2014 -- H 8042 SUBSTITUTE A

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LC005388/SUB A

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2014

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A N   A C T

RELATING TO INSURANCE - INSURANCE COVERAGE FOR MENTAL ILLNESS AND

SUBSTANCE USE DISORDERS

     Introduced By: Representatives Serpa, Tomasso, Fellela, Ferri, and Silva

     Date Introduced: April 10, 2014

     Referred To: House Corporations

     It is enacted by the General Assembly as follows:

     SECTION 1. Sections 27-38.2-1, 27-38.2-2 and 27-38.2-4 of the General Laws in

Chapter 27-38.2 entitled "Insurance Coverage for Mental Illness and Substance Abuse" are

hereby amended to read as follows:

     27-38.2-1. Mental illness coverage Coverage for the treatment of mental health and

substance use disorders. -- Every health care insurer that delivers or issues for delivery or

renews in this state a contract, plan, or policy except contracts providing supplemental coverage

to Medicare or other governmental programs, shall provide coverage for the medical treatment of

mental illness and substance abuse under the same terms and conditions as that 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

mental illness as for other illnesses and diseases.

     (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 therapy, including methadone maintenance services, for the

treatment of substance use disorders, opioid overdoses, and chronic addiction is included within

the appropriate classification based on the site of the service.

     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.

     (2) "Group health plan" means an employee welfare benefit plan as defined in 29 USC

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

for delivery, or renewed by a health insurer.

      (1)(4) "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 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;

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

substance abuse use 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 and that substantially limits the life

activities of the person with the illness; provided, that tobacco and caffeine are excluded from the

definition of "substance" for the purposes of this chapter. "Mental illness" shall not include: (i)

mental retardation, (ii) learning disorders, (iii) motor skills disorders, (iv) communication

disorders, and (v) mental disorders classified as "V" codes. Nothing shall preclude persons with

these conditions from receiving benefits provided under this chapter for any other diagnoses

covered by this chapter.

     (6) "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) "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 .

      (3) "Mental illness coverage" means inpatient hospitalization, 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. It shall not

include methadone maintenance services or community residential care services for mental

illnesses other than substance abuse disorders.

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      (4) "Outpatient services" means office visits that provide for the treatment of mental

illness and substance abuse.

      (5) "Community residential care services" mean those facilities as defined and licensed

in accordance with chapter 24 of title 40.1.

     27-38.2-4. Limitations of coverage Network coverage. -- (a) The health care benefits

outlined in this chapter apply only to services delivered within the state of Rhode Island health

insurer's provider network; provided, that all health insurers shall be required to provide coverage

for those benefits mandated by this chapter outside of the state of Rhode Island health insurer's

provider network where it can be established through a pre-authorization process that the required

services 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; 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 2. Section 27-38.2-5 of the General Laws in Chapter 27-38.2 entitled

"Insurance Coverage for Mental Illness and Substance Abuse" is hereby repealed.

     27-38.2-5. Credentialing or contracting 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 3. Sections 23-17.26-2 and 23-17.26-3 of the General Laws in Chapter 23-

17.26 entitled "Comprehensive Discharge Planning" are hereby amended to read as follows:

     23-17.26-2. Definitions. -- As used in this chapter:

     (1) "Director" means the director of department of health.

     (2) "Department" means the department of health.

     (3) "Emergency room diversion facility" means a health care facility approved by the

Rhode Island department of behavioral healthcare, developmental disabilities and hospitals to act

as an immediate alternative to a hospital or emergency room, and which concentrates on treating

non-urgent substance use disorders that can be appropriately treated in alternative settings.

     (4) "Health care clinic" means a health care facility licensed in accordance with chapter

17 of this title and that primarily delivers ambulatory care on an out-patient basis.

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     (3)(5) "Hospital" means a person or governmental entity licensed in accordance with

chapter 17 of this title to establish, maintain, and operate a hospital.

     (6) "Urgent care center" means a health care facility licensed in accordance with chapter

17 of this title that primarily provides emergent health care services and urgent health care

services as defined in § 23-17.12-2.

     23-17.26-3. Comprehensive discharge planning. -- (a) On or before July 1, 2015, each

hospital operating in the State of Rhode Island shall submit to the director:

      (1) Evidence of participation in a high-quality comprehensive discharge planning and

transitions improvement project operated by a nonprofit organization in this state; or

      (2) A plan for the provision of comprehensive discharge planning and information to be

shared with patients transitioning from the hospitals care. Such plan shall contain the adoption of

evidence-based practices including, but not limited to:

      (i) Providing in-hospital education prior to discharge;

      (ii) Ensuring patient involvement such that, at discharge, patients, and caregivers

understand the patient's conditions and medications and have a point of contact for follow-up

questions;

      (iii) Attempting to identify patients' primary care providers and assisting with scheduling

post-hospital follow-up appointments prior to patient discharge;

      (iv) Expanding the transmission of the department of health's continuity of care form, or

successor program, to include primary care providers' receipt of information at patient discharge

when the primary care provider is identified by the patient; and

      (v) Coordinating and improving communication with outpatient providers.

     (3) The discharge plan and transition process shall also be made for patients with opioid

and other substance use disorders, which plan and transition process shall include the elements

contained in subsections (a)(1) or (a)(2) of this section, as applicable. In addition, such discharge

plan and transition process shall also include:

     (i) Assistance, with patient consent, in securing at least one follow-up appointment for

the patient within seven (7) days of discharge, as clinically appropriate: (A) With a facility

licensed by the department of behavioral healthcare, developmental disabilities and hospitals to

provide treatment of substance use disorders; (B) With a certified recovery coach; (C) With a

licensed clinician with expertise in the treatment of substance use disorders or (D) With a Rhode

Island licensed hospital with a designated program for the treatment of substance use disorders.

The patient shall be informed of said appointment prior to the patient being discharged from the

hospital;

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     (ii) In the absence of a scheduled follow-up appointment pursuant to subsection (a)(3)(i),

every reasonable effort shall be made to contact the patient within thirty (30) days post-discharge

to provide the patient with a referral and other such assistance as the patient needs to obtain a

follow-up appointment; and

     (iii) That the patient receives information about the real-time availability of appropriate

in-patient and out-patient services in Rhode Island.

     (4) On or before November 1, 2014, the director of the department of health shall develop

and disseminate to all hospitals, health care clinics, urgent care centers, and emergency room

diversion facilities a model discharge plan and transition process for patients with opioid and

other substance use disorders. This model plan may be used as a guide, but may be amended and

modified to meet the specific needs of each hospital, health care clinic, urgent care center and

emergency room diversion facility.

     SECTION 4. Sections 1 and 2 of this act shall take effect upon passage and shall apply to

plans offered, issued or renewed after January 1, 2015. Section 3 of this act shall take effect on

October 1, 2014. Section 4 of 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

***

     This act would require mandatory health insurance coverage for the treatment of mental

health and substance use disorders under the same terms and conditions that are provided for

other illnesses and diseases. The act establishes and defines the concept of a "mental health or

substance use disorder". This act would also require hospitals to amend their discharge plans and

transition processes to address patients with opioid and other substance use disorders. The

director of the department of health would be directed to develop and disseminate to all hospitals,

health care clinics, urgent care centers, and emergency room diversion facilities a model

discharge plan and transition process for patients with opioid and other substance use disorders.

     Sections 1 and 2 of this act would take effect upon passage and would apply to plans

offered, issued or renewed after January 1, 2015. Section 3 of this act would take effect on

October 1, 2014. Section 4 of this act would take effect upon passage.

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