2013 -- H 5613

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LC01539

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STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2013

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A N A C T

RELATING TO INSURANCE - COVERAGE FOR MENTAL ILLNESS AND SUBSTANCE

ABUSE

     

     

     Introduced By: Representatives Ajello, Handy, O`Grady, McNamara, and Keable

     Date Introduced: February 27, 2013

     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 27-38.2-3 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. Every health care insurer that delivers or issues for

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

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coverage to Medicare or other governmental programs, shall: (1) Provide provide coverage for

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the medical treatment of mental illness and substance abuse under the same terms and conditions

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as that coverage is provided for other illnesses and diseases; and (2) Ensure that reimbursement

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for professional providers providing treatment of mental illness and substance abuse is

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determined using the same methodology as reimbursement for professional providers of medical

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services. Insurance coverage offered pursuant to this statute must include the same durational

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limits, amount limits, deductibles, and co-insurance factors for mental illness as for other illnesses

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and diseases.

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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) "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 title,

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nonprofit hospital and/or medical service plans, whether organized under chapter 19 or 20 of this

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title or under any public law, or by special act of the general assembly or by executive order,

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health maintenance organizations, or any other entity which insures or reimburses for diagnostic,

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therapeutic, or preventive services to a determined population on the basis of a periodic premium.

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Provided, this 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) "Mental illness" means any mental disorder and substance abuse disorder that is

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listed in the most recent revised publication or the most updated volume of either the Diagnostic

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

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

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Health Organization and that substantially limits the life activities of the person with the illness;

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provided, that tobacco and caffeine are excluded from the definition of "substance" for the

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purposes of this chapter. "Mental illness" shall not include: (i) mental retardation, (ii) learning

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disorders, (iii) motor skills disorders, (iv) communication disorders, and (v) mental disorders

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classified as "V" codes. Nothing shall preclude persons with these conditions from receiving

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benefits provided under this chapter for any other diagnoses covered by this chapter.

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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 means those facilities as defined and

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licensed in accordance with chapter 24 of title 40.1 or as similarly licensed outside the state of

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Rhode Island.

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     (6) "Commissioner" means the commissioner of the office of the health insurance

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commissioner.

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     27-38.2-3. Medical necessity and appropriateness of treatment. -- (a) Upon request of

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the reimbursing health insurers, all providers of treatment of mental illness shall furnish medical

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records or other necessary data which substantiates that initial or continued treatment is at all

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times medically necessary and appropriate. When the provider cannot establish the medical

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necessity and/or appropriateness of the treatment modality being provided, neither the health

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insurer nor the patient shall be obligated to reimburse for that period or type of care that was not

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established. The exception to the preceding can only be made if the patient has been informed of

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the provisions of this subsection and has agreed in writing to continue to receive treatment at his

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or her own expense.

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      (b) The health insurers, when making the determination of medically necessary and

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appropriate treatment, must do so in a manner consistent with that used to make the determination

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for the treatment of other diseases or injuries covered under the health insurance policy or

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agreement.

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      (c) Any subscriber who is aggrieved by a denial of benefits provided under this chapter

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may appeal a denial in accordance with the rules and regulations promulgated by the department

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of health pursuant to chapter 17.12 of title 23. Any aggrieved subscriber is entitled to receive the

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medical criteria used to make the denial determination as well as the reason(s) for denial of

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payment of benefits in writing.

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     SECTION 2. Section 27-38.2-4 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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     27-38.2-4. Limitations of coverage. -- (a) The health care benefits outlined in this

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chapter apply only to services delivered within the state of Rhode Island; provided, that all health

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insurers shall be required to provide coverage for those benefits mandated by this chapter outside

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of the state of Rhode Island where it can be established through a pre-authorization process that

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the required services are not available in the state of Rhode Island from a provider in the health

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insurer's 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 3. Chapter 27-38.2 of the General Laws entitled "Insurance Coverage for

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

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     27-38.2-6. Regulations. (a) The commissioner is hereby authorized to promulgate rules

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and regulations to implement the provisions of this chapter.

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     (b) Upon issuance of final federal rules implementing the Paul Wellstone and Pete

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Domenici Mental Health Parity and Addiction Equity Act of 2008, the commissioner shall

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ensure that state rules and regulations are in compliance with federal rules.

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     SECTION 4. This act shall take effect upon passage.

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LC01539

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N A C T

RELATING TO INSURANCE - COVERAGE FOR MENTAL ILLNESS AND SUBSTANCE

ABUSE

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     This act would ensure that reimbursement for professional providers providing treatment

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of mental illness and substance abuse is determined using the same methodology as

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reimbursement for professional providers of medical services.

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     This act would take effect upon passage.

     

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LC01539

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H5613