CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Mental Illness and Substance Use Disorders Mandate

Administrative policy documenting Rhode Island mandate (RIGL 27-38.2) requirements for coverage of mental illness and substance use disorder treatment for commercial products; explains parity and network/medical necessity expectations.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Mental Illness and Substance Use Disorders Mandate

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 3, 2021

Next Review DateN/A

Key ActionContact the BCBSRI Behavioral Health Vendor at 800-274-2958 for prior authorization details.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Commercialapplicability

No annual/lifetimefinancial limits

Parity requiredparity

Vendorauth contact

Coverage Criteria and Parity Requirements

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Statutory coverage and parity

Covered when statutory conditions of RIGL 27-38.2 and MHPAEA parity requirements are met

Statutory coverage and parity: Group and individual health plans must provide coverage for treatment of mental health and substance use disorders under the same terms and conditions as coverage for other illnesses; no annual or lifetime dollar limits may be imposed; financial requirements and quantitative treatment limitations for MH/SUD must not be more restrictive than the predominant medical/surgical requirements; and non-quantitative treatment limitations must be comparable to and applied no more stringently than those applied to medical/surgical benefits.

RIGL 27-38.2; MHPAEA

Network and out-of-network coverage

Network applicability and out-of-network coverage requirement

Network availability: Mandated benefits apply to services delivered within the insurer's provider network; the insurer must provide coverage outside the network when it is established that the required services are not available from a provider in the insurer's network.

RIGL 27-38.2-3

Providers must be able to substantiate that initial and continued treatment is medically necessary and appropriate. Upon request, providers are required to furnish medical records or other necessary data to the reimbursing health insurer to support medical necessity. If the provider cannot establish medical necessity and/or appropriateness for a period or type of care, neither the insurer nor the patient is obligated to reimburse for that care unless the patient, after being informed, agrees in writing to continue treatment at their own expense. Denials of benefits may be appealed in accordance with applicable department rules and regulations.

Provider Requirements and Authorization

Prior Authorization

For information regarding Prior Authorization requirements, providers should contact the BCBSRI Behavioral Health Vendor at 800-274-2958.

Behavioral health prior authorization — Prior authorization requirements are handled by the BCBSRI Behavioral Health Vendor; providers should contact 800-274-2958 for authorization.

Note

ASAM Criteria for Levels of Care

When developing levels of care for substance use disorder treatment, payors shall rely upon the criteria of the American Society of Addiction Medicine (ASAM). This guidance applies to defining appropriate levels of care and to coverage determinations for medication-assisted treatment and maintenance services (for example, methadone, buprenorphine, naltrexone) based on the site of service.

ASAM criteria for levels of care — Payors shall rely upon the ASAM criteria when developing coverage for levels of care for substance use disorder treatment.
Medication-assisted treatment included — Medication-assisted treatment or maintenance services for substance use disorders (e.g., methadone, buprenorphine, naltrexone) are covered within the appropriate classification based on site of service.

Documentation Required

Medical Necessity and Documentation

Providers must furnish medical records or other necessary data upon request to substantiate that initial or continued treatment is medically necessary and appropriate. Failure to establish medical necessity and appropriateness may result in denial of reimbursement for that period or type of care. Providers and patients may appeal a denial in accordance with applicable rules and regulations.

Provider documentation requirement — Upon request by the reimbursing health insurer, providers must supply medical records or other data substantiating medical necessity and appropriateness of treatment.
Medical necessity documentation impacts payment — If the provider cannot establish medical necessity and/or appropriateness, neither the insurer nor the patient is obligated to reimburse for the period or type of care not established; denials may be appealed per applicable procedures.

Policy Background

This administrative policy documents Rhode Island statutory requirements to ensure coverage parity and to mandate coverage of treatment for mental illness and substance use disorders. It records that group and individual health plans must provide coverage for behavioral health treatment under the same terms and conditions as other illnesses, and that financial limitations such as annual or lifetime dollar limits are not permitted for these benefits.

Definitions

Medication-assisted treatment — definition and scope

DefinitionMedication-assisted treatment (MAT) includes medication-assisted treatment or medication-assisted maintenance services for substance use disorders, including methadone, buprenorphine, naltrexone, or other clinically appropriate medications.

ScopeMAT is included within the appropriate classification based on site of service (e.g., inpatient vs outpatient, in-network vs out-of-network).

Parity requirementCoverage for MAT must be provided under the same terms and conditions as other illnesses and not subject to more restrictive financial or non-quantitative treatment limitations than medical/surgical benefits.

Reference statuteRIGL S 27-38.2-1 mandates inclusion of MAT as part of coverage for treatment of mental health and substance use disorders.

Examples of medicationsSpecifically cited medications include methadone, buprenorphine, and naltrexone.

Treatment Modalities and MAT

Medication-assisted treatment (MAT)

Medication-assisted treatment or maintenance services for substance use disorders, including methadone, buprenorphine, naltrexone, or other clinically appropriate medications, are included within the appropriate classification based on site of service.

RIGL inclusion; providers must substantiate medical necessity for treatment