Insurance Health Benefits Required Under Rhode Island Law

These laws are not applied to Medicare, Medicaid, and ERISA Plans

What Are Health Benefits?

Health Benefits are services covered by a health insurance plan and the financial terms of such coverage, including cost sharing and limitations on amounts of service. They are called "covered benefits" or "covered services."

A health insurance plan is an organization that acts as an insurer for an enrolled population.

The following are health benefits required under Rhode Island Law to be offered by these certified insurance companies:

• Aetna U.S. Health Care, Inc.
  
• Blue Cross/Blue Shield of Rhode Island
  
• CIGNA
  
• Harvard Pilgrim Health Care, Inc.
  
• Neighborhood Health Plan of Rhode Island
  
• Tufts Health Plan of New England, Inc.
  
• United Health Care of New England, Inc.
  

Health Benefits for Cancer

Acupuncture Treatment:  Coverage provided as an optional rider to health care coverage. (RIGL 27-18-55)

Drug Coverage for Non-Formulary Medications: Coverage for non-formulary medication (medications not covered by a health plan) when prescribed by a physician if believed medically necessary, and if it meets the medical exception criteria. (RIGL 27-18-50)

Human Leukocyte Antigen Testing:  Coverage for human leukocyte antigen testing for A, B, and DR antigens for utilization in bone marrow transplantation. (RIGL 27-18-49)

Cancer Screening:  Mammogram and Pap smears in accordance with guidelines established by the American Cancer Society. (RIGL 27-20-17; 42-62-36; 27-41-30) Prostate and colorectal examinations and laboratory tests in accordance with the American Cancer Society guidelines. (RIGL 27-19-48)

Mastectomy Treatment:  Minimum 48-hour hospital stay after mastectomy; 24-hour stay after axillary node dissection. Prosthetic devices and/or reconstructive surgery to restore and achieve symmetry subject to deductible and coinsurance conditions applied to mastectomy. Time limit 18 months from original mastectomy. (RIGL 27-38.2-1)

New Cancer Therapies:  Coverage for cancer therapies (still under investigation) under certain circumstances—Phase II, III, IV clinical trials approved by National Institutes of Health and others. (RIGL 27-18-36; 27-20-27; 27-41-41)

Off-Label Cancer Drug Use:  Insurers must cover drugs for cancer treatment if their use is recognized by standard medical references. (RIGL 27-55-2; 27-18-36.2)

Genetic Testing:  An insurer cannot use the results of genetic testing to reject, deny, limit, cancel, or refuse to renew, increase the rates of, or otherwise affect a health insurance policy contract. (RIGL 27-18-52)

MRI Quality Assurance Standards:  Coverage for MRI (Magnetic Resonance Imaging) examination only if the provider meets the state-approved quality assurance standards for taking, processing, and interpreting MRI examinations. (RIGL 27-18-37)

Pre-Existing Condition Clauses Prohibited:  No limit on coverage for any pre-existing condition for any individual who has been continuously insured or covered for 12 months immediately prior to the date of application. (RIGL 27-18-37)

Health Benefit Terms

Coinsurance:  Each time you receive health care services; you pay a percentage of the charge.

Co-payment:  Each time you receive certain health care services you pay a set amount of money stated in your health plan contract.

Deductible:  The amount of money that you must pay for covered services before your health plan begins to pay for the services.

Medically Necessary:  Your provider thinks you need certain health care services to treat your health care problem. Your health plan may review these services to determine if they are necessary under their own set of medical or health standards. They may disagree with the health provider and not cover the services.

Pre-Existing Condition:  A medical or health condition that was diagnosed or treated by a provider before you joined your current health plan.

Provider:  A provider is a person or an organization that delivers health care services.

Rider:  This is a separate part of your health care coverage that adds specific benefits to your general health plan. There will be an additional cost for a rider paid. Riders are agreed upon before you enroll in a health plan.

For further information about specific mandated benefits,
contact the Rhode Island Department of Business Regulation at:
401-222-2223

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