Rhode Island 2023 Regular Session

Rhode Island House Bill H6218 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1
2	2
3	3
4	4
5	5	2023 -- H 6218
6	6	========
7	7	LC002569
8	8	========
9	9	S T A T E O F R H O D E I S L A N D
10	10	IN GENERAL ASSEMBLY
11	11	JANUARY SESSION, A.D. 2023
12	12	____________
13	13
14	14	A N A C T
15	15	RELATING TO INSURANCE – INSURANCE COVERAGE FOR MENTAL ILLNESS AND
16	16	SUBSTANCE ABUSE
17	17	Introduced By: Representative Stephen M. Casey
18	18	Date Introduced: March 29, 2023
19	19	Referred To: House Health & Human Services
20	20
21	21
22	22	It is enacted by the General Assembly as follows:
23	23	SECTION 1. Section 27-38.2-2 of the General Laws in Chapter 27-38.2 entitled "Insurance 1
24	24	Coverage for Mental Illness and Substance Abuse" is hereby amended to read as follows: 2
25	25	27-38.2-2. Definitions. 3
26	26	For the purposes of this chapter, the following words and terms have the following 4
27	27	meanings: 5
28	28	(1) “Financial requirements” means deductibles, copayments, coinsurance, or out-of-6
29	29	pocket maximums. 7
30	30	(2) “Group health plan” means an employee welfare benefit plan as defined in 29 U.S.C. § 8
31	31	1002(1) to the extent that the plan provides health benefits to employees or their dependents directly 9
32	32	or through insurance, reimbursement, or otherwise. For purposes of this chapter, a group health 10
33	33	plan shall not include a plan that provides health benefits directly to employees or their dependents, 11
34	34	except in the case of a plan provided by the state or an instrumentality of the state. 12
35	35	(3) “Health insurance plan” means health insurance coverage offered, delivered, issued for 13
36	36	delivery, or renewed by a health insurer. 14
37	37	(4) “Health insurers” means all persons, firms, corporations, or other organizations offering 15
38	38	and assuring health services on a prepaid or primarily expense-incurred basis, including but not 16
39	39	limited to, policies of accident or sickness insurance, as defined by chapter 18 of this title; nonprofit 17
40	40	hospital or medical service plans, whether organized under chapter 19 or 20 of this title or under 18
41	41
42	42
43	43	LC002569 - Page 2 of 4
44	44	any public law or by special act of the general assembly; health maintenance organizations, or any 1
45	45	other entity that insures or reimburses for diagnostic, therapeutic, or preventive services to a 2
46	46	determined population on the basis of a periodic premium. Provided, this chapter does not apply to 3
47	47	insurance coverage providing benefits for: 4
48	48	(i) Hospital confinement indemnity; 5
49	49	(ii) Disability income; 6
50	50	(iii) Accident only; 7
51	51	(iv) Long-term care; 8
52	52	(v) Medicare supplement; 9
53	53	(vi) Limited benefit health; 10
54	54	(vii) Specific disease indemnity; 11
55	55	(viii) Sickness or bodily injury or death by accident or both; and 12
56	56	(ix) Other limited benefit policies. 13
57	57	(5) “Mental health or substance use disorder” means any mental disorder and substance 14
58	58	use disorder that is listed in the most recent revised publication or the most updated volume of 15
59	59	either the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American 16
60	60	Psychiatric Association or the International Classification of Disease Manual (ICO) published by 17
61	61	the World Health Organization; provided, that tobacco and caffeine are excluded from the 18
62	62	definition of “substance” for the purposes of this chapter. 19
63	63	(6) “Non-quantitative treatment limitations” means: (i) Medical management standards; 20
64	64	(ii) Formulary design and protocols; (iii) Network tier design; (iv) Standards for provider admission 21
65	65	to participate in a network; (v) Reimbursement rates and methods for determining usual, customary, 22
66	66	and reasonable charges; and (vi) Other criteria that limit scope or duration of coverage for services 23
67	67	in the treatment of mental health and substance use disorders, including restrictions based on 24
68	68	geographic location, facility type, and provider specialty. 25
69	69	(7) “Quantitative treatment limitations” means numerical limits on coverage for the 26
70	70	treatment of mental health and substance use disorders based on the frequency of treatment, number 27
71	71	of visits, days of coverage, days in a waiting period, or other similar limits on the scope or duration 28
72	72	of treatment. 29
