A N A C T
RELATING TO INSURANCE COVERAGE FOR MENTAL ILLNESS
It is enacted by the General Assembly as follows:
SECTION 1. The title of Chapter 27-38.2 of the General Laws entitled "Insurance Coverage for Serious Mental Illness" is hereby amended to read as follows:
INSURANCE COVERAGE FOR SERIOUS MENTAL ILLNESS
INSURANCE COVERAGE FOR MENTAL ILLNESS AND SUBSTANCE ABUSE
SECTION 2. Sections 27-38.2-1, 27-38.2-2, 27-38.2-3 and 27-38.2-4 of the General Laws in Chapter 27-38.2 entitled "Insurance Coverage for Serious Mental Illness" are hereby amended to read as follows:
27-38.2-1. Mental illness coverage. -- Every health care insurer that delivers or issues for delivery or renews in this state on or after January 1, 2002, a contract, plan, or policy except contracts providing supplemental coverage to medicare or other governmental programs, shall provide coverage for the medical treatment of serious mental illness and substance abuse under the same terms and conditions as such coverage is provided for other illnesses and diseases. Insurance coverage offered pursuant to this statute must include the same durational limits, amount limits, deductibles, and co-insurance factors for serious mental illness as for other illnesses and diseases.
27-38.2-2. Definitions. -- For the purposes of this chapter, the following words and terms shall have the following meanings:
(1) "Health insurers" means all persons, firms, corporations, or other organizations offering and assuring health services on a prepaid or primarily expense-incurred basis, including but not limited to policies of accident or sickness insurance, as defined by chapter 18 of this title, nonprofit hospital or medical service plans, whether organized under chapter 19 or 20 of this title or under any public law or by special act of the general assembly, health maintenance organizations, or any other entity which insures or reimburses for diagnostic, therapeutic, or preventive services to a determined population on the basis of a periodic premium, except for supplemental policies which only provide coverage for specified diseases. Provided, however, this chapter does not apply to insurance coverage providing benefits for: (i) hospital confinement indemnity; (ii) disability income; (iii) accident only; (iv) long-term care; (v) medicare supplement; (vi) limited benefit health; (vii) specific disease indemnity; (viii) sickness or bodily injury or death by accident or both; and (ix) other limited benefit policies.
(2) "Serious mental Mental illness" means any mental disorder and substance abuse disorder that is listed in the most recent revised publication or the most updated volume of either the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association or the International Classification of Disease Manual (ICO) published by the World Health Organization that current medical science affirms is caused by a biological disorder of the brain and that substantially limits the life activities of the person with the illness, provided, however, that tobacco and caffeine are hereby excluded from the definition of "substance" for the purposes of this chapter. "Mental illness" shall not include: (a) mental retardation, (b) learning disorders, (c) motor skills disorders, (d) communication disorders, and (e) mental disorders classified as "V" codes. Nothing shall preclude persons with the foregoing conditions from receiving benefits provided under this chapter for any other diagnoses covered by this chapter. The term includes, but is not limited to:
(i) Schizophrenia;
(ii) Schizoaffective disorder;
(iii) Delusional disorder;
(iv) Bipolar affective disorders;
(v) Major depression;
(vi) Obsessive compulsive disorder.
(3) "Medical Mental illness coverage" means inpatient hospitalization, and out-patient medication visits. partial hospitalization provided in a hospital or any other licensed facility, intensive out patient services, outpatient services and community residential care services for substance abuse treatment. However, it shall not include methadone maintenance services or community residential care services for mental illnesses other than substance abuse disorders.
(4) "Outpatient services" means office visits which provide for the treatment of mental illness and substance abuse.
(5) "Community residential care services" shall mean those facilities as defined and licensed in accordance with chapter 24 of title 40.1.
27-38.2-3. Medical necessity and appropriateness of treatment. -- Upon request of the reimbursing health insurers, all providers of treatment of serious mental illness shall furnish medical records or other necessary data which substantiates that initial or continued treatment is at all times medically necessary and appropriate. When the provider cannot so establish the medical necessity and/or appropriateness of the treatment modality being provided, neither the health insurer nor the patient shall be obligated to reimburse for that period or type of care which was not so established. The exception to the preceding can only be made if the patient has been informed of the above and has agreed in writing to continue to receive treatment at his or her own expense.
