2026 -- S 2564

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LC005074

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2026

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A N   A C T

RELATING TO INSURANCE -- INSURANCE COVERAGE FOR MENTAL ILLNESS AND

SUBSTANCE USE DISORDERS

     Introduced By: Senators Ujifusa, Euer, Mack, Zurier, Murray, Acosta, DiMario,
Valverde, Lauria, and Bell

     Date Introduced: February 13, 2026

     Referred To: Senate Health & Human Services

     It is enacted by the General Assembly as follows:

     SECTION 1. Sections 27-38.2-1 and 27-38.2-2 of the General Laws in Chapter 27-38.2

entitled "Insurance Coverage for Mental Illness and Substance Use Disorders" are 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 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 provide coverage for substance use disorders, at a minimum, in

accordance with the criteria of the American Society of Addiction Medicine when developing

coverage for levels of care for substance use disorder treatment.

     (h) In conducting utilization review relating to service intensity or level of care placement

for a mental health or substance use disorder, a payor shall exclusively apply the most recent

version of the age-appropriate patient placement criteria developed by nonprofit professional

provider associations of the relevant clinical specialty and shall authorize placement at the service

intensity or level of care consistent with those criteria. If the payor’s application of the relevant

patient placement criteria is not consistent with the service intensity or level of care placement

requested by the patient or their provider, any adverse benefit determination notice shall include

full details of the payor’s assessment under the relevant criteria to the provider and the patient.

     (i) Mental health and substance use disorder coverage and clinical criteria shall not deviate

from generally accepted standards of care.

     (h)(j) 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)(k) 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.

     27-38.2-2. Definitions.

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

meanings:

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

pocket maximums.

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     (2) "Generally accepted standards of care" means standards of care and clinical practice

that are generally recognized by healthcare providers practicing in relevant clinical specialties such

as psychiatry, psychology, clinical social work, addiction medicine and counseling, and behavioral

health treatment, as reflected in sources including, but not limited to, patient placement criteria,

service intensity determination, and clinical practice guidelines developed by nonprofit

professional provider associations including, but not limited to, the Level of Care Utilization

System (LOCUS), the Child and Adolescent Level of Care/Service Intensity Utilization System

(CALOCUS-CASII), and the Early Childhood Service Intensity Instrument.

     (2)(3) “Group health plan” means an employee welfare benefit plan as defined in 29 U.S.C.

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

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

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

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

     (3)(4) “Health insurance plan” means health insurance coverage offered, delivered, issued

for delivery, or renewed by a health insurer.

     (4)(5) “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 that insures or reimburses for diagnostic, therapeutic, or preventive services to

a determined population on the basis of a periodic premium. Provided, 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.

     (5)(6) “Mental health or substance use disorder” means any mental disorder and substance

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

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either the

     (i) 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; provided, that tobacco and caffeine are excluded from

the definition of “substance” for the purposes of this chapter, or The Diagnostic Classification of

Mental Health and Developmental Disorders of Infancy and Early Childhood.

     (7) "Nonprofit professional provider association" means a not-for-profit healthcare

provider professional association or specialty society that is generally recognized by clinicians

practicing in the relevant clinical specialty and issues peer-reviewed guidelines, criteria, or other

clinical recommendations developed through a transparent process, including the American

Psychiatric Association, American Psychological Association, American Society of Addiction

Medicine, American Academy of Child and Adolescent Psychiatry, and the American Association

for Community Psychiatry.

     (6)(8) “Non-quantitative treatment limitations” means: (i) Medical management standards;

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

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

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

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

geographic location, facility type, and provider specialty.

     (7)(9) “Quantitative treatment limitations” means numerical limits on coverage for the

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

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

of treatment.

     SECTION 2. This act shall take effect upon passage.

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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 USE DISORDERS

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     This act would provide that for insurance coverage for treatment of mental health and

substance use disorders, payors would rely upon criteria which reflect generally accepted standards

of care when developing coverage for levels of care for mental health treatment. This act would

also provide that payors would not modify clinical criteria to reduce coverage for mental health

treatment below the level established by the generally accepted standards of care upon which their

clinical criteria are based. This act would also provide a definition for the term “generally accepted

standards of care.”

     This act would take effect upon passage.

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