AN ACT RELATING TO INSURANCE -- INSURANCE COVERAGE FOR MENTAL ILLNESS AND SUBSTANCE USE DISORDERS (Amends the provisions for insurance coverage of mental health, mental illness, and substance use disorders.)

H7944

2026 -- H 7944
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LC005172
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STATE OF RHODE ISLAND
IN GENERAL ASSEMBLY
JANUARY SESSION, A.D. 2026
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A N A C T
RELATING TO INSURANCE -- INSURANCE COVERAGE FOR MENTAL ILLNESS AND
SUBSTANCE USE DISORDERS

Introduced By:
Representatives Tanzi, Kislak, Alzate, Spears, McGaw, Speakman,
Donovan, Cruz, Stewart, and Hull

Date Introduced:
February 27, 2026

Referred To:
House Health & Human Services
It is enacted by the General Assembly as follows:
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SECTION 1. Sections 27-38.2-1 and 27-38.2-2 of the General Laws in Chapter 27-38.2
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entitled "Insurance Coverage for Mental Illness and Substance Use Disorders" are hereby amended
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to read as follows:
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27-38.2-1. Coverage for treatment of mental health and substance use disorders.
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(a) A group health plan and an individual or group health insurance plan shall provide
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coverage for the treatment of mental health and substance use disorders under the same terms and
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conditions as that coverage is provided for other illnesses and diseases.
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(b) Coverage for the treatment of mental health and substance use disorders shall not
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impose any annual or lifetime dollar limitation.
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(c) Financial requirements and quantitative treatment limitations on coverage for the
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treatment of mental health and substance use disorders shall be no more restrictive than the
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predominant financial requirements applied to substantially all coverage for medical conditions in
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each treatment classification.
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(d) Coverage shall not impose non-quantitative treatment limitations for the treatment of
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mental health and substance use disorders unless the processes, strategies, evidentiary standards,
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or other factors used in applying the non-quantitative treatment limitation, as written and in
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operation, are comparable to, and are applied no more stringently than, the processes, strategies,
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evidentiary standards, or other factors used in applying the limitation with respect to

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medical/surgical benefits in the classification.
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(e) The following classifications shall be used to apply the coverage requirements of this
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chapter: (1) Inpatient, in-network; (2) Inpatient, out-of-network; (3) Outpatient, in-network; (4)
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Outpatient, out-of-network; (5) Emergency care; and (6) Prescription drugs.
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(f) Medication-assisted treatment or medication-assisted maintenance services of substance
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use disorders, opioid overdoses, and chronic addiction, including methadone, buprenorphine,
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naltrexone, or other clinically appropriate medications, is included within the appropriate
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classification based on the site of the service.
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(g) Payors shall
rely upon

provide coverage for substance use disorders, at a minimum, in
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accordance with
the criteria of the American Society of Addiction Medicine
when developing
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coverage for levels of care for substance use disorder treatment
.