The health insurers, when making the above determination of medically necessary and appropriate treatment, must do so in a manner consistent with that used to make the determination for the treatment of other diseases or injuries covered under the health insurance policy or agreement.
Any subscriber who is aggrieved by a denial of benefits provided under this chapter may appeal a denial in accordance with the rules and regulations promulgated by the department of health pursuant to chapter 17.12 of title 23.
27-38.2-4. Limitations of coverage. - (a) The health care benefits outlined in this chapter apply only to services delivered within the state of Rhode Island.
Inpatient coverage in cases where continuous hospitalization is medically necessary shall be limited to ninety (90) consecutive days. ; provided, however, that all health insurers shall be required to provide coverage for those benefits mandated by this chapter outside of the state of Rhode Island where it can be established through a pre-authorization process that the services requires are not available in the state of Rhode Island from a provider in the health insurer's network.
(b) For the purposes of this chapter, outpatient services, with the exception of outpatient medication visits, shall be provided for up to thirty (30) visits in any calendar year, however, outpatient services for substance abuse treatment shall be provided for up to thirty (30) hours in any calendar year; community residential care services for substance abuse treatment shall be provided for up to thirty (30) days in any calendar year; and detoxification benefits shall be provided for up to five (5) detoxification occurrences or thirty (30) days in any calendar year, whichever comes first.
SECTION 3. Chapter 27-38.2 of the General Laws entitled "Insurance Coverage for Serious Mental Illness" is hereby amended by adding thereto the following section:
27-38.2-5. Credentialing or contractng practices. -- Nothing in this chapter shall be construed to require a change in the credentialing or contracting practices of health insurers for mental health or substance abuse providers.
SECTION 4. Chapter 27-38 of the General Laws entitled "Insurance Coverage for Treatment of Substance Abuse" is hereby repealed in its entirety.
CHAPTER 38
Insurance Coverage for Treatment of Substance Abuse
27-38-1. Health insurance coverage. -- (a) Every health insurer shall provide coverage for services relating to medically necessary treatment for substance dependency and substance abuse, including medically necessary treatment for substance dependency and substance abuse that is ordered as a condition of sentencing by any court in the State of Rhode Island. The court ordered treatment must be within the provisions of this chapter. For the purposes of this chapter, the term "substance dependency and substance abuse" is defined as the pattern of pathological use of alcohol or other psychoactive drugs characterized by impairments in social and/or occupational functioning, debilitating physical condition, inability to abstain from or reduce consumption of the substance, or the need for daily substance use for adequate functioning. The term "substance" is defined to include alcohol and those drugs included on the department of health list of addictive drugs as of January 1, 1988; provided, however, that tobacco and caffeine are hereby excluded from the definition of "substance" for the purposes of this chapter.
(b) Benefits for expenses arising from medically necessary treatment for substance dependency and substance abuse shall include the following and shall be reimbursed in accordance with the provisions of this chapter and the reimbursement policies and procedures of each health insurer:
(1) Benefits based upon inpatient services in a hospital licensed in Rhode Island or in a department of health licensed community residential facility for substance dependency and substance abuse treatment as defined in chapter 24 of title 40.1 shall be reimbursed in accordance with each health insurer's respective principles and mechanisms of reimbursement for services provided by hospitals, skilled nursing facilities, or other nonhospital providers of substance dependency and substance abuse services;
(2) Benefits based upon day or evening treatment services and/or partial hospitalization services in a hospital licensed in Rhode Island or in a department of health licensed community residential facility for substance dependency and substance abuse treatment as defined in chapter 24 of title 40.1 or a department of health licensed nonresidential facility for substance abuse treatment as defined in chapter 24 of title 40.1 shall be reimbursed in accordance with each health insurer's respective principles and mechanisms of reimbursement for services provided by hospitals, skilled nursing facilities, or other nonhospital providers of substance dependency and substance abuse services; and
(3) Outpatient benefits of thirty (30) hours for each individual under treatment and twenty (20) hours for family members in any twelve (12) month period shall cover substance dependency and substance abuse services furnished in a hospital licensed in Rhode Island or in a department of health licensed public or private facility providing services especially for the rehabilitation of substance abusers.