73	73	(8) "Step therapy protocol" means a protocol that establishes a specific sequence in which 30
74	74	prescription drugs for a specified medical condition are medically necessary for a particular 31
75	75	enrollee and are covered under a pharmacy or medical benefit by a carrier, including self-32
76	76	administered and physician-administered drugs. 33
77	77	SECTION 2. Chapter 27-38.2 of the General Laws entitled "Insurance Coverage for Mental 34
78	78
79	79
80	80	LC002569 - Page 3 of 4
81	81	Illness and Substance Abuse" is hereby amended by adding thereto the following section: 1
82	82	27-38.2-7. Prohibition of prior authorization or step therapy protocol. 2
83	83	(a) A group health plan, an individual or group health insurance plan, as defined under 3
84	84	chapters 18, 19, 20, and 41 of title 27, the Rhode Island medical assistance program, as defined 4
85	85	under chapter 8 of title 40, and any contract between the Rhode Island medical assistance program 5
86	86	and a managed care organization shall not require prior authorization or a step therapy protocol for 6
87	87	the prescription of a nonpreferred medication on their drug formulary and used to assess or treat an 7
88	88	enrollee diagnosed with a bipolar disorder, schizophrenia or schizotypal disorder, major depressive 8
89	89	disorder, or post-traumatic stress disorder as defined by the American Psychiatric Association’s 9
90	90	Diagnostic and Statistical Manual of Mental Disorders, fifth edition. 10
91	91	(b) The provisions of subsection (a) of this section does not affect clinical prior 11
92	92	authorization edits to preferred and nonpreferred prescriptions of medications to treat serious 12
93	93	mental illness 13
94	94	(c) If it determines that authorization from a federal agency if necessary for the 14
95	95	implementation of this section, the executive office of health and human services is authorized to 15
96	96	seek such state plan amendment and may delay implementing the provisions until the authorization 16
97	97	is granted. 17
98	98	(d) The Rhode Island medical assistance program, as defined under chapter 8 of title 40, 18
99	99	shall require through amending current and future medical assistance managed care contracts, that 19
100	100	the managed care organizations meet the provisions of this section. 20
101	101	(e) This section does not prevent a group health plan, an individual or group health 21
102	102	insurance plan, as defined under chapters 18, 19, 20, and 41 of title 27, the Rhode Island medical 22
103	103	assistance program, as defined under chapter 8 of title 40, and any contract between the Rhode 23
104	104	Island medical assistance program and a managed care organization from denying an exception for 24
105	105	a drug that has been removed from the market due to safety concerns from the federal Food and 25
106	106	Drug Administration. 26
107	107	SECTION 3. This act shall take effect upon passage and applies to all policies, contracts, 27
108	108	and certificates executed, delivered, issued for delivery, continued or renewed in this state on or 28
109	109	after January 1, 2024. 29
110	110	========
111	111	LC002569
112	112	========
113	113
114	114
115	115	LC002569 - Page 4 of 4
116	116	EXPLANATION
117	117	BY THE LEGISLATIVE COUNCIL
118	118	OF
119	119	A N A C T
120	120	RELATING TO INSURANCE – INSURANCE COVERAGE FOR M ENTAL ILLNESS AND
121	121	SUBSTANCE ABUSE
122	122	***
123	123	This act would define step therapy protocol and prohibit a group health plan, an individual 1
124	124	or group health insurance plan, the Rhode Island medical assistance program, and any contract 2
125	125	between the Rhode Island medical assistance program and a managed care organization from 3
126	126	requiring prior authorization or a step therapy protocol for the prescription of a nonpreferred 4
127	127	medication on their drug formulary and used to assess or treat an enrollee diagnosed with a bipolar 5
128	128	disorder, schizophrenia or schizotypal disorder, major depressive disorder, or post-traumatic stress 6
129	129	disorder as defined by the American Psychiatric Association’s Diagnostic and Statistical Manual 7
130	130	of Mental Disorders, fifth edition. 8
131	131	This act would take effect upon passage and would apply to all policies, contracts, and 9
132	132	plans executed, delivered, issued for delivery, continued or renewed in this state on or after January 10
133	133	1, 2024. 11
134	134	========
135	135	LC002569
136	136	========