CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy | Mental Illness and Substance Use Disorders Mandate

Documents BCBSRI coverage for treatment of mental illness and substance use disorders for Commercial Products in compliance with Rhode Island mandate §27-38.2 and federal Mental Health Parity requirements; informs providers about applicability and prior authorization contact. Affects commercial members and providers in Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMental Illness and Substance Use Disorders Mandate (medical coverage policy)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date01|01|2022

Next Review DateN/A

Key ActionFor prior authorization, contact BCBSRI Behavioral Health Utilization Management at 800-274-2958.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CommercialPlan applicability

2022-01-01Effective

NoneNo dollar limits

RequiredParity referenced

Coverage Criteria and Applicability

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Covered with statutory parity criteria

Covered when consistent with Rhode Island statute §27-38.2 and federal Mental Health Parity requirements

Commercial product coverage: Treatment of mental illness and substance use disorder is a covered benefit for Commercial Products.

Benefits may vary by group; self-funded groups may not follow state mandates.

Parity of terms: Coverage must be provided under the same terms and conditions as other illnesses; financial requirements and quantitative treatment limitations shall be no more restrictive than the predominant requirements for medical conditions within each treatment classification.

Per §27-38.2-1(a) and (c); federal parity requirements apply as referenced by MHPAEA.

No annual or lifetime dollar limits: Coverage shall not impose any annual or lifetime dollar limitation for treatment of mental health and substance use disorders.

Per §27-38.2-1(b).

Non-quantitative treatment limitations (NQTLs) may not be imposed unless the processes, strategies, evidentiary standards, and other factors are comparable to and applied no more stringently than those used for medical/surgical benefits.

Per §27-38.2-1(d).

Medication-assisted treatment coverage: Medication-assisted treatment and 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.

Per §27-38.2-1(f).

Treatment classifications applied: The following classifications shall be used to apply coverage requirements: inpatient in‑network; inpatient out‑of‑network; outpatient in‑network; outpatient out‑of‑network; emergency care; prescription drugs.

Per §27-38.2-1(e).

Network coverage fallback: Mandated benefits apply to in‑network services; insurers must provide coverage out‑of‑network where required services are not available in‑network.

Per §27-38.2-4.

Cost‑sharing parity for visits: Cost‑sharing for behavioral health counseling and medication maintenance visits must be consistent with cost‑sharing applied to primary care office visits regardless of provider license, when care is within scope and credentialing provisions.

Per §27-38.2-1(i).

Medical necessity and documentation: Providers must furnish medical records or other necessary data upon insurer request to substantiate that initial or continued treatment is medically necessary and appropriate; failure to establish medical necessity may result in non‑payment unless the patient agrees in writing to continue at their own expense.

Per §27-38.2-3(a) and (b).

This policy applies to Commercial Products only. Benefits may vary between groups or contracts; refer to the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for specific substance use disorder coverage. Self-funded groups may not be subject to state mandates and therefore might not follow this policy.

Per Rhode Island statute §27-38.2-3, when a provider cannot establish that initial or continued treatment is medically necessary and appropriate, neither the insurer nor the patient is obligated to reimburse for that period or type of care. An exception exists only if the patient has been informed of this provision and has provided written agreement to continue treatment at their own expense.

Consistent with BCBSRI policy guidance, providers should note that benefits and eligibility are determined by the member’s subscriber agreement or employer agreement; services determined not to be medically necessary may not be charged to the member unless the member has been informed and has agreed in writing in advance to continue treatment at their own expense.

Coding and Treatment Classifications

Codingmixed

No codes listed

Treatment classifications

Inpatient in-networkListed as one of the required treatment classifications for applying coverage requirements under §27-38.2-1(e).

Inpatient out-of-networkListed as one of the required treatment classifications for applying coverage requirements under §27-38.2-1(e).

Outpatient in-networkListed as one of the required treatment classifications for applying coverage requirements under §27-38.2-1(e).

Outpatient out-of-networkListed as one of the required treatment classifications for applying coverage requirements under §27-38.2-1(e).

Emergency careListed as one of the required treatment classifications for applying coverage requirements under §27-38.2-1(e).

Prescription drugsListed as one of the required treatment classifications for applying coverage requirements under §27-38.2-1(e).

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Handled by BCBSRI Behavioral Health UM

Prior authorization requirements for behavioral health services are managed by BCBSRI Behavioral Health Utilization Management. Providers must contact BCBSRI Behavioral Health UM at 800-274-2958 to determine whether prior authorization is required and to initiate any authorization requests.

BCBSRI Behavioral Health UM: 800-274-2958

Step Therapy

Step Therapy / Levels of Care Guidance

Payors must rely on the American Society of Addiction Medicine (ASAM) criteria when developing levels of care for substance use disorder (SUD) treatment. No additional step-therapy rules are specified in state statute; providers and payors should use ASAM placement criteria for determining appropriate levels of care.

Use ASAM criteria for SUD levels of care

Documentation Required

Medical Necessity Documentation and Prior Authorization Records

Upon request by the insurer, providers must furnish medical records or other necessary data to substantiate that initial or continued behavioral health or SUD treatment is medically necessary and appropriate. If a provider cannot establish medical necessity for the care provided, neither the insurer nor the patient is obligated to reimburse for that period or type of care unless the patient was informed and agreed in writing to self-pay.

Providers must produce records to support medical necessity when requested
If medical necessity cannot be established, insurer/patient not obligated to reimburse unless patient provided written informed agreement to pay

Background and Scope

This policy documents that treatment for mental illness and substance use disorders must be covered under the same terms and conditions as treatment for other illnesses, reflecting both federal parity requirements and Rhode Island statute §27-38.2. Cost-sharing, quantitative treatment limitations, and non-quantitative treatment limitations must be no more restrictive than those applied to medical/surgical benefits, and parity requirements supersede where applicable.

The statute explicitly includes coverage for medication-assisted treatment (e.g., methadone, buprenorphine, naltrexone) within the appropriate service classification based on site of service, and prohibits imposing annual or lifetime dollar limits for these treatments.

Where required services are not available in-network, the law requires insurers to provide coverage out-of-network; payors are also instructed to rely on American Society of Addiction Medicine (ASAM) criteria when developing levels of care for substance use disorder treatment.

OpenPayer

Medical Coverage Policy | Mental Illness and Substance Use Disorders Mandate

Coverage Criteria and Applicability

Coding and Treatment Classifications

Prior Authorization, Documentation, and Provider Requirements

Background and Scope

Definitions

Statutory Classifications / Level-of-Care

Treatment Modalities and MAT Criteria