Federal & State Regulations | Health plans - Rhode Island

State Info

Summary of differences between federal and state regulations

Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).

Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply. Rhode Island laws include the following provisions:

Coverage for newborns to screening tests for metabolic, endocrine, and hemoglobinopathy disorders.
Coverage for newborns to be evaluated for the detection of hearing impairments.
Coverage for screening for lead poisoning and lead screening related services for children under six years old.
If a parent is required by a court or administrative order to provide health coverage, which is available through an employer doing business in this state, the employer is required to permit the parent to enroll, under family coverage, any child who is eligible for coverage without regard to any enrollment season restrictions; if the parent is enrolled but fails to make application to obtain coverage of the child, to enroll the child under family coverage upon application by the child's other parent, or by the department of human services acting as the state Medicaid and/or child support enforcement program; and not to disenroll (or eliminate coverage of) the child unless the employer is provided satisfactory written evidence.
Employers that contribute to a group health insurance contract or dental benefit plan covering 25 or more persons, which restricts the participants in selecting dental care services providers to a single or limited number of dentists, must also offer its employees or eligible dependents at least one alternative cover of comparable benefits which permits covered persons to obtain dental care services from the licensed dentist of their choice if the alternate coverage is proposed to the employer or other organization by either an insurance company or a hospital, medical, or dental service corporation.
Adopted children are covered without any waiting period.
Plans that cover pregnancy must cover medically necessary expenses of diagnosis and treatment of infertility.
Coverage for the services of licensed midwives.
Coverage for the services of a certified registered nurse practitioner and psychiatric and mental health nurse clinical specialist practicing collaboration with or in the employ of a physician.
Coverage for the services of counselors in mental health and therapists in marriage and family practice.
Coverage for new cancer therapies still under investigation.
Coverage for certain equipment and supplies, self-management and medical nutrition education, and home visits when medically necessary for the treatment of diabetes.
Coverage for the services of certified registered nurse anesthetists.
Coverage for services rendered by a registered nurse first assistant.
Coverage of the cost for human leukocyte antigen testing.
If the plan utilizes a formulary of medications for which coverage is provided, the master contract must allow any physician to prescribe medication to prescribe from the formulary.
Health plan providers are prohibited from using genetic information for plan considerations, or releasing genetic information without prior written authorization of the individual.
Optional coverage for the services of a doctor of acupuncture.
If the plan covers prescriptions it must cover F.D.A. approved contraceptive drugs and devices requiring a prescription, except the prescription drug RU 486.
Coverage for prostate and colorectal examinations and laboratory tests.
The plan must coverage for one thousand dollars ($1,000) (as of 1/1/05); four hundred dollars ($400) (as of 1/1/06) per hearing aid, per ear, every three years. The plan must also offer optional rider for additional hearing aid coverage for plans issued or renewed on or after July 1, 2006.
If the plan covers dependent or minor children, it must include benefits for pediatric preventive care.
Coverage for mental illness and substance abuse under the same terms and conditions as for other illnesses and diseases.
Coverage for off-label use of certain drugs for cancer.
If the plan covers dependent children, it must cover early intervention services.
As of June 28, 2005, mandated benefit laws do not prohibit plans from including any deductible and/or other cost-sharing provisions suitable to qualify a health plan, which may be purchased for use with health savings accounts, as a high deductible health plan or any other similar tax preference. High deductible health plans are not exempt from any other provision of applicable mandated benefits. This shall be repealed effective July 1, 2010.
As of January 1, 2007, if the plan provides medical coverage including physician services in a physician's office, and plans that provide major medical or similar comprehensive-type coverage, it must cover smoking cessation treatment. If the coverage does not include prescription drug coverage, the plan does not have to include coverage for prescription nicotine replacement therapy.
Effective January 1, 2007, if the plan provides medical coverage including physician services in a physician's office, and plans that provide major medical or similar comprehensive-type coverage, it must cover an unmarried child under the age of 19, an unmarried child who is a student under the age of 25 and who is financially dependent upon the parent, and an unmarried child of any age who is financially dependent upon the parent and medically determined to have a physical or mental impairment that can be expected to result in death or which has lasted or can be expected to last at least 12 months.
Employees on extended medical leave who have been full-time employees for at lest three months and are covered under the group health plan are entitled to continue coverage for up to 18 months from the beginning of leave. Employees may be required to provide a written statement explaining why they can no longer work full time. The employer is responsible for determining whether the employee is eligible for extended medical leave. Employers are not required to provide extended medical leave, but if they do, these provisions apply.