Rhode Island § 27-74-3 - Discount Medical Plan Organization Act

§ 27-74-3. Definitions.

As used in this chapter:

(1) “Affiliate” means a person that directly, or indirectly through one or more intermediaries, controls, or is controlled by, or is under common control with, the person specified.

(2) “Ancillary services” includes, but is not limited to, audiology, dental, vision, mental health, substance abuse, chiropractic, and podiatry services.

(3) “Commissioner” means the health insurance commissioner.

(4) “Control” or “controlled by” or “under common control with” means the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract other than a commercial contract for goods or nonmanagement services, or otherwise, unless the power is the result of an official position with or corporate office held by the person. Control shall be presumed to exist if any person, directly or indirectly, owns, controls, holds with the power to vote, or holds proxies representing ten percent (10%) or more of the voting securities of any other person. This presumption may be rebutted by a showing made in the manner provided by § 27-35-3(k) that control does not exist in fact. The commissioner may determine, after furnishing all persons in interest notice and opportunity to be heard and making specific findings of fact to support the determination, that control exists in fact, notwithstanding the absence of a presumption to that effect.

(5)(i) “Discount medical plan” means a business arrangement or contract in which a person, in exchange for fees, dues, charges, or other consideration, offers access for its members to providers of medical or ancillary services and the right to receive discounts on medical or ancillary services provided under the discount medical plan from those providers.

(ii) “Discount medical plan” does not include a plan that does not charge a membership or other fee to use the plan’s discount medical card.

(6) “Discount medical plan organization” means an entity that, in exchange for fees, dues, charges, or other consideration, provides access for discount medical plan members to providers of medical or ancillary services and the right to receive medical or ancillary services from those providers at a discount. It is the organization that contracts with providers, provider networks, or other discount medical plan organizations to offer access to medical or ancillary services at a discount and determines the charge to discount medical plan members.

(7)(i) “Facility” means an institution providing medical or ancillary services or a healthcare setting.

(ii) “Facility” includes, but is not limited to:

(A) A hospital or other licensed inpatient center;

(B) An ambulatory surgical or treatment center;

(C) A skilled nursing center;

(D) A residential treatment center;

(E) A rehabilitation center; and

(F) A diagnostic, laboratory, or imaging center.

(8) “Healthcare professional” means a physician or other healthcare practitioner who is licensed, accredited, or certified to perform specified medical or ancillary services within the scope of his or her license, accreditation, certification, or other appropriate authority and consistent with state law.

(9) “Health carrier” means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including a sickness and accident insurance company, a health maintenance organization, a nonprofit hospital and medical service corporation, or any other entity providing a plan of health insurance, health benefits, or medical or ancillary services.

(10) “Marketer” means a person or entity that markets, promotes, sells, or distributes a discount medical plan, including a private label entity that places its name on and markets or distributes a discount medical plan pursuant to a marketing agreement with a discount medical plan organization.

(11)(i) “Medical services” means any maintenance care of, or preventive care for, the human body or care, service, or treatment of an illness or dysfunction of, or injury to, the human body.

(ii) “Medical services” includes, but is not limited to, physician care, inpatient care, hospital surgical services, emergency services, ambulance services, laboratory services, and medical equipment and supplies.

(iii) “Medical services” does not include pharmacy services or ancillary services.

(12) “Member” means any individual who pays fees, dues, charges, or other consideration for the right to receive the benefits of a discount medical plan.

(13) “Person” means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing.

(14) “Provider” means any healthcare professional or facility that has contracted, directly or indirectly, with a discount medical plan organization to provide medical or ancillary services to members.

(15) “Provider network” means an entity that negotiates directly or indirectly with a discount medical plan organization on behalf of more than one provider to provide medical or ancillary services to members.