Rhode Island 2025 Regular Session

Rhode Island Senate Bill S0193 Compare Versions

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

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5	5	2025 -- S 0193
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7	7	LC001182
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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. 2025
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 USE DISORDERS
17	17	Introduced By: Senators Ujifusa, Lauria, Murray, Valverde, DiMario, Quezada, DiPalma,
18	18	Bell, and Mack
19	19	Date Introduced: February 07, 2025
20	20	Referred To: Senate Health & Human Services
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23	23	It is enacted by the General Assembly as follows:
24	24	SECTION 1. Sections 27-38.2-1 and 27-38.2-2 of the General Laws in Chapter 27-38.2 1
25	25	entitled "Insurance Coverage for Mental Illness and Substance Use Disorders" are hereby amended 2
26	26	to read as follows: 3
27	27	27-38.2-1. Coverage for treatment of mental health and substance use disorders. 4
28	28	(a) A group health plan and an individual or group health insurance plan shall provide 5
29	29	coverage for the treatment of mental health and substance use disorders under the same terms and 6
30	30	conditions as that coverage is provided for other illnesses and diseases. 7
31	31	(b) Coverage for the treatment of mental health and substance use disorders shall not 8
32	32	impose any annual or lifetime dollar limitation. 9
33	33	(c) Financial requirements and quantitative treatment limitations on coverage for the 10
34	34	treatment of mental health and substance use disorders shall be no more restrictive than the 11
35	35	predominant financial requirements applied to substantially all coverage for medical conditions in 12
36	36	each treatment classification. 13
37	37	(d) Coverage shall not impose non-quantitative treatment limitations for the treatment of 14
38	38	mental health and substance use disorders unless the processes, strategies, evidentiary standards, 15
39	39	or other factors used in applying the non-quantitative treatment limitation, as written and in 16
40	40	operation, are comparable to, and are applied no more stringently than, the processes, strategies, 17
41	41	evidentiary standards, or other factors used in applying the limitation with respect to 18
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45	45	medical/surgical benefits in the classification. 1
46	46	(e) The following classifications shall be used to apply the coverage requirements of this 2
47	47	chapter: (1) Inpatient, in-network; (2) Inpatient, out-of-network; (3) Outpatient, in-network; (4) 3
48	48	Outpatient, out-of-network; (5) Emergency care; and (6) Prescription drugs. 4
49	49	(f) Medication-assisted treatment or medication-assisted maintenance services of substance 5
50	50	use disorders, opioid overdoses, and chronic addiction, including methadone, buprenorphine, 6
51	51	naltrexone, or other clinically appropriate medications, is included within the appropriate 7
52	52	classification based on the site of the service. 8
53	53	(g) Payors shall rely upon the criteria of the American Society of Addiction Medicine when 9
54	54	developing coverage for levels of care for substance use disorder treatment. 10
55	55	(h) Payors shall rely upon criteria which reflect generally accepted standards of care when 11
56	56	developing coverage for levels of care for mental health treatment. 12
57	57	(i) Payors shall not modify clinical criteria to reduce coverage for mental health treatment 13
58	58	below the level established by the generally accepted standards of care upon which their clinical 14
59	59	criteria are based. 15
60	60	(j) Patients with substance use disorders shall have access to evidence-based, non-opioid 16
61	61	treatment for pain, therefore coverage shall apply to medically necessary chiropractic care and 17
62	62	osteopathic manipulative treatment performed by an individual licensed under § 5-37-2. 18
63	63	(i)(k) Parity of cost-sharing requirements. Regardless of the professional license of the 19
64	64	provider of care, if that care is consistent with the provider’s scope of practice and the health plan’s 20
65	65	credentialing and contracting provisions, cost sharing for behavioral health counseling visits and 21
66	66	medication maintenance visits shall be consistent with the cost sharing applied to primary care 22
67	67	office visits. 23
68	68	27-38.2-2. Definitions. 24
69	69	For the purposes of this chapter, the following words and terms have the following 25
70	70	meanings: 26
71	71	(1) “Financial requirements” means deductibles, copayments, coinsurance, or out-of-27
72	72	pocket maximums. 28
73	73	(2) “Generally accepted standards of care” means standards of care and clinical practice 29
74	74	that are generally recognized by healthcare providers practicing in relevant clinical specialties such 30
75	75	as psychiatry, psychology, clinical sociology, addiction medicine and counseling, and behavioral 31
