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Guarantee that every Rhode Islander can see a doctor and be covered for primary and emergent care. The first requirement is physicians. Everything in this plan begins by bringing them back.

The plan opens with a mandate on the insurance companies. Every insurer operating in Rhode Island must pay providers at a benchmark rate, pegged to what Massachusetts and Connecticut pay, in full and on time. This is the foundation the rest is built on.

Reliable, competitive payment is what makes Rhode Island a place a physician will practice. The reason to leave for Massachusetts disappears, and the reason to stay appears. This is how the shortage reverses. It does not happen overnight. The exodus stops first, and recruitment follows.

A requirement to pay fairly and promptly ends the business model built on underpayment and delay. An insurer may stay and operate under the new rules. An insurer may also decide Rhode Island is no longer worth its while and leave. The plan is built for both outcomes.

Established in the same act, the Trust is a public payer that operates alongside the private insurers rather than in place of them. It is a catch net. Rhode Islanders keep the coverage they have, and the Trust makes certain that no one loses care when the market shifts beneath them.

When a carrier withdraws from Rhode Island, its members transfer to the Trust automatically. The patient does nothing, changes nothing, and misses no care. The state carries the burden of the paperwork and the transition. Benefits are paid as the policy requires, and providers are paid the benchmark rate that keeps them here.

The Trust is capitalized by assessments on the insurance industry and by the redirected premiums of the members it takes on, held in a segregated fund. Rhode Island has assessed insurers in this manner since 1985, each time a carrier fails. No worker’s wages are reduced and no new tax is created.

Social Security and Medicare have retained public confidence for nearly a century because their trust funds are walled off by law and cannot be diverted to other purposes. The Rhode Island Health Trust rests on the same principle. Its enabling statute confines every dollar to the payment of care.

For the members it covers, the Trust carries none of the marketing, broker commissions, prior-authorization machinery, or profit margin that a commercial carrier must. Federal law already caps that overhead at 15 to 20 cents of every premium dollar. The Trust runs well below it, so more of each dollar reaches care and providers are paid competitively.

Nothing is turned off on a single day. As the market rewards fair payment and penalizes the old model, coverage shifts over time. Some insurers adapt and remain. Others leave, and the Trust catches their members. Rhode Island moves toward universal coverage without a day of forced upheaval.

A single limit disciplines the entire design. Reimbursement set too low drives physicians out of the state and renders the coverage meaningless. The Trust therefore captures administrative overhead but never reduces provider payment below the benchmark that retains physicians. The case for savings and the case for keeping doctors are the same case.

A fund of this significance cannot be administered by the insurers it is meant to hold accountable. The Trust is governed by a small board of qualified experts, selected through a bipartisan nomination process, serving long and staggered terms that extend beyond any single administration, removable only for cause, and prohibited from employment with the carriers they oversee. Vermont’s health board is constituted on these principles. The design places the Trust beyond the reach of the industry it regulates.

The projected savings are a target, not a guarantee, and an independent actuary will set the precise assessment. Capacity takes time. A state cannot conjure doctors or hospital beds overnight, which is exactly why the payer mandate comes first, to start the recovery now. The insurance industry will oppose the measure, because it ends a model that profits from delay. Yet the present system already absorbs enormous cost through emergency care and through disease detected too late. The Trust does not add that cost. It redirects it.

Pay the providers. Bring the doctors back. Guarantee that no Rhode Islander loses care when the market shifts. Begin where success is achievable, and build from there. That is how Rhode Island restores access to a physician, and how it moves, over time, toward covering everyone.

A medical-loss-ratio floor is written into the same bill, with mandatory rebates. A premium increase can only reflect real spending on care. Any padding is returned to policyholders, and an excess-margin assessment funds a relief pool for individuals and small businesses.

A carrier that exits must give eighteen months’ notice and fund transition coverage for its members. Streamlined licensing lets other carriers enter on the same terms, terms Massachusetts and Connecticut carriers already meet. And behind that stands the State Backstop. If a carrier quits and no one assumes its members, the Trust catches them. The member keeps the card already in their wallet, the claim reroutes to the Trust, and it pays at the benchmark. It is funded by carrier reserves, not tax dollars. The last card the industry holds, that leaving takes your coverage with it, is answered before it is played.

The law reaches only the fully-insured and individual markets, which states plainly regulate under McCarran-Ferguson and the ACA. Self-funded plans are carved out in the text. Rate regulation of licensed insurers is core state power that OHIC already exercises, and Rhode Island’s prompt-pay statute, Section 27-18-61, has operated for years.

The Supreme Court decided this in 2020. In Rutledge v. PCMA it unanimously upheld a state law regulating reimbursement rates against an ERISA challenge, holding that rate regulation affects costs without dictating plan design and is therefore not preempted. A reimbursement floor on licensed carriers is the same species of law, and ERISA’s own savings clause preserves state laws that regulate insurance.

Pay-first does not extinguish any right. It reallocates the timing: pay now, dispute after, through a defined recoupment process. Courts have long upheld pay-first-litigate-later structures, from tax law to Medicare recoupment. The insurer keeps its full remedy. It simply can no longer use delay as the remedy.

The benchmark is a reference index, not a regulation of out-of-state conduct. It is the regional median commercial rate as determined annually by OHIC, applied identically to every carrier licensed in Rhode Island. Using regional data as an index is no different from pegging rates to Medicare. There is no extraterritorial regulation and no discrimination.

Deductible and out-of-pocket ceilings are indexed to an affordability standard, and any cost-sharing increase above the index requires OHIC approval. The medical-loss-ratio rebate catches padded margin in the aggregate. Every carrier reports its cost-sharing trends, so a shift is visible the year it happens.

Network adequacy standards set maximum wait times and travel times for primary care, enforced with the same escalating fines as the payment rules. The rate floor also removes the reason to narrow a network in the first place. With a floor, there is no below-floor discount left to extract.

The statute defines a clean claim tightly, by reference to existing federal transaction standards, so a carrier cannot invent new documentation prerequisites. A claim not rejected with specific, valid deficiencies within a short window is deemed clean as a matter of law, and the payment clock runs from original submission. The reject-and-reset game ends.

Recoupment demands must be filed within a defined window, state specific grounds, and stay confined to the claims disputed. There is no offsetting against unrelated current payments. If a recoupment claim fails at review, the carrier pays the provider’s review costs.

The benchmark methodology is fixed in statute: a regional median from defined data sources, published annually with the underlying numbers. Penalty interest accrues by operation of law and the deemed-clean provisions execute without an enforcement action, so the law enforces itself where capture would otherwise bite. Annual public reporting lets the legislature and the press see underperformance even if the regulator goes quiet.

This is the one move outside the reach of a state bill, and the answer is political rather than legal. By the time any federal preemption effort matures, the law has a constituency: the doctors who stayed and the patients who found care. A working model is the hardest thing to preempt.

Rutledge v. Pharmaceutical Care Management Assn., 592 U.S. 80 (2020), unanimous.
Kentucky Assn. of Health Plans v. Miller, 538 U.S. 329 (2003).
ERISA savings clause, 29 U.S.C. § 1144(b)(2)(A).
McCarran-Ferguson Act, 15 U.S.C. §§ 1011-1015.
R.I. Gen. Laws § 27-18-61, the existing prompt-pay statute being strengthened.
R.I. Gen. Laws ch. 27-34.3, the 1985 Guaranty Association, the assessment model behind the backstop.