2014 -- S 2701

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LC004743

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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 ABUSE

     Introduced By: Senators Cool Rumsey, Miller, Jabour, Sosnowski, and Ottiano

     Date Introduced: March 05, 2014

     Referred To: Senate Health & Human Services

     It is enacted by the General Assembly as follows:

     SECTION 1. Sections 27-38.2-1, 27-38.2-2 and 27-38.2-3 of the General Laws in

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

hereby amended to read as follows:

     27-38.2-1. Mental illness coverage. -- Every health care insurer that delivers or issues

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

supplemental coverage to Medicare or other governmental programs, shall provide coverage for

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

as that coverage is provided for other illnesses and diseases. Insurance coverage offered pursuant

to this statute must include the same durational limits, amount limits, deductibles, and co-

insurance factors for mental illness as for other illnesses and diseases. shall provide equivalent

health benefits for addiction and behavioral health care and surgical services, including a primary

care practitioner's diagnosis of mental health or a substance abuse disorder, and the associated

coverage of any medication or therapy for treatment of the disorder in a prescription drug

formulary. Every health care insurer covered by this chapter shall also be prohibited from

imposing separate or more restrictive financial requirements or treatment limitations on mental

health and substance abuse disorder benefits than those they imposed on other general medical

benefits for the individual policy holders, enrollees, subscribers, or members for policies subject

to federal MHPAEA and all provisions of this chapter.

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

have the following meanings:

      (1) "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 which 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.

      (2) "Mental illness" means any mental disorder and substance abuse 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 and that substantially limits the life activities of the person with the illness;

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

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

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

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

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

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

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

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

include methadone maintenance services or community residential care services for mental

illnesses other than substance abuse disorders.

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

illness and substance abuse.

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

in accordance with chapter 24 of title 40.1.

     (6) "MHPAEA" means the Paul Wellstone and Pete Domenici Mental Health Parity and

Addition Equity Act of 2008 section 511 of Pub. L. 110-343 and all subsequent rules and

regulations.

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

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

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

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

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

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

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

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

or her own expense.

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

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

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

agreement and shall use medical management standards that are comparable to and applied no

more stringently than the standards used to determine medical necessity for other medical and

surgical services and/or procedures.

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

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

of health pursuant to chapter 17.12 of title 23.

     SECTION 2. This act shall take effect upon passage.

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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 specify the nature and extent of the health benefits for addictive and

behavioral healthcare and surgical services that health insurers must offer in their health

insurance policies relating to a diagnosis of mental health or substance abuse disorders in order to

make these benefits equivalent to those benefits offered for general medical benefits.

     This act would take effect upon passage.

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