2022 -- H 7078

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LC003679

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2022

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A N   A C T

RELATING TO INSURANCE -- INSURANCE COVERAGE FOR MENTAL ILLNESS AND

SUBSTANCE ABUSE

     

     Introduced By: Representatives Edwards, Fogarty, Caldwell, Bennett, Cassar, Filippi,
Baginski, and Shanley

     Date Introduced: January 12, 2022

     Referred To: House Health & Human Services

     It is enacted by the General Assembly as follows:

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

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

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

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

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

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

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

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illnesses and diseases.

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

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impose any annual or lifetime dollar limitation.

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

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

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

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each treatment classification.

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

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

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

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

 

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

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medical/surgical benefits in the classification.

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

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

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

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

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use disorders, opioid overdoses, and chronic addiction, including methadone, buprenorphine,

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

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classification based on the site of the service.

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

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

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treatment.

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

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

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

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

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

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

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

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office visits.

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

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

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

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

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subsection.

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

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

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

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

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

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

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

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

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(48) hours of admission.

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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and continuation of care.

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

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

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

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

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

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

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

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

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

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deductible otherwise required under the policy.

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

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provider network.

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

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

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

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

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

 

LC003679 - Page 3 of 5

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diversion program.

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     SECTION 2. This act shall take effect on January 1, 2023.

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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

***

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

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

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

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     This act would take effect on January 1, 2023.

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