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 | |
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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: | |
1 | SECTION 1. Section 27-38.2-2 of the General Laws in Chapter 27-38.2 entitled "Insurance |
2 | Coverage for Mental Illness and Substance Abuse" is hereby amended to read as follows: |
3 | 27-38.2-2. Definitions. |
4 | For the purposes of this chapter, the following words and terms have the following |
5 | meanings: |
6 | (1) “Financial requirements” means deductibles, copayments, coinsurance, or out-of- |
7 | pocket maximums. |
8 | (2) “Group health plan” means an employee welfare benefit plan as defined in 29 U.S.C. § |
9 | 1002(1) to the extent that the plan provides health benefits to employees or their dependents directly |
10 | or through insurance, reimbursement, or otherwise. For purposes of this chapter, a group health |
11 | plan shall not include a plan that provides health benefits directly to employees or their dependents, |
12 | except in the case of a plan provided by the state or an instrumentality of the state. |
13 | (3) “Health insurance plan” means health insurance coverage offered, delivered, issued for |
14 | delivery, or renewed by a health insurer. |
15 | (4) “Health insurers” means all persons, firms, corporations, or other organizations offering |
16 | and assuring health services on a prepaid or primarily expense-incurred basis, including but not |
17 | limited to, policies of accident or sickness insurance, as defined by chapter 18 of this title; nonprofit |
18 | hospital or medical service plans, whether organized under chapter 19 or 20 of this title or under |
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1 | any public law or by special act of the general assembly; health maintenance organizations, or any |
2 | other entity that insures or reimburses for diagnostic, therapeutic, or preventive services to a |
3 | determined population on the basis of a periodic premium. Provided, this chapter does not apply to |
4 | insurance coverage providing benefits for: |
5 | (i) Hospital confinement indemnity; |
6 | (ii) Disability income; |
7 | (iii) Accident only; |
8 | (iv) Long-term care; |
9 | (v) Medicare supplement; |
10 | (vi) Limited benefit health; |
11 | (vii) Specific disease indemnity; |
12 | (viii) Sickness or bodily injury or death by accident or both; and |
13 | (ix) Other limited benefit policies. |
14 | (5) “Mental health or substance use disorder” means any mental disorder and substance |
15 | use disorder that is listed in the most recent revised publication or the most updated volume of |
16 | either the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American |
17 | Psychiatric Association or the International Classification of Disease Manual (ICO) published by |
18 | the World Health Organization; provided, that tobacco and caffeine are excluded from the |
19 | definition of “substance” for the purposes of this chapter. |
20 | (6) “Non-quantitative treatment limitations” means: (i) Medical management standards; |
21 | (ii) Formulary design and protocols; (iii) Network tier design; (iv) Standards for provider admission |
22 | to participate in a network; (v) Reimbursement rates and methods for determining usual, customary, |
23 | and reasonable charges; and (vi) Other criteria that limit scope or duration of coverage for services |
24 | in the treatment of mental health and substance use disorders, including restrictions based on |
25 | geographic location, facility type, and provider specialty. |
26 | (7) “Quantitative treatment limitations” means numerical limits on coverage for the |
27 | treatment of mental health and substance use disorders based on the frequency of treatment, number |
28 | of visits, days of coverage, days in a waiting period, or other similar limits on the scope or duration |
29 | of treatment. |
30 | (8) "Step therapy protocol" means a protocol that establishes a specific sequence in which |
31 | prescription drugs for a specified medical condition are medically necessary for a particular |
32 | enrollee and are covered under a pharmacy or medical benefit by a carrier, including self- |
33 | administered and physician-administered drugs. |
34 | SECTION 2. Chapter 27-38.2 of the General Laws entitled "Insurance Coverage for Mental |
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1 | Illness and Substance Abuse" is hereby amended by adding thereto the following section: |
2 | 27-38.2-7. Prohibition of prior authorization or step therapy protocol. |
3 | (a) A group health plan, an individual or group health insurance plan, as defined under |
4 | chapters 18, 19, 20, and 41 of title 27, the Rhode Island medical assistance program, as defined |
5 | under chapter 8 of title 40, and any contract between the Rhode Island medical assistance program |
6 | and a managed care organization shall not require prior authorization or a step therapy protocol for |
7 | the prescription of a nonpreferred medication on their drug formulary and used to assess or treat an |
8 | enrollee diagnosed with a bipolar disorder, schizophrenia or schizotypal disorder, major depressive |
9 | disorder, or post-traumatic stress disorder as defined by the American Psychiatric Association’s |
10 | Diagnostic and Statistical Manual of Mental Disorders, fifth edition. |
11 | (b) The provisions of subsection (a) of this section does not affect clinical prior |
12 | authorization edits to preferred and nonpreferred prescriptions of medications to treat serious |
13 | mental illness |
14 | (c) If it determines that authorization from a federal agency if necessary for the |
15 | implementation of this section, the executive office of health and human services is authorized to |
16 | seek such state plan amendment and may delay implementing the provisions until the authorization |
17 | is granted. |
18 | (d) The Rhode Island medical assistance program, as defined under chapter 8 of title 40, |
19 | shall require through amending current and future medical assistance managed care contracts, that |
20 | the managed care organizations meet the provisions of this section. |
21 | (e) This section does not prevent a group health plan, an individual or group health |
22 | insurance plan, as defined under chapters 18, 19, 20, and 41 of title 27, the Rhode Island medical |
23 | assistance program, as defined under chapter 8 of title 40, and any contract between the Rhode |
24 | Island medical assistance program and a managed care organization from denying an exception for |
25 | a drug that has been removed from the market due to safety concerns from the federal Food and |
26 | Drug Administration. |
27 | SECTION 3. This act shall take effect upon passage and applies to all policies, contracts, |
28 | and certificates executed, delivered, issued for delivery, continued or renewed in this state on or |
29 | 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 | |
*** | |
1 | This act would define step therapy protocol and prohibit a group health plan, an individual |
2 | or group health insurance plan, the Rhode Island medical assistance program, and any contract |
3 | between the Rhode Island medical assistance program and a managed care organization from |
4 | requiring prior authorization or a step therapy protocol for the prescription of a nonpreferred |
5 | medication on their drug formulary and used to assess or treat an enrollee diagnosed with a bipolar |
6 | disorder, schizophrenia or schizotypal disorder, major depressive disorder, or post-traumatic stress |
7 | disorder as defined by the American Psychiatric Association’s Diagnostic and Statistical Manual |
8 | of Mental Disorders, fifth edition. |
9 | This act would take effect upon passage and would apply to all policies, contracts, and |
10 | plans executed, delivered, issued for delivery, continued or renewed in this state on or after January |
11 | 1, 2024. |
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