Title 27
Insurance

Chapter 38.2
Insurance Coverage for Mental Illness and Substance Use Disorders

§ 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 U.S.C. § 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.

(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 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;

(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.

(5) “Mental health or substance use disorder” means any mental disorder and substance 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; provided, that tobacco and caffeine are excluded from the definition of “substance” for the purposes of 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.