Definition


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Parity is about fairness. Americans with behavioral health conditions often have more difficulty getting the treatment and services they need when compared to individuals seeking other medical care. Explore parity-related information regarding legislation, statutes, and regulatory actions since the Federal Parity Law was passed in 2008.

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 Commissionerto 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.

State Parity Reports

View the state parity reports to learn about legislation, regulation, and litigation related to parity implementation

State Parity Reports

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Common Violations

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