Introduced By: Senators Perry, Roberts, Cicilline, Graziano and Gallo
Date Introduced : February 9, 1999
It is enacted by the General Assembly as follows:
SECTION 1. Sections 27-38.2-2 and 27-38.2-3 of the General Laws in Chapter 27-38.2 entitled "Insurance Coverage for Serious Mental Illness" are hereby amended to read as follows:
27-38.2-2. 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.
(2) "Serious mental illness" means any mental disorder 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. 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 coverage" means inpatient hospitalization and out-patient medication visits.
27-38.2-3. Medical necessity and appropriateness of treatment. -- Denial of benefits -- Appeal. -- 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.
{ADD Any subscriber who is aggrieved by a denial of benefits to be 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. ADD}
SECTION 2. This act shall take effect upon passage.
