42 U.S.C. § 1395ss];
(ii) Coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)).
(iii) Similar supplemental coverage provided to coverage under a group health plan. (17)(21) “Licensed midwife” means any midwife licensed under § 23-13-9. (18)(22) “Medical services” means those professional services rendered by persons duly licensed under the laws of this state to practice medicine, surgery, chiropractic, podiatry, and other professional services rendered by a licensed midwife, certified registered nurse practitioners, and psychiatric and mental health nurse clinical specialists, and appliances, drugs, medicines, supplies, and nursing care necessary in connection with the services, or the expense indemnity for the services, appliances, drugs, medicines, supplies, and care, as may be specified in any nonprofit medical service plan. Medical service shall not be construed to include hospital services.
(23) "Mobile integrated healthcare community paramedicine program" means the provision of healthcare using patient-centered, mobile resources in the out-of-hospital environment pursuant to an EMS agency's plan approved by the department of health utilizing licensed emergency medical service practitioners working in collaboration with physicians, nurses, mid- level practitioners, community health teams and social, behavioral and substance use disorder specialists to address the unmet needs of individuals experiencing intermittent health care issues; provided that, only those emergency medical services (EMS) agencies who submit plans that meet the minimum requirements for participation set and approved by the department of health shall be eligible to participate in a mobile integrated healthcare/community paramedicine program. (19)(24) “Nonprofit medical service corporation” means any corporation organized pursuant hereto for the purpose of establishing, maintaining, and operating a nonprofit medical service plan. (20)(25) “Nonprofit medical service plan” means a plan by which specified medical service is provided to subscribers to the plan by a nonprofit medical service corporation.
(21) “Office of the health insurance commissioner” means the agency established under § 42-14.5-1. (22)(26) “Psychiatric and mental health nurse clinical specialist” is an expanded role utilizing independent knowledge and management of mental health and illnesses. The practice includes collaboration with other licensed healthcare professionals, including, but not limited to: psychiatrists, psychologists, physicians, pharmacists, and nurses. (23)(27) “Rescission” means a cancellation or discontinuance of coverage that has retroactive effect for reasons unrelated to timely payment of required premiums or contribution to costs of coverage. (24)(28) “Subscribers” means those persons or groups of persons who contract with a nonprofit medical service corporation for medical service pursuant to a nonprofit medical service plan. (25)(29) “Therapist in marriage and family practice” means a person who has been licensed pursuant to § 5-63.2-10. 27-20-55. Licensed ambulance service.
(a) No individual or group health insurance contract, plan, or policy delivered, issued for delivery, or renewed in this state on or after January 1, 2009, shall provide for a copayment for ground ambulance services in excess of fifty dollars ($50.00).
(b) As used in this section, the term “ground ambulance services” shall mean those services provided by an ambulance service licensed to operate in Rhode Island in accordance with § 23-4.1- 6. The term excludes air and water ambulance services and ambulance services provided outside of Rhode Island.
(c) This section Subsections (a) and (d) of this section shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by accident, or both; and (9) Other limited benefit policies.
(d) Individual and group health insurance contracts, plans, and policies issued for delivery, or renewed in this state on or after January 1, 2027, shall provide coverage and reimbursement for ground ambulance services, as defined in § 27-20-1, equal to coverage and reimbursement rates provided by Medicare for the same medical services, and shall reimburse the emergency medical services provider staffed by emergency medical services practitioners, as defined in § 27-20-1, at the level of care provided, regardless of whether the patient is transported, such coverage and reimbursement shall be inclusive of the community-based healthcare services, to include mobile integrated health community paramedicine programs approved by the department of health; provided that, mobile integrated health community paramedicine programs services shall be performed by emergency medical services staffed by emergency medical practitioners. If the ground ambulance service provider participates in the carrier's network, the carrier shall cover and reimburse the ambulance service provider at the ambulance service provider's rate for the level of care provided, regardless of whether the patient is transported. This coverage and reimbursement shall also extend to ambulance services which are in- network (“INN”) ground ambulance services, out-of-network (“OON”) ground ambulance services, INN and OON community-based healthcare services, and INN and OON mobile integrated health community paramedicine programs approved by the department of health.
SECTION 5. Sections 27-41-2 and 27-41-73 of the General Laws in Chapter 27-41 entitled "Health Maintenance Organizations" are hereby amended to read as follows: 27-41-2. Definitions. As used in this chapter:
(1) “Adverse benefit determination” means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of an individual’s eligibility to participate in a plan or to receive coverage under a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate. The term also includes a rescission of coverage determination.
(2) “Affordable Care Act” means the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119, as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029, and federal regulations adopted thereunder.
