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This page lists some of the action toward parity compliance undertaken by Rhode Island regulatory agencies since 2008.

Are we missing any actions taken by state regulatory agencies? Let us know at info@paritytrack.org.

Action in the Regulatory Arena

1/2018

Primary Focus: Parity-General
Agency: Executive Office of Health and Human Services
Title/Description: Medicaid Managed Care Delivery Options
Citation: 210 RICR 030-05-2
Summary: Explanation of Rite Care which is a managed care delivery system to increase access to primary and preventative care for certain individuals and families who otherwise might not be able to afford or obtain affordable coverage. The rule is consistent with the federal managed care rules, certain mental health parity requirements added to the Public Health Service Act by the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.  The rule prohibits Rite Care from applying treatment limitations on mental health and substance use disorders that would be more restrictive than those applied to medical/surgical benefits. Rite Care MCOs must maintain provider networks in locations that are geographically accessible to the populations to be served, comprised of hospitals, physicians, advanced practice practitioners, mental health providers, substance use disorder providers, pharmacies, transportation services, dentists, school based health centers, etc. in sufficient numbers to make available all services in a timely manner. Rite Care MCOs must make services available within twenty-four (24) hours and seven (7) days per week, including services for mental health and substance use disorders for treatment of an urgent medical problem. The MCOs must make services available within thirty (30) days for treatment of a non-emergent, non- urgent medical problem. This thirty (30) day standard does not apply to appointments for routine physical examinations, nor for regularly scheduled visits to monitor a chronic medical condition if the schedule calls for visits less frequently than once every thirty (30) days. Non- emergent, non-urgent mental health or substance use appointments for diagnosis and treatment must be made available within ten (10) days.
Effective Date: January 8, 2018 (a technical revision made effective date July 29, 2018)
Notes: Inactive Rule 210-7571 led to 210 RICR 030-05-02, was promulgated to reformat, consolidate, and amend the existing regulations in the Medicaid Code of Administrative Rules as follows: #0350, “RIte Smiles”; #1309, “RIte Care Program”; #1310 “Rhody Health Program”; #1311 “Enrollment”; and #1314 “Communities of Care” and replace these five rules with one newly amended rule. This one rule will supersede ERLIDs # 8365; 8366; 7807; 7575; 6935.

9/2016

OHIC held a meeting of the Health Insurance Advisory Council. The meeting minutes (pdf | Get Adobe® Reader®) reveal that OHIC suspended their mental health parity market conduct exams because of budget cuts. However, OHIC applied for the Health Insurance Enforcement and Consumer Protections Grant, (pdf | Get Adobe® Reader®) which would allow the Office to hire additional staff and resume the exams.

6/2016

OHIC held a meeting of the Health Insurance Advisory Council. The meeting minutes (pdf | Get Adobe® Reader®) reveal that the council discussed many topics, including current efforts targeting mental health parity. Unfortunately because of the end of federal grants and no increased appropriation during the state budget process, Health Commissioner Hittner stated that they will have to discontinue their mental health parity work.

3/2016

OHIC released a press release to bring awareness to S2510/H7625. The senate bill was filed at the request of Attorney General Peter F. Kilmartin and would require plans to cover at least 90 days of residential or inpatient services for mental health and substance use disorders. This bill passed the house but died in the senate in 6/2016.

12/2015

After receiving complaints from consumers that insurance plans were not covering needed behavioral health services, the Office of the Health Insurance Commissioner (OHIC) has initiated market conduct examinations on four insurers to see if they are violating parity laws. The meeting minutes (pdf | Get Adobe® Reader®) from a meeting of the Governor’s Council on Behavioral Health in January, 2016 provides a summary of these exams on pg. 2-3.The OHIC sent letters to all insurers in the state that they must submit any information requested as part of the market conduct examinations.

2015

OHIC released a bulletin (pdf | Get Adobe® Reader®) highlighting 2015 legislative changes. They mention H5837/S490 which requires insurers to rely upon the criteria by the American Society for Addiction Medicine when determining coverage levels for substance use disorder treatment.

