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:

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

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

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hereby amended to read as follows:

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

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

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

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

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

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provided for other illnesses and diseases. Insurance coverage offered pursuant to this statute must

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include the same durational limits, amount limits, deductibles, and co-insurance factors for

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mental illness as for other illnesses and diseases.

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     (a) A group health plan, and an individual or group health insurance plan shall provide

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coverage for the treatment of mental health and substance use disorders under the same terms and

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conditions as that coverage is provided for other illnesses and diseases.

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     (b) Coverage for the treatment of mental health and substance use disorders shall not

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impose any annual or lifetime dollar limitation.

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     (c) Financial requirements and quantitative treatment limitations on coverage for the

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treatment of mental health and substance use disorders shall be no more restrictive than the

 

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predominant financial requirements applied to substantially all coverage for medical conditions in

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each treatment classification.

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     (d) Coverage shall not impose non-quantitative treatment limitations for the treatment of

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mental health and substance use disorders unless the processes, strategies, evidentiary standards,

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or other factors used in applying the non-quantitative treatment limitation, as written and in

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operation, are comparable to, and are applied no more stringently than, the processes, strategies,

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evidentiary standards, or other factors used in applying the limitation with respect to

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medical/surgical benefits in the classification.

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     (e) The following classifications shall be used to apply the coverage requirements of this

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chapter: (1) Inpatient, in-network; (2) Inpatient, out-of-network; (3) Outpatient, in-network; (4)

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Outpatient, out-of-network; (5) Emergency care; and (6) Prescription drugs.

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     (f) Medication-assisted therapy, including methadone maintenance services, for the

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

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the appropriate classification based on the site of the service.

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     27-38.2-2. Definitions. -- For the purposes of this chapter, the following words and terms

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have the following 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 USC

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

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

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

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dependents, 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

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for delivery, or renewed by a health insurer.

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

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offering and assuring health services on a prepaid or primarily expense-incurred basis, including

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but not limited to, policies of accident or sickness insurance, as defined by chapter 18 of this

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

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this title or under any public law or by special act of the general assembly,; health maintenance

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organizations, or any other entity which that insures or reimburses for diagnostic, therapeutic, or

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preventive services to a determined population on the basis of a periodic premium. Provided, this

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chapter does not apply to 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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      (2)(5) "Mental illness health or substance use disorder" means any mental disorder and

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substance abuse use disorder that is listed in the most recent revised publication or the most

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updated volume of either the Diagnostic and Statistical Manual of Mental Disorders (DSM)

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published by the American Psychiatric Association or the International Classification of Disease

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Manual (ICO) published by the World Health Organization and that substantially limits the life

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

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

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

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

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

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covered by this chapter.

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

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

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admission to participate in a network; (v) Reimbursement rates and methods for determining

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usual, customary, and reasonable charges; and (vi) Other criteria that limit scope or duration of

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coverage for services in the treatment of mental health and substance use disorders, including

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restrictions based on 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,

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

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or duration of treatment .

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      (3) "Mental illness coverage" means inpatient hospitalization, partial hospitalization

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provided in a hospital or any other licensed facility, intensive out patient services, outpatient

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services and community residential care services for substance abuse treatment. It shall not

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include methadone maintenance services or community residential care services for mental

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illnesses other than substance abuse disorders.

 

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

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illness and substance abuse.

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

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in accordance with chapter 24 of title 40.1.

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

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

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

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

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

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services are not available in the state of Rhode Island from a provider in the health insurer's

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network.

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      (b) For the purposes of this chapter, outpatient services, with the exception of outpatient

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medication visits, shall be provided for up to thirty (30) visits in any calendar year; outpatient

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services for substance abuse treatment shall be provided for up to thirty (30) hours in any

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calendar year; community residential care services for substance abuse treatment shall be

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provided for up to thirty (30) days in any calendar year; and detoxification benefits shall be

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provided for up to five (5) detoxification occurrences or thirty (30) days in any calendar year,

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whichever comes first.

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

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

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     27-38.2-5. Credentialing or contracting practices. -- Nothing in this chapter shall be

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construed to require a change in the credentialing or contracting practices of health insurers for

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mental health or substance abuse providers.

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     SECTION 3. Sections 23-17.26-2 and 23-17.26-3 of the General Laws in Chapter 23-

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

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

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

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

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

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

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

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

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

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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

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

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

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

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services as defined in ยง 23-17.12-2.

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

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

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

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

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

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

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evidence-based practices including, but not limited to:

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

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

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

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questions;

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

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

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

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

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

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      (v) Coordinating and improving communication with outpatient providers.

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

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

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

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plan and transition process shall also include:

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

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

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

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

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

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

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

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hospital;

 

LC005388/SUB A - Page 5 of 7

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

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

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

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follow-up appointment; and

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

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

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

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

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

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

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

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emergency room diversion facility.

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

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

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

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LC005388/SUB A

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LC005388/SUB A - Page 6 of 7

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 require mandatory health insurance coverage for the treatment of mental

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

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

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

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

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

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

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

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

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

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

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LC005388/SUB A

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