CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Mental Illness and Substance Use Disorders Mandate

Administrative policy documenting Rhode Island State Mandate §27-38.2 and federal parity requirements for coverage of mental illness and substance use disorder treatment; affects commercial BCBSRI products and providers delivering those services in Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMental Illness and Substance Use Disorders Mandate

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2001

Next Review DateN/A

Key ActionCall the BCBSRI Behavioral Health Vendor at 800-274-2958 for prior authorization information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

§ 27-38.2Statute cited

No annual or lifetimeDollar limits

ASAM referencedASAM

Prior auth vendorPrior auth vendor

Coverage variesBenefit variability

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Coverage Criteria (Rhode Island Mandate & Applicability)

Statutory and parity coverage criteria

Coverage and requirements under Rhode Island statute and federal parity:

Statutory coverage requirements: A group or individual health plan shall provide coverage for treatment of mental health and substance-use disorders under the same terms and conditions as other illnesses and diseases; coverage shall not impose annual or lifetime dollar limitations; financial requirements and quantitative treatment limitations must be no more restrictive than the predominant requirements applied to medical conditions in each treatment classification.

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

Classifications: Coverage classifications to apply: inpatient in-network; inpatient out-of-network; outpatient in-network; outpatient out-of-network; emergency care; and prescription drugs.

Medication-assisted treatment and maintenance services (including methadone, buprenorphine, naltrexone, or other clinically appropriate medications) are included within the appropriate classification based on site of service.

Levels of care for SUD: Payors shall rely upon the criteria of the American Society of Addiction Medicine (ASAM) when developing coverage for levels of care for substance-use disorder treatment.

Access to non-opioid pain treatments: Patients with substance-use disorders shall have access to evidence-based, non-opioid treatment for pain; coverage includes medically necessary chiropractic care and osteopathic manipulative treatment performed by a licensed individual.

Medical necessity determination parity: Insurers must determine medical necessity and appropriateness of treatment in a manner consistent with determinations for other diseases or injuries covered under the policy.

Mandate precedence note: This policy documents services that may be covered under the Rhode Island General Law and Federal Mental Health Parity Act; the federal Mental Health Parity Act supersedes the Rhode Island State mandate where applicable.

Product-specific applicability

Applicability by product

Commercial: Treatment of mental illness and substance use disorder is a covered benefit for Commercial products; benefits may vary between groups/contracts and the specific Benefit Booklet, Evidence of Coverage, or Subscriber Agreement should be consulted for applicable coverage.

BlueCHiP for Medicare: Rhode Island mandated benefits do not apply to BlueCHiP for Medicare plans unless noted in policy sections; self-funded groups may or may not follow state mandates depending on contract terms.

This Rhode Island administrative policy documents statutory coverage for treatment of mental illness and substance-use disorders and explains product applicability. Commercial products issued by Blue Cross & Blue Shield of Rhode Island provide coverage for mental health and substance-use disorder treatment subject to the terms of the member's benefit booklet or subscriber agreement; benefits may vary between groups/contracts and the specific contract controls. BlueCHiP for Medicare plans are exempt from Rhode Island mandated benefits unless the policy specifically states otherwise. Additionally, self‑funded (ERISA) group plans may choose whether to follow state mandates; applicability should be confirmed in the employer agreement or benefit documents.

Under § 27-38.2-3, providers must furnish medical records or other necessary data upon request to substantiate that initial or continued treatment is medically necessary and appropriate. If a provider cannot establish the medical necessity and/or appropriateness of the treatment modality being provided, neither the insurer nor the patient is obligated to reimburse for that period or type of care. The only exception is when the patient has been informed of these provisions and has agreed in writing to continue treatment at their own expense.

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior Authorization Contact

For information regarding Prior Authorization requirements, please refer to the BCBSRI Behavioral Health Vendor at 800-274-2958.

Behavioral Health Vendor: 800-274-2958

Note

Non-Quantitative Treatment Limitations (NQTLs)

Non-quantitative treatment limitations (NQTLs) applied to mental health and substance-use disorder benefits must be comparable to, and applied no more stringently than, the processes, strategies, evidentiary standards, and other factors used for medical/surgical benefits in the same classification (inpatient/outpatient, in-network/out-of-network, emergency care, prescription drugs).

Documentation Required

Medical Records to Substantiate Necessity

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. If the provider cannot establish medical necessity/appropriateness for a period or type of care, the insurer and the patient are not obligated to reimburse for that care unless the patient has been informed and agreed in writing to continue at their own expense.

Denial Risk

Documentation Triggers Denial Risk

If providers cannot substantiate medical necessity or appropriateness when requested, that inability may result in denial of payment for the affected period or type of care. Providers should be aware that denials may be appealed per applicable state regulations and insurer appeal processes, but prior written patient agreement to self-pay is required to charge the patient for non-covered or non-substantiated services.

Denial may apply to initial or continued treatment periods lacking documentation
Providers must inform patient and obtain written agreement before charging patient for non-covered care

Definitions

Medication-assisted treatment (MAT) — definition and scope for MAT and related services

DefinitionMedication-assisted treatment (MAT) includes medication-assisted treatment or medication-assisted maintenance services for substance-use disorders, opioid overdoses, and chronic addiction (examples: methadone, buprenorphine, naltrexone, or other clinically appropriate medications).

ScopeMAT is included within the appropriate coverage classification based on site of service (inpatient in-network, inpatient out-of-network, outpatient in-network, outpatient out-of-network, emergency care, prescription drugs).

Examples of covered medicationsMethadone, buprenorphine, naltrexone, or other clinically appropriate medications for treatment of opioid use disorder or chronic addiction.

Relation to treatment classificationMAT services are classified according to the site of service and subject to the same financial and quantitative treatment limitations as other medical conditions within each classification (no annual or lifetime dollar limits for MH/SUD).

Access to non-opioid pain treatmentPatients with substance-use disorders shall have access to evidence-based, non-opioid pain treatments; coverage includes medically necessary chiropractic care and osteopathic manipulative treatment when performed by a licensed individual.

ASAM criteria — reference for levels of care

DefinitionASAM criteria refers to the American Society of Addiction Medicine criteria that payors shall rely upon when developing coverage for levels of care for substance-use disorder treatment.

Use in policyPayors must use ASAM criteria to develop coverage determinations for levels of care for substance-use disorder treatment (admission, continued stay, discharge considerations).

Integration with classificationsASAM-based levels of care should be applied within the statutory coverage classifications (inpatient/outpatient, in-network/out-of-network, emergency, prescription drugs).

Background

This document is an administrative policy that implements Rhode Island Statute § 27-38.2 and incorporates federal Mental Health Parity requirements. It establishes that coverage for mental illness and substance-use disorders must be provided under the same terms and conditions as other illnesses, prohibits annual or lifetime dollar limits for these benefits, and requires that non-quantitative treatment limitations (such as medical necessity determinations) be applied no more stringently than for medical/surgical benefits. The policy also notes that payors shall rely upon ASAM criteria when developing levels of care for substance-use disorder treatment and that medication-assisted treatment (MAT) (for example, methadone, buprenorphine, naltrexone) is included within the appropriate classification based on site of service. Finally, the policy reminds providers that benefits and eligibility are governed by the member's subscriber agreement or employer agreement and that this policy is informational and not a guarantee of payment.

OpenPayer

Mental Illness and Substance Use Disorders Mandate

Coverage Criteria (Rhode Island Mandate & Applicability)

Substance Use Disorder Levels of Care (ASAM Reliance)

Permitted Treatment Modalities

Coding

Provider Actions, Prior Authorization & Documentation

Definitions

Background