03/2014

OHIC released a document (pdf | Get Adobe® Reader®) highlighting 2014 legislative changes. They mention H7569/S2534/H7477 which prevent health insurance plans from the following actions:

  • Requiring individuals use an opioid drug not approved by the FDA prior to using a non-opioid drug approved by the FDA
  • Requiring individuals use a non-abuse deterrent opioid prior to an abuse-deterrent opioid

2014

The Rhode Island Office of the Health Insurance Commissioner (OHIC) requires small employer fully-insured plans and individual plans to complete this checklist (pdf | Get Adobe® Reader®) each year (this particular link is from 2014). On page 13 plans must certify that they comply with the Federal Parity Law, the final regulation (pdf | Get Adobe® Reader®) of the Federal Parity Law, and the section of the state law about parity (section of state law summarized below under “Rhode Island Parity Law”). The checklist asks plans to:

“…describe, through illustrations, FAQ’s, or other consumer explanation how the Plan provides for Parity in connection with financial requirements, quantitative treatment limitations, prescription drug benefits, and non-quantitative treatment limitations.

Rhode Island Parity Law

There is a section of Rhode Island’s state insurance law about parity for behavioral health coverage and another section about autism coverage. There is a subsection (subsection j) within the section of state law that requires the Health Insurance Commissioner to monitor plans for compliance with the Federal Parity Law. There is also a section of the state’s health and safety law that is relevant to parity for insurance plans’ utilization review programs.

Behavioral Health Coverage

This section of the state insurance law requires large employer fully-insured plans, small employer fully-insured plans, and individual plans to cover services for all behavioral health conditions that are in the DSM or ICD on the “same terms and conditions” as other medical services.

Financial requirements and quantitative treatment limitations for behavioral health services must be “no more restrictive” than those in place for other medical services.

If plans use non-quantitative treatment limitations for behavioral health services, they must be used similarly and “no more stringently” than those used for other medical services. Non-quantitative treatment limitations are defined as:

  • Medical management standards
  • Formulary design and protocols
  • Network tier design
  • Standards for provider admission to participate in a network
  • Reimbursement rates and methods for determining usual, customary, and reasonable charges
  • Other criteria that limit scope or duration of coverage for services in the treatment of mental health and substance use disorders, including restrictions based on geographic location, facility type, and provider specialty

Plans are required to cover medications for substance use disorders, specifically those used for opioid overdoses (like naloxone) and those used for chronic addiction (like methadone).

When conducting medical necessity reviews for behavioral health services, plans must do so in a way that is the same as how medical necessity reviews are conducted for other medical services.

Utilization Review

There is a section of the health and safety law that requires the Office of the Health Insurance Commissioner to develop reporting requirements for insurance plans’ utilization review programs for compliance with the Federal Parity Law and the Affordable Care Act.

This section also requires the Office of the Health Insurance Commissioner to make recommendations to the General Assembly as to how state laws and regulations could be changed to improve parity compliance for utilization review programs, or make these regulatory changes itself. Included among these recommendations or changes, this section of the law requires the Office of the Health Insurance Commissioner to describe the process by which the Office will investigate insurance plans for parity compliance in their utilization review programs.

Autism

This section of the law requires large employer fully-insured plans to cover autism services for children through age 14. Autism spectrum disorders are defined as “any of the pervasive developmental disorders” listed in the most recent version of the DSM.

“Coverage for physical therapy, speech therapy and occupational therapy and psychology, psychiatry and pharmaceutical services” for autism services must be similar to what is in place for treatment of other medical conditions.

There is a $32,000 annual maximum for applied behavior analysis.

Plans must cover out-of-network services outside of Rhode Island if it is determined these services are not available in-network.

Insurance plans are allowed to review a child’s treatment plan once every 3 months.

Deductibles, coinsurance, and general annual maximums for autism services must be similar to those used for other medical services.

Get Support

Rhode Island Insurance Division

Common Violations

In seeking care or services, be aware of the common ways parity rights can be violated.

Common Violations

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