(c) Benefits under subsections (b)(1) and (b)(2) shall be provided as follows:
(1) Detoxification benefits shall be provided for up to three (3) detoxification occurrences or twenty-one (21) days per year, whichever comes first; and
(2) Intensive rehabilitation services benefits shall be provided for a period not to exceed thirty (30) days in any twelve (12) month period. Health insurers shall provide a lifetime benefit per patient of ninety (90) days for intensive rehabilitation. In calculating those benefits:
(i) One day of treatment provided in a residential treatment program shall be counted as one day of intensive rehabilitation treatment; and
(ii) Two (2) days of treatment provided in a day or evening and/or partial hospitalization program shall be counted as one day of intensive rehabilitative treatment.
(d) There shall be no reimbursement under subsection (b) other than for facility payment.
(e) Licensed providers of substance dependency and substance abuse treatment shall submit to health insurers upon request financial data including financial statements, budgets, cost allocations, volume projections, charges and any other data necessary to determine reasonableness of costs and/or of charges.
(f) Health insurers shall not be required under this chapter to provide benefit coverage for substance dependency and substance abuse treatment services rendered at a facility located outside of Rhode Island unless that facility meets reasonable criteria established by the health insurers.
(g) Notwithstanding the terms and limitations set forth in subsections (b) and (f), health insurers shall be required to provide benefit coverage for services at an out of state facility in cases where it can be established through a pre-admission certification process that the treatment services required are not offered at any facility in Rhode Island or at any out of state facility that has met a health insurer's criteria.
(h) Nothing in this chapter shall prevent the conducting of managed care reviews and medical necessity reviews by an insurer or hospital, medical service corporation or health maintenance organization.
27-38-2. Medical necessity and appropriateness of treatment. -- All providers of treatment for substance dependency and substance abuse shall gather and make available upon request of reimbursing health insurers medical records or other necessary data sufficient to prove that initial or continued treatment is at all times medically necessary and the treatment modality is medically appropriate. When the provider cannot so establish the medical necessity and/or medical appropriateness of the treatment modality for substance dependency and substance abuse treatment being provided, neither the health insurer nor the patient shall be obligated to reimburse for that period or type of care which was not so established, unless the patient has been so informed that either initial or continued treatment is not medically necessary and/or the treatment modality is not medically appropriate and will not be paid in whole or in part by a health insurer and has agreed in writing to continue receiving treatment at his own expense. Each provider shall be responsible for establishing and operating an effectively functioning utilization review program on a concurrent basis.
27-38-3. Evaluation of treatment. -- All participating providers shall be required to collect and routinely make available to health insurers, and the department of mental health, retardation, and hospitals, cost data in amounts deemed sufficient by health insurers to enable them to compare the relative effectiveness of treatment among different treatment modes over time, both in terms of result in regard to whether the total health care cost has increased or decreased as a result of specialized substance dependency and substance abuse treatment. The availability of the cost data shall be in conformity with the confidentiality of health records under federal and state law.
27-38-4. Standards. -- (a) All providers seeking reimbursement hereunder must as a condition of reimbursement meet or prove capability to meet reasonable standards of participation. Among other requirements, the providers must be:
(1) A licensed hospital located in Rhode Island which is accredited by the joint commission on the accreditation of hospitals;
(2) An inpatient facility with residential rehabilitation treatment and/or detoxification programs as licensed by the department of mental health, retardation, and hospitals and accredited by the joint commission on accreditation of hospitals. Treatment must be rendered under the direct supervision of a licensed doctor of medicine;
(3) Day or evening treatment services and/or partial hospitalization services in a licensed hospital located in Rhode Island or in a MHRH licensed facility for substance dependency and substance abuse treatment;
(4) A facility located in Rhode Island with nonresidential treatment programs and facilities approved and licensed by the department of mental health, retardation, and hospitals; or
(5) An out-of-state facility which either (A) meets reasonable criteria established by the health insurers as provided in section 27-38-1(f) or (B) satisfies the requirements of section 27-38-1(g).