76	76	health treatment, as reflected in sources including, but not limited to, patient placement criteria and 32
77	77	clinical practice guidelines, the Level of Care Utilization System (LOCUS), the Child and 33
78	78	Adolescent Level of Care Utilization System (CALOCUS), the Child and Adolescent Service 34
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82	82	Intensity Instrument (CASII), recommendations of federal government agencies, and drug labeling 1
83	83	approved by the United States Food and Drug Administration. 2
84	84	(2)(3) “Group health plan” means an employee welfare benefit plan as defined in 29 U.S.C. 3
85	85	§ 1002(1) to the extent that the plan provides health benefits to employees or their dependents 4
86	86	directly or through insurance, reimbursement, or otherwise. For purposes of this chapter, a group 5
87	87	health plan shall not include a plan that provides health benefits directly to employees or their 6
88	88	dependents, except in the case of a plan provided by the state or an instrumentality of the state. 7
89	89	(3)(4) “Health insurance plan” means health insurance coverage offered, delivered, issued 8
90	90	for delivery, or renewed by a health insurer. 9
91	91	(4)(5) “Health insurers” means all persons, firms, corporations, or other organizations 10
92	92	offering and assuring health services on a prepaid or primarily expense-incurred basis, including 11
93	93	but not limited to, policies of accident or sickness insurance, as defined by chapter 18 of this title; 12
94	94	nonprofit hospital or medical service plans, whether organized under chapter 19 or 20 of this title 13
95	95	or under any public law or by special act of the general assembly; health maintenance organizations, 14
96	96	or any other entity that insures or reimburses for diagnostic, therapeutic, or preventive services to 15
97	97	a determined population on the basis of a periodic premium. Provided, this chapter does not apply 16
98	98	to insurance coverage providing benefits for: 17
99	99	(i) Hospital confinement indemnity; 18
100	100	(ii) Disability income; 19
101	101	(iii) Accident only; 20
102	102	(iv) Long-term care; 21
103	103	(v) Medicare supplement; 22
104	104	(vi) Limited benefit health; 23
105	105	(vii) Specific disease indemnity; 24
106	106	(viii) Sickness or bodily injury or death by accident or both; and 25
107	107	(ix) Other limited benefit policies. 26
108	108	(5)(6) “Mental health or substance use disorder” means any mental disorder and substance 27
109	109	use disorder that is listed in the most recent revised publication or the most updated volume of 28
110	110	either the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American 29
111	111	Psychiatric Association or the International Classification of Disease Manual (ICO) published by 30
112	112	the World Health Organization; provided, that tobacco and caffeine are excluded from the 31
113	113	definition of “substance” for the purposes of this chapter. 32
114	114	(6)(7) “Non-quantitative treatment limitations” means: (i) Medical management standards; 33
115	115	(ii) Formulary design and protocols; (iii) Network tier design; (iv) Standards for provider admission 34
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119	119	to participate in a network; (v) Reimbursement rates and methods for determining usual, customary, 1
120	120	and reasonable charges; and (vi) Other criteria that limit scope or duration of coverage for services 2
121	121	in the treatment of mental health and substance use disorders, including restrictions based on 3
122	122	geographic location, facility type, and provider specialty. 4
123	123	(7)(8) “Quantitative treatment limitations” means numerical limits on coverage for the 5
124	124	treatment of mental health and substance use disorders based on the frequency of treatment, number 6
125	125	of visits, days of coverage, days in a waiting period, or other similar limits on the scope or duration 7
126	126	of treatment. 8
127	127	SECTION 2. This act shall take effect upon passage. 9
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134	134	EXPLANATION
135	135	BY THE LEGISLATIVE COUNCIL
136	136	OF
137	137	A N A C T
138	138	RELATING TO INSURANCE -- INSURANCE COVERAGE FOR MENTAL ILLNESS AND
139	139	SUBSTANCE USE DISORDERS
140	140	***
141	141	This act would provide that for insurance coverage for treatment of mental health and 1
142	142	substance use disorders, payors would rely upon criteria which reflect generally accepted standards 2
143	143	of care when developing coverage for levels of care for mental health treatment. This act would 3
144	144	also provide that payors would not modify clinical criteria to reduce coverage for mental health 4
145	145	treatment below the level established by the generally accepted standards of care upon which their 5
146	146	clinical criteria are based. This act would also provide a definition for the term “generally accepted 6
147	147	standards of care.” 7
148	148	This act would take effect upon passage. 8
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