2023 -- H 6218

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LC002569

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2023

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A N   A C T

RELATING TO INSURANCE – INSURANCE COVERAGE FOR MENTAL ILLNESS AND

SUBSTANCE ABUSE

     

     Introduced By: Representative Stephen M. Casey

     Date Introduced: March 29, 2023

     Referred To: House Health & Human Services

     It is enacted by the General Assembly as follows:

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     SECTION 1. Section 27-38.2-2 of the General Laws in Chapter 27-38.2 entitled "Insurance

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Coverage for Mental Illness and Substance Abuse" is hereby amended to read as follows:

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     27-38.2-2. Definitions.

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

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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 U.S.C. §

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

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

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

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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 for

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delivery, or renewed by a health insurer.

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     (4) “Health insurers” means all persons, firms, corporations, or other organizations offering

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and assuring health services on a prepaid or primarily expense-incurred basis, including but not

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limited to, policies of accident or sickness insurance, as defined by chapter 18 of this title; nonprofit

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

 

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any public law or by special act of the general assembly; health maintenance organizations, or any

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other entity that insures or reimburses for diagnostic, therapeutic, or preventive services to a

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determined population on the basis of a periodic premium. Provided, this chapter does not apply to

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

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

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either the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American

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Psychiatric Association or the International Classification of Disease Manual (ICO) published by

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the World Health Organization; provided, that tobacco and caffeine are excluded from the

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definition of “substance” for the purposes of 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 admission

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

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

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

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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, number

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

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of treatment.

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     (8) "Step therapy protocol" means a protocol that establishes a specific sequence in which

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prescription drugs for a specified medical condition are medically necessary for a particular

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enrollee and are covered under a pharmacy or medical benefit by a carrier, including self-

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administered and physician-administered drugs.

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     SECTION 2. Chapter 27-38.2 of the General Laws entitled "Insurance Coverage for Mental

 

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Illness and Substance Abuse" is hereby amended by adding thereto the following section:

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     27-38.2-7. Prohibition of prior authorization or step therapy protocol.

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     (a) A group health plan, an individual or group health insurance plan, as defined under

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chapters 18, 19, 20, and 41 of title 27, the Rhode Island medical assistance program, as defined

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under chapter 8 of title 40, and any contract between the Rhode Island medical assistance program

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and a managed care organization shall not require prior authorization or a step therapy protocol for

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the prescription of a nonpreferred medication on their drug formulary and used to assess or treat an

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enrollee diagnosed with a bipolar disorder, schizophrenia or schizotypal disorder, major depressive

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disorder, or post-traumatic stress disorder as defined by the American Psychiatric Association’s

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Diagnostic and Statistical Manual of Mental Disorders, fifth edition.

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     (b) The provisions of subsection (a) of this section does not affect clinical prior

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authorization edits to preferred and nonpreferred prescriptions of medications to treat serious

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mental illness

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     (c) If it determines that authorization from a federal agency if necessary for the

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implementation of this section, the executive office of health and human services is authorized to

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seek such state plan amendment and may delay implementing the provisions until the authorization

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is granted.

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     (d) The Rhode Island medical assistance program, as defined under chapter 8 of title 40,

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shall require through amending current and future medical assistance managed care contracts, that

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the managed care organizations meet the provisions of this section.

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     (e) This section does not prevent a group health plan, an individual or group health

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insurance plan, as defined under chapters 18, 19, 20, and 41 of title 27, the Rhode Island medical

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assistance program, as defined under chapter 8 of title 40, and any contract between the Rhode

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Island medical assistance program and a managed care organization from denying an exception for

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a drug that has been removed from the market due to safety concerns from the federal Food and

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Drug Administration.

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     SECTION 3. This act shall take effect upon passage and applies to all policies, contracts,

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and certificates executed, delivered, issued for delivery, continued or renewed in this state on or

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after January 1, 2024.

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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 ABUSE

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     This act would define step therapy protocol and prohibit a group health plan, an individual

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or group health insurance plan, the Rhode Island medical assistance program, and any contract

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between the Rhode Island medical assistance program and a managed care organization from

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requiring prior authorization or a step therapy protocol for the prescription of a nonpreferred

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medication on their drug formulary and used to assess or treat an enrollee diagnosed with a bipolar

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disorder, schizophrenia or schizotypal disorder, major depressive disorder, or post-traumatic stress

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disorder as defined by the American Psychiatric Association’s Diagnostic and Statistical Manual

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of Mental Disorders, fifth edition.  

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     This act would take effect upon passage and would apply to all policies, contracts, and

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plans executed, delivered, issued for delivery, continued or renewed in this state on or after January

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1, 2024. 

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