2022 -- H 8169

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LC005759

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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 Casey, Edwards, Filippi, Chippendale, and Cassar

     Date Introduced: April 27, 2022

     Referred To: House Finance

     It is enacted by the General Assembly as follows:

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     SECTION 1. Section 27-38.2-2 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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     27-38.2-2. Definitions.

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     For the purposes of this chapter, the following words and terms have the following

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meanings:

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     (1) "Financial requirements" means deductibles, copayments, coinsurance, or out-of-

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pocket maximums.

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     (2) "Group health plan" means an employee welfare benefit plan as defined in 29 U.S.C. §

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1002(1) to the extent that the plan provides health benefits to employees or their dependents directly

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or through insurance, reimbursement, or otherwise. For purposes of this chapter, a group health

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plan shall not include a plan that provides health benefits directly to employees or their dependents,

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except in the case of a plan provided by the state or an instrumentality of the state.

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     (3) "Health insurance plan" means health insurance coverage offered, delivered, issued for

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delivery, or renewed by a health insurer.

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     (4) "Health insurers" means all persons, firms, corporations, or other organizations offering

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and assuring health services on a prepaid or primarily expense-incurred basis, including but not

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limited to, policies of accident or sickness insurance, as defined by chapter 18 of this title; nonprofit

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hospital or medical service plans, whether organized under chapter 19 or 20 of this title or under

 

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any public law or by special act of the general assembly; health maintenance organizations, or any

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other entity that insures or reimburses for diagnostic, therapeutic, or preventive services to a

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determined population on the basis of a periodic premium. Provided, this chapter does not apply to

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insurance coverage providing benefits for:

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     (i) Hospital confinement indemnity;

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     (ii) Disability income;

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     (iii) Accident only;

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     (iv) Long-term care;

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     (v) Medicare supplement;

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     (vi) Limited benefit health;

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     (vii) Specific disease indemnity;

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     (viii) Sickness or bodily injury or death by accident or both; and

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     (ix) Other limited benefit policies.

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     (5) "Mental health or substance use disorder" means any mental disorder and substance use

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disorder that is listed in the most recent revised publication or the most updated volume of either

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the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American

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Psychiatric Association or the International Classification of Disease Manual (ICO) published by

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the World Health Organization; provided, that tobacco and caffeine are excluded from the

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definition of "substance" for the purposes of this chapter.

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     (6) "Non-quantitative treatment limitations" means: (i) Medical management standards; (ii)

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Formulary design and protocols; (iii) Network tier design; (iv) Standards for provider admission to

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participate in a network; (v) Reimbursement rates and methods for determining usual, customary,

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and reasonable charges; and (vi) Other criteria that limit scope or duration of coverage for services

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in the treatment of mental health and substance use disorders, including restrictions based on

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geographic location, facility type, and provider specialty.

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     (7) "Quantitative treatment limitations" means numerical limits on coverage for the

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treatment of mental health and substance use disorders based on the frequency of treatment, number

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of visits, days of coverage, days in a waiting period, or other similar limits on the scope or duration

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of treatment.

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     (8) "Serious mental illness" means a mental disorder as defined in the most recent edition

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of the Diagnostic and Statistical Manual of Mental Disorders published by the American

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Psychiatric Association that results in serious functional impairment that substantially interferes

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with or limits one or more major life activities.

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     (9) "Step therapy protocol" means a protocol that establishes a specific sequence in which

 

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prescription drugs for a specified medical condition are medically necessary for a particular

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enrollee and are covered under a pharmacy or medical benefit by a carrier, including self-

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administered and physician-administered drugs.

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     SECTION 2. Chapter 27-38.2 of the General Laws entitled "Insurance Coverage for Mental

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Illness and Substance Abuse" is hereby amended by adding thereto the following section:

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     27-38.2-6. Prohibition of prior authorization or step therapy protocol.

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     A group health plan, an individual or group health insurance plan, as defined under chapters

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18, 19, 20, and 41 of title 27, the Rhode Island medical assistance program, as defined under chapter

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8 of title 40, and any contract between the Rhode Island medical assistance program and a health

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insurer shall not require prior authorization or a step therapy protocol for the prescription of

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medication used to assess or treat an enrollee’s serious mental illness.

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     SECTION 3. This act shall take effect upon passage and shall apply to all policies,

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contracts, and certificates executed, delivered, issued for delivery, continued or renewed in this

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state on or after 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 prohibit a group health plan, an individual or group health insurance plan,

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the Rhode Island medical assistance program, and any contract between the Rhode Island medical

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assistance program and a health insurer from utilizing prior authorization or a step therapy protocol

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for the prescription of medication used to assess or treat an enrollee’s serious mental illness.

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     This act would take effect upon passage and would apply to all policies, contracts, and

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certificates executed, delivered, issued for delivery, continued or renewed in this state on or after

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January 1, 2023.

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