Rhode Island medical-plan questions focus on four areas:

• Benefit mandates: mental health parity, infertility, mastectomy and mammography, Lyme disease, diabetes, midwives.
• ACA-style protections written into state law.
• Prompt payment of health claims.
• Coverage of newborns, adopted children and dependents.

Remember that the Health Insurance Commissioner (OHIC) enforces the insurance laws for health insurers, while DBR keeps producer licensing. The general material (indemnity vs. managed care, HMOs and PPOs, cost sharing, HDHPs, the ACA) is in the national Medical Plans guide.

Children and dependents

Newborns (230-RICR-20-30-1.5)

• Covered from the moment of birth, including medically diagnosed congenital defects and birth abnormalities.
• If extra premium is required, notice and payment may be required within 31 days of birth.

Adopted children (27-18-27)

• A child adopted from the custody of the Department of Children, Youth and Families is covered without a waiting period, even with a preexisting condition.

Age limits (27-18-59)

• Coverage for children must be available to age 26.
• An unmarried child of any age may stay on if financially dependent and has an impairment expected to last at least 12 months or result in death.

Newborn screening (23-13-14)

• The state newborn screening program is a covered benefit.

Benefit mandates

Mental health and substance use parity (27-38.2)

• Covered on the same terms as other illnesses.
• No annual or lifetime dollar limits.
• Substance use levels of care follow ASAM (American Society of Addiction Medicine) criteria.
• Doesn't apply to disability income or hospital confinement indemnity policies.

Infertility (27-18-30)

• Applies to contracts with pregnancy-related benefits.
• Covers diagnosis and treatment for women ages 25 to 42.
• Infertility means being unable to conceive or sustain a pregnancy for 1 year.
• Copayments for infertility-only procedures can't exceed 20%.

Mastectomy (27-18-39, 27-18-40)

• At least a 48-hour inpatient stay.
• If the patient agrees to leave earlier, at least one home visit by a physician or registered nurse is covered.
• Reconstruction of the other breast for symmetry is covered.

Mammograms (27-18-41)

• A woman treated for breast cancer within the last 5 years is covered for two screening mammograms a year when her physician recommends.

Lyme disease (27-18-62)

• Long-term antibiotic treatment of chronic Lyme disease is covered when medically necessary. It can't be denied just because it is called experimental.

Diabetes (27-18-38)

• Copays or deductibles for supplies and equipment can't be higher than for other supplies, equipment or office visits.

Midwives (27-18-31)

• Licensed midwives' services are covered. A referral can't be required unless it is required for other provider types.

OB-GYN (27-18-44)

• An annual routine gynecological visit to an in-network OB-GYN without a referral.

Pediatric preventive care (27-38.1)

• Required, but insurers don't have to pay for the vaccine biologicals themselves.

State-law ACA protections

• No preexisting condition exclusions for plan years from January 1, 2014, except grandfathered individual plans (27-18-71).
• No annual dollar limits on essential health benefits (27-18-73).
• Rescission only for fraud or intentional material misrepresentation, with at least 30 days' advance written notice (27-18-72).
• Emergency conditions are judged by the prudent layperson standard (27-18-76).
• HIV: a health insurer may not cancel or nonrenew coverage because of a positive HIV test (23-6.3-16).

Prompt payment (27-18-61)

• Late payments carry 12% interest a year, starting on day 31 for electronic claims or day 41 for paper.
• Denied or pended claims: written reasons and any information needed are due within 30 days of receipt.

Other rules

• HMO option (27-41-27): an employer averaging at least 25 employees must offer membership in a qualified HMO where one serves the area.
• Unregulated plans (27-42-6): a producer selling a health plan that isn't fully insured by a regulated entity must tell buyers about the lack of insurance.
• Stop-loss (27-8.2-3): may not be issued with a specific attachment point below $20,000, or an aggregate attachment point below 120% of expected claims.
• Guaranty protection: the Rhode Island Life and Health Insurance Guaranty Association covers basic hospital, medical and surgical or major medical benefits up to $500,000 (27-34.3-3).

Common exam traps

• Health insurers answer to the Health Insurance Commissioner. Producer licensing stays with DBR.
• Prompt pay: 30 days electronic, 40 days paper, 12% interest.
• Infertility: ages 25-42, after 1 year, copay no more than 20%.
• Rescission needs fraud or intentional misrepresentation plus 30 days' notice.
• Dependents: to 26, or any age for a dependent child with a qualifying impairment.