2021 -- H 5243

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LC000735

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2021

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A N   A C T

RELATING TO INSURANCE -- INSURANCE COVERAGE FOR MENTAL ILLNESS AND

SUBSTANCE ABUSE

     Introduced By: Representative John G. Edwards

     Date Introduced: January 29, 2021

     Referred To: House Health & Human Services

     It is enacted by the General Assembly as follows:

     SECTION 1. Section 27-38.2-1 of the General Laws in Chapter 27-38.2 entitled "Insurance

Coverage for Mental Illness and Substance Abuse" is hereby amended to read as follows:

     27-38.2-1. Coverage for treatment of mental health and substance use disorders.

     (a) A group health plan and an individual or group health insurance plan, and any contract

between the Rhode Island Medicaid program and any health insurance carrier, as defined under

chapters 18, 19, 20, and 41 of title 27, shall provide coverage for the treatment of mental-health

and substance-use disorders under the same terms and conditions as that coverage is provided for

other illnesses and diseases.

     (b) Coverage for the treatment of mental-health and substance-use disorders shall not

impose any annual or lifetime dollar limitation.

     (c) Financial requirements and quantitative treatment limitations on coverage for the

treatment of mental-health and substance-use disorders shall be no more restrictive than the

predominant financial requirements applied to substantially all coverage for medical conditions in

each treatment classification.

     (d) Coverage shall not impose non-quantitative treatment limitations for the treatment of

mental health and substance-use disorders unless the processes, strategies, evidentiary standards,

or other factors used in applying the non-quantitative treatment limitation, as written and in

operation, are comparable to, and are applied no more stringently than, the processes, strategies,

evidentiary standards, or other factors used in applying the limitation with respect to

medical/surgical benefits in the classification.

     (e) The following classifications shall be used to apply the coverage requirements of this

chapter: (1) Inpatient, in-network; (2) Inpatient, out-of-network; (3) Outpatient, in-network; (4)

Outpatient, out-of-network; (5) Emergency care; and (6) Prescription drugs.

     (f) Medication-assisted treatment or medication-assisted maintenance services of

substance-use disorders, opioid overdoses, and chronic addiction, including methadone,

buprenorphine, naltrexone, or other clinically appropriate medications, is included within the

appropriate classification based on the site of the service.

     (g) Payors shall rely upon the criteria of the American Society of Addiction Medicine when

developing coverage for levels of care and determining placements for substance-use disorder

treatment.

     (h) Patients with substance-use disorders shall have access to evidence-based, non-opioid

treatment for pain, therefore coverage shall apply to medically necessary chiropractic care and

osteopathic manipulative treatment performed by an individual licensed under § 5-37-2.

     (i) Parity of cost-sharing requirements. Regardless of the professional license of the

provider of care, if that care is consistent with the provider's scope of practice and the health plan's

credentialing and contracting provisions, cost-sharing for behavioral health counseling visits and

medication maintenance visits shall be consistent with the cost-sharing applied to primary care

office visits.

     (j) Consistent with coverage for medical and surgical services, a health plan as defined in

subsection (a) of this section shall cover clinically appropriate and medically necessary residential

or inpatient services, including detoxification and stabilization services, for the treatment of mental

health and substance use disorders, including alcohol use disorders, in accordance with this

subsection.

     (1) The health plan shall provide coverage for clinically appropriate and medically

necessary residential or inpatient services, including American Society of Addiction Medicine

levels of care for residential and inpatient services, and shall not require preauthorization prior to a

patient obtaining such services; provided, that the facility shall provide the health plan with:

notification of admission, proof that an assessment was conducted based upon the criteria of the

American Society of Addiction Medicine or after an appropriate psychiatric assessment for mental

health disorders, that residential or inpatient services is the most appropriate and least restrictive

level of care necessary, the initial treatment plan, and estimated length of stay within forty-eight

(48) hours of admission.

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     (2) Notwithstanding § 27-38.2-3, coverage provided under this subsection shall not be

subject to concurrent utilization review during the first twenty-eight (28) days of the residential or

inpatient admission provided that the facility notifies the health plan as provided in subsection (j)(1)

of this section. The facility shall perform daily clinical review of the patient, including consultation

with the health plan at or just prior to the fourteenth day of treatment to ensure that the facility

determined that the residential or inpatient treatment was clinically appropriate and medically

necessary for the patient using an assessment based upon the criteria of the American Society of

Addiction Medicine or after an appropriate psychiatric assessment for mental health disorders.

     (3) Prior to discharge from residential or inpatient services, the facility shall provide the

patient and the health plan with a written discharge plan which shall describe arrangements for

additional services that are needed following discharge from the residential or inpatient facility as

determined using an assessment based upon the criteria of the American Society of Addiction

Medicine or after an appropriate psychiatric assessment for mental health disorders. Prior to

discharge, the facility shall indicate to the health plan whether services included in the discharge

plan are secured or determined to be reasonably available. The health plan may conduct utilization

review procedures, in consultation with the patient’s treating clinician, regarding the discharge plan

and continuation of care.

     (4) Any utilization review of treatment provided under this subsection may include a

review of all services provided during the residential or inpatient treatment, including all services

provided during the first twenty-eight (28) days of such residential or inpatient treatment. Provided,

however, the health plan shall only deny coverage for any portion of the initial twenty-eight (28)

days of residential or inpatient treatment on the basis that such treatment was not medically

necessary if such residential or inpatient treatment was contrary to the assessment based upon the

criteria of the American Society of Addiction Medicine or after an appropriate psychiatric

assessment for mental health disorders. A patient shall not have any financial obligation to the

facility for any treatment under this subsection other than any copayment, coinsurance, or

deductible otherwise required under the policy.

     (5) This subsection shall apply only to covered services delivered within the health plan’s

provider network.

     (6) Nothing herein prohibits the health plan from conducting quality of care reviews.

     (k) No health plan as provided in subsection (a) of this section shall refuse to cover

treatment for mental health and substance use disorders, including alcohol use disorders, regardless

of the level of care, that such health plan is required to cover pursuant to this section solely because

such treatment is ordered by a court of competent jurisdiction or by a government operated

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diversion program.

     SECTION 2. This act shall take effect on January 1, 2022.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE -- INSURANCE COVERAGE FOR MENTAL ILLNESS AND

SUBSTANCE ABUSE

***

     This act would require a health plan to cover clinically appropriate and medically necessary

residential or inpatient services, including detoxification and stabilization services, for the

treatment of mental health and substance use disorders, including alcohol use disorders.

     This act would take effect on January 1, 2022.

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