(b) In addition, all providers must collect and maintain reliable data on costs and treatment effectiveness and where applicable, have received appropriate certificate of need certification.
27-38-5. Applicability. -- (a) The provisions of this chapter shall apply to services provided to residents of this state in any facility which meets the criteria in section 27-38-4.
(b) The provisions of this chapter shall apply to residents of this state who are receiving Medicare supplementary benefits from health insurers at such times as benefits for specialized substance dependency and substance abuse treatment facilities are provided under the Medicare law.
(c) The provisions of this chapter shall not apply to any health insurer which offers, provides, or sells only specialized supplemental policies which provide coverage only for specified diseases.
(d) The provisions of this chapter shall not apply to "blanket student accident" policies.
27-38-6. "Health insurers" defined. -- (a) The term "health insurers" as used herein shall include all persons, firms, corporations, or other organizations offering and assuring health services on a prepaid or primarily expense incurred basis, including but not limited to policies of accident or sickness insurance, as defined by chapter 18 of this title, nonprofit hospital or medical service plans, whether organized under chapter 19 or 20 of this title or under any public law or by special act of the general assembly, health maintenance organizations, and any other entity which insures or reimburses for diagnostic, therapeutic, or preventive services to a defined population on the basis of a periodic premium.
(b) The term shall also include all organizations providing health benefits coverage for employees on a self-insurance basis without the intervention of other entities.
27-38-7. Informational filings. -- Every health insurer providing coverage for services relating to treatment for substance dependency and substance abuse shall annually report to the director of business regulation the terms of the coverage including provisions for payment by the insured party to the provider for any portion of the services rendered. The health insurers will file any material changes to the terms of coverage no later than fifteen (15) days after the changes become effective. The director of business regulation may, after an opportunity for a hearing, revoke or suspend the authority of a health insurer to sell in this state if the terms or conditions are not in compliance with this chapter. The director of business regulation shall make available to providers of treatment for substance dependency and substance abuse all information gathered pursuant to this section. The director of business regulation may designate annual reporting dates pursuant to this section.
27-38-8. Establishment of permanent advisory commission. -- (a) The commission to study the feasibility and desirability of mandating third party coverage of alcoholism treatment, originally created by resolution 78S-2833, passed on April 28, 1978, and which became effective May 10, 1978, and became resolution no. 61 which was reinstated and the reporting date extended to May 2, 1980, and which was established by Public Laws 1980, ch. 282, section 1, as the permanent advisory commission to study the continuation and desirability of maintaining third party coverage of alcoholism treatment, is hereby reestablished as the permanent advisory commission on third party coverage for substance dependency and substance abuse treatment, and the permanent advisory commission shall meet on a regular basis as determined by the chairman, at which time all data provided to the commission by all concerned parties shall be reviewed to determine the continuation of third party coverage for substance dependency and substance abuse treatment within the state of Rhode Island.
(b) The membership of the permanent commission shall be concomitant with the original appointments of the study commission.
(c) The permanent commission shall file an annual report with the general assembly no later than January 10 of each year.
27-38-9. Hearings. -- In the event of noncompliance with or failure to implement the provisions of this chapter by any health insurer, any aggrieved party may request a hearing before the permanent advisory commission on third party coverage for substance dependency and substance abuse treatment. The permanent commission may establish rules and regulations for the conduct of the hearings that it may deem advisable. All complaints filed with the commission and the commission's findings with respect thereto shall be included in the general report of the commission. Nothing herein shall be construed to confer upon the permanent advisory commission power to adjudicate rights and responsibilities between or among health care providers, health insurers, and insureds.
SECTION 5. This act shall take effect January 1, 2002.