(a)  Every individual or group health insurance contract, or every individual or group hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery, or renewed in this state on or after January 1, 2009, shall provide coverage for nonprescription enteral formulas for home use for which a physician has issued a written order and that are medically necessary for the treatment of malabsorption caused by Crohn’s disease, ulcerative colitis, gastroesophageal reflux, chronic intestinal pseudo-obstruction, and inherited diseases of amino acids and organic acids. Coverage for inherited diseases of amino acids and organic acids shall include food products modified to be low protein and shall extend to all recipients regardless of age.

Terms Used In Rhode Island General Laws 27-41-74

  • Contract: A legal written agreement that becomes binding when signed.
  • Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
  • Health maintenance organization: means a single public or private organization which:

    (1)  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;

    (2)  Is compensated, except for copayments, for the provision of the basic healthcare services listed in subdivision (1) of this subsection to enrolled participants on a predetermined periodic rate basis; and

    (3)(i)  Provides physicians' services primarily:

    (A)  Directly through physicians who are either employees or partners of the organization; or

    (B)  Through arrangements with individual physicians or one or more groups of physicians organized on a group practice or individual practice basis;

    (ii)  "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;

    (4)  Provides the services of licensed midwives primarily:

    (i)  Directly through licensed midwives who are either employees or partners of the organization; or

    (ii)  Through arrangements with individual licensed midwives or one or more groups of licensed midwives organized on a group practice or individual practice basis. See Rhode Island General Laws 27-41-2

  • Physician: includes podiatrist as defined in chapter 29 of Title 5. See Rhode Island General Laws 27-41-2

(b)  Benefit plans offered by a health maintenance organization may impose a copayment and/or deductible for the benefits mandated by this section, however, in no instance shall the copayment or deductible amount be greater than the copayment of deductible amount imposed for prescription enteral formulas or nutritional aids. Benefits for services under this chapter shall be reimbursed in accordance with the respective principles and mechanisms of reimbursement for each insurer, hospital, or medical service corporation, or health maintenance organization. Reimbursement shall be provided according to the respective principles and policies of the accident and sickness insurer. Nothing contained in this section precludes the accident and sickness insurer from conducting managed care, medical necessity, or utilization review.

(c)  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.

History of Section.
P.L. 2008, ch. 253, § 4; P.L. 2014, ch. 269, § 4; P.L. 2014, ch. 519, § 4.