(3) "Ambulance" means any publicly or privately owned vehicle, designed, constructed, equipped, and operated for emergency medical treatment and/or transportation of persons who are sick or injured. (3)(4) “Commissioner” or “health insurance commissioner” means that individual appointed pursuant to § 42-14.5-1. (4)(5) “Covered health services” means the services that a health maintenance organization contracts with enrollees and enrolled groups to provide or make available to an enrolled participant. (5)(6) “Director” means the director of the department of business regulation or his or her duly appointed agents.
(7) "Emergency medical services" or "EMS agencies" means the practitioners, ambulance vehicles, and ambulance service entities licensed in accordance with chapter 4.1 of title 23 to provide emergency medical care, transportation, and prevention care to mitigate loss of life or exacerbation of illness or injury including, but not limited to, EMS responding to the 911 system established pursuant to the provisions of § 39-21.1-2.
(8) "Emergency medical services practitioner" means an individual who is licensed in accordance with state laws and regulations to perform emergency medical care and preventive care to mitigate loss of life or exacerbation of illness or injury, including emergency medical technicians, advanced emergency medical technicians, advanced emergency medical technicians cardiac, and paramedics. (6)(9) “Employee” means any person who has entered into the employment of or works under a contract of service or apprenticeship with any employer. It shall not include a person who has been employed for less than thirty (30) days by his or her employer, nor shall it include a person who works less than an average of thirty (30) hours per week. For the purposes of this chapter, the term “employee” means a person employed by an “employer” as defined in subsection (7) of this section. Except as otherwise provided in this chapter, the terms “employee” and “employer” are to be defined according to the rules and regulations of the department of labor and training. (7)(10) “Employer” means any person, partnership, association, trust, estate, or corporation, whether foreign or domestic, or the legal representative, trustee in bankruptcy, receiver, or trustee of a receiver, or the legal representative of a deceased person, including the state of Rhode Island and each city and town in the state, that has in its employ one or more individuals during any calendar year. For the purposes of this section, the term “employer” refers only to an employer with persons employed within the state of Rhode Island. (8)(11) “Enrollee” means an individual who has been enrolled in a health maintenance organization. (9)(12) “Essential health benefits” shall have the meaning set forth in section 1302(b) of the Patient Protection and Affordable Care Act [42 U.S.C. § 18022(b)]. (10)(13) “Evidence of coverage” means any certificate, agreement, or contract issued to an enrollee setting out the coverage to which the enrollee is entitled. (11)(14) “Grandfathered health plan” means any group health plan or health insurance coverage subject to 42 U.S.C. § 18011.
(15) "Ground ambulances services" means those services provided by an ambulance service licensed to operate in Rhode Island in accordance with § 23-4.1-6. The term excludes air and water ambulance services and ambulance services provided outside of Rhode Island. (12)(16) “Group health insurance coverage” means, in connection with a group health plan, health insurance coverage offered in connection with that plan. (13)(17) “Group health plan” means an employee welfare benefit plan as defined in 29 U.S.C. § 1002(1), to the extent that the plan provides health benefits to employees or their dependents directly or through insurance, reimbursement, or otherwise. (14)(18) “Health benefits” or “covered benefits” means coverage or benefits for the diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body including coverage or benefits for transportation primarily for and essential thereto, and including medical services as defined in § 27-19-17. (15)(19) “Healthcare facility” means an institution providing healthcare services or a healthcare setting, including, but not limited, to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings. (16)(20) “Healthcare professional” means a physician or other healthcare practitioner licensed, accredited, or certified to perform specified healthcare services consistent with state law. (17)(21) “Healthcare provider” or “provider” means a healthcare professional or a healthcare facility. (18)(22) “Healthcare services” means any services included in the furnishing to any individual of medical, podiatric, or dental care, or hospitalization, or incident to the furnishing of that care or hospitalization, and the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability. (19)(23) “Health insurance carrier” means a person, firm, corporation, or other entity subject to the jurisdiction of the commissioner under this chapter, and includes a health maintenance organization. Such term does not include a group health plan. (20)(24) “Health maintenance organization” means a single public or private organization that:
(i) Provides or makes available to enrolled participants healthcare services, including at least the following basic healthcare services: usual physician services, hospitalization, laboratory, x-ray, emergency, and preventive services, and out-of-area coverage, and the services of licensed midwives;
(ii) Is compensated, except for copayments, for the provision of the basic healthcare services listed in subsection (20)(i) of this section to enrolled participants on a predetermined periodic rate basis; (iii)(A) Provides physicians’ services primarily:
(I) Directly through physicians who are either employees or partners of the organization; or
(II) Through arrangements with individual physicians or one or more groups of physicians organized on a group practice or individual practice basis;
(B) “Health maintenance organization” does not include prepaid plans offered by entities regulated under chapter 1, 2, 19, or 20 of this title that do not meet the criteria above and do not purport to be health maintenance organizations; and
(iv) Provides the services of licensed midwives primarily:
(A) Directly through licensed midwives who are either employees or partners of the organization; or
(B) Through arrangements with individual licensed midwives or one or more groups of licensed midwives organized on a group practice or individual practice basis. (21)(25) “Licensed midwife” means any midwife licensed pursuant to § 23-13-9. (22)(26) “Material modification” means only systemic changes to the information filed under § 27-41-3.
(27) "Mobile integrated healthcare community paramedicine program" means the provision of healthcare using patient-centered, mobile resources in the out-of-hospital environment pursuant to an EMS agency's plan approved by the department of health utilizing licensed emergency medical service practitioners working in collaboration with physicians, nurses, mid- level practitioners, community health teams and social, behavioral and substance use disorder specialists to address the unmet needs of individuals experiencing intermittent health care issues; provided that, only those emergency medical services (EMS) agencies who submit plans that meet the minimum requirements for participation set and approved by the department of health shall be eligible to participate in a mobile integrated healthcare/community paramedicine program. (23)(28) “Net worth,” for the purposes of this chapter, means the excess of total admitted assets over total liabilities. (24)(29) “Office of the health insurance commissioner” means the agency established under § 42-14.5-1. (25)(30) “Physician” includes a podiatrist as defined in chapter 29 of title 5. (26)(31) “Private organization” means a legal corporation with a policy-making and governing body. (27)(32) “Provider” means any physician, hospital, licensed midwife, or other person who or that is licensed or authorized in this state to furnish healthcare services. (28)(33) “Public organization” means an instrumentality of government. (29)(34) “Rescission” means a cancellation or discontinuance of coverage that has retroactive effect for reasons unrelated to timely payment of required premiums or contribution to costs of coverage. (30)(35) “Risk-based capital (‘RBC’) instructions” means the risk-based capital report including risk-based capital instructions adopted by the National Association of Insurance Commissioners (“NAIC”), as these risk-based capital instructions are amended by the NAIC in accordance with the procedures adopted by the NAIC. (31)(36) “Total adjusted capital” means the sum of:
(i) A health maintenance organization’s statutory capital and surplus (i.e., net worth) as determined in accordance with the statutory accounting applicable to the annual financial statements required to be filed under § 27-41-9; and
(ii) Any other items, if any, that the RBC instructions provide.
(32) “Uncovered expenditures” means the costs of healthcare services that are covered by a health maintenance organization, but that are not guaranteed, insured, or assumed by a person or organization other than the health maintenance organization. Expenditures to a provider who or that agrees not to bill enrollees under any circumstances are excluded from this definition. 27-41-73. Licensed ambulance service.
(a) No individual or group health insurance contract, plan, or policy delivered, issued for delivery, or renewed in this state on or after January 1, 2009, shall provide for a copayment for ground ambulance services in excess of fifty dollars ($50.00).
(b) As used in this section, the term “ground ambulance services” shall mean those services provided by an ambulance service licensed to operate in Rhode Island in accordance with § 23-4.1- 6. The term excludes air and water ambulance services and ambulance services provided outside of Rhode Island.
(c) This section Subsections (a) and (d) of this section shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by accident or both; and (9) Other limited benefit policies.
(d) Individual and group health insurance contracts, plans, and policies issued for delivery, or renewed in this state on or after January 1, 2027, shall provide coverage and reimbursement for ground ambulance services, as defined in § 27-41-2, equal to coverage and reimbursement rates provided by Medicare for the same medical services, and shall reimburse the emergency medical services provider staffed by emergency medical services practitioners, as defined in § 27-41-2, at the level of care provided, regardless of whether the patient is transported, such coverage and reimbursement shall be inclusive of the community-based healthcare services, to include mobile integrated health community paramedicine programs approved by the department of health; provided that, mobile integrated health community paramedicine programs services shall be performed by emergency medical services staffed by emergency medical practitioners. If the ground ambulance service provider participates in the carrier's network, the carrier shall cover and reimburse the ambulance service provider at the ambulance service provider's rate for the level of care provided, regardless of whether the patient is transported. This coverage and reimbursement shall also extend to ambulance services which are in- network (“INN”) ground ambulance services, out-of-network (“OON”) ground ambulance services, INN and OON community-based healthcare services, and INN and OON mobile integrated health community paramedicine programs approved by the department of health.
SECTION 6. This act shall take effect upon passage.
