SECTION 1. Legislative findings. The general assembly finds and declares that:
(1) All Rhode Islanders deserve timely, high quality primary care without access limitations;
(2) Primary care practices face challenges including administrative burdens, physician shortages, and burnout, which threaten overall access to care;
(3) Innovative models can help sustain practices and improve convenience while preserving equity, but must never result in a pay to play system where ability to pay determines the quality or speed of essential medical care;
(4) Optional fees for non-covered services can support practice viability if they are strictly voluntary, transparent, and do not affect access to or delivery of covered, medically necessary primary care services;
(5) Maintaining reasonable panel sizes for licensed practitioners is the key to a healthy workforce and cared-for constituency. Innovative models can provide primary care practices the opportunity to maintain reasonable panel sizes while growing the practice to service more patients;
(6) The goal of this legislation is to enhance access to care, not limit it, as well as protect some of our most valuable healthcare resources, primary care practitioners;
(7) In order to maintain access for all Rhode Island patients, regardless of ability to participate in membership-model tiers, private practices must be made viable for growth and stability.
SECTION 2. Title 23 of the General Laws entitled "HEALTH AND SAFETY" is hereby amended by adding thereto the following chapter: 23-106-1. Short title. This chapter shall be known and may be cited as the "Equitable Access Primary Care Practices Act." 23-106-2. Definitions. As used in this chapter, the following terms have the following meanings:
(1) “Access fee” or “membership fee” means an optional, voluntary annual or periodic fee charged solely for non-covered services and conveniences not reimbursable by any third-party payer and not required for any medically necessary covered service.
(2) “Equitable access primary care practice” means a primary care practice that:
(i) Accepts and bills third-party payers, including commercial insurers, Medicare, Medicaid, and other government payers, for covered health services in full compliance with law and contracts; and
(ii) May offer patients the voluntary choice of access tiers for non-covered services, including:
(A) A tiered system of non-covered services, including the option for access to care without financial purchase beyond general third-party or self-pay fee schedules.
(3) “Non-covered services” means conveniences such as coordination of non-covered testing, enhanced availability or priority scheduling that do not include or substitute for medically necessary covered services and are not billable to payers.
(4) “Primary care practice” means a medical practice licensed in Rhode Island providing primary care through licensed physicians, physician assistants, or nurse practitioners, and owned and operated by licensed physicians or nurse practitioners.
(5) “Third-party payer” means any health insurer, health maintenance organization, Medicare, Medicaid, or other government payer program. 23-106-3. Authorization and strict equity requirements.
(a) A licensed primary care practice may offer voluntary access fees for non-covered services as described in § 23-106-2(2)(ii), in addition to billing third-party payers for covered services.
(b) Access fees shall apply exclusively to non-covered services. Practices shall not bill payers for these fees, apply them to deductibles, copayments, or coinsurance, or submit claims for them.
(c) No patient shall be required to pay any access fee to:
(1) Receive any medically necessary covered service;
(2) Access emergency, urgent, or same day care when clinically indicated; or
(3) Receive equal clinical attention, treatment quality, or medical decision making.
(d) All patients, regardless of tier, shall receive identical standards of medical care, provider expertise for covered services, and nondiscrimination in clinical prioritization based on medical need rather than financial tier. 23-106-4. Robust patient protections and transparency.
(a) Before any patient elects a tier, the practice shall obtain signed informed consent in plain language that explicitly states:
(1) The access fee is completely optional and pays only for conveniences such as faster scheduling or enhanced availability and not for better medical treatment;
(2) Choosing the basic tier without a fee does not result in inferior care, longer waits for urgent needs, or any disadvantage in clinical outcomes; and
(3) Fees are not insurance, are not reimbursable by any payer, and do not count toward insurance obligations.
(b) Practices shall not deny, delay, downgrade, or otherwise disadvantage medically necessary care based on tier choice or inability or unwillingness to pay a fee. Urgent or emergent needs shall take precedence over scheduling preferences. 23-106-5. Prohibition on insurer interference and safeguards.
(a) No health insurer or third-party payer regulated by the state shall prohibit, penalize, or restrict a provider from offering voluntary non-covered amenity tiers; provided that, all covered services are billed and delivered equitably.
(b) This section shall not override federal Medicare rules concerning beneficiary protections, assignment, or opt-out requirements. 23-106-6. Medicaid and Medicare compliance. The executive office of health and human services shall issue rules and regulations within one hundred eighty (180) days of the effective date of this chapter to ensure that Medicaid providers may offer non-covered amenity fees consistent with federal rules and without charging beneficiaries for covered services. Nothing in this chapter authorizes fees that violate Medicare statutes or beneficiary protections. 23-106-7. Enforcement and penalties. The department of health and the office of the health insurance commissioner shall enforce the provisions of this chapter. Violations that threaten patient equity may result in sanctions pursuant to chapter 37 of title 5 or title 27, including fines, license restrictions, or corrective action plans. The department shall adopt rules and regulations to monitor and promote equitable access. 23-106-8. Severability. If any provision of this chapter or its application is held invalid, the remainder shall remain in effect.
SECTION 3. This act shall take effect upon passage.
