CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Mental Illness and Substance Use Disorders Mandate

Administrative policy documenting Rhode Island state mandate (27-38.2) and federal parity applicability for coverage of mental illness and substance use disorders for Commercial Products; describes notification requirements, applicability to Medicare Advantage, and background statutory requirements. Not a utilization or medical necessity criteria policy.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Mental Illness and Substance Use Disorders Mandate

Policy CodePolicy N/A

Change Typeclarified

Effective DateFeb 5, 2024

Next Review Date

Key ActionParticipating and non-participating providers must notify BCBSRI Behavioral Health Utilization Management within 48 hours of admission and within 48 hours after discharge for specified behavioral health levels of care; contact 1-800-274-2958.

SourceLink

POLICY UPDATE CHANGES

Policy documents applicability to Commercial Products and notes Medicare Advantage coverage is not subject to the Rhode Island mandate.

5Levels of Care Requiring Admission Notification

Commercial-onlyPrimary Applicability

Parity appliesParity Statement

Policy overview

Background: Rhode Island General Law 27-38.2 requires group and individual health plans to provide coverage for the treatment of mental health and substance use disorders under the same terms and conditions as coverage for other illnesses and diseases, prohibits lifetime dollar limits, and requires that non-quantitative treatment limits be comparable to those applied to medical/surgical benefits. The statute also directs reliance on the American Society of Addiction Medicine (ASAM) criteria when developing coverage for levels of care for substance use disorder treatment and includes provisions establishing an Infant and Early Childhood Mental Wellness Task Force with guidance on screening, diagnosis, and evidence-based parent-child dyadic therapies for children birth through age five.

Scope: This is an administrative policy for Commercial Products documenting the Rhode Island state mandate (27-38.2) and federal parity applicability for coverage of mental illness and substance use disorders. It is not a utilization or medical necessity criteria policy.

Effective date02/05/2024

Last review02/05/2025

Next review

Policy titleMental Illness and Substance Use Disorders Mandate (RI)

PayerBlue Cross Blue Shield - Rhode Island

Policy typeadministrative

Primary applicabilityCommercial-only

Coverage stance and legal mandate

Coverage stance: Informational. This policy documents the Rhode Island state mandate (27-38.2) requiring parity for mental health and substance use disorder benefits with medical/surgical benefits and clarifies related administrative requirements such as notification of admissions for specified levels of care.

Medicare Advantage: Medicare Advantage plans provide coverage for treatment of mental illness and substance use disorder, but such plans are not subject to the Rhode Island mandate.

Definition

TermParity

DefinitionRequirement that coverage for mental health and substance use disorders be provided under the same terms and conditions as for other illnesses and diseases; cost-sharing and treatment limitations must not be more restrictive than medical/surgical benefits.

What providers must do

Notification of Admission Requirement

Notification to BCBSRI within 48 hours of admission and within 48 hours after discharge is required for the following levels of care:

ALL of the following

Inpatient mental health and substance use disorder treatment
Crisis Stabilization (CSU)
Inpatient withdrawal management (detoxification)
Residential mental health and substance use disorder treatment
Partial hospitalization mental health and substance use disorder treatment

Documentation Required

Submit notification of admission and discharge to BCBSRI at 1-800-274-2958 within 48 hours

Submit notification of admission and discharge to BCBSRI Behavioral Health Utilization Management at 1-800-274-2958 within 48 hours of admission and within 48 hours after discharge to ensure correct claims processing.

Documentation Required

Medical necessity documentation must be provided upon request

Provide medical necessity documentation upon request. Upon request by the reimbursing health insurer, providers must furnish medical records or other necessary data that substantiate that initial or continued treatment is medically necessary and appropriate.

Failure to establish medical necessity and/or appropriateness may result in noncoverage for that period or type of care, or the member may elect to continue treatment at their own expense in writing.

Billing Rule

Benefits determined by subscriber agreement / EOC / employer agreement

Member-specific benefits are governed by the subscriber agreement, Evidence of Coverage, or employer agreement which supersede this policy.

Benefits may vary between groups/contracts; self-funded groups may or may not follow state mandates.

Statutory and clinical references

Statutory basis: Rhode Island General Law 27-38.2 (Coverage for treatment of mental health and substance use disorders) requires parity with medical/surgical benefits, prohibits lifetime dollar limits, and mandates that non-quantitative treatment limitations be no more restrictive than those applied to medical/surgical benefits across specified classifications (inpatient, outpatient, emergency, prescription drugs, etc.).

Recommendation for levels of care: The statute advises payors to rely upon the criteria of the American Society of Addiction Medicine (ASAM) when developing coverage for levels of care for substance use disorder treatment.

Infant/early childhood provisions: The law establishes an Infant and Early Childhood Mental Wellness Task Force and includes provisions on the use of developmentally appropriate screening and evidence-based parent-child dyadic therapies for children from birth through age five.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Mental Illness and Substance Use Disorders Mandate

Policy CodePolicy N/A

Change Typeclarified

Effective DateFeb 5, 2024

Next Review Date

SourceLink

On This Page

OpenPayer

Medical Coverage Policy Mental Illness and Substance Use Disorders Mandate

Policy overview

Coverage stance and legal mandate

What providers must do

Coding

Statutory and clinical references

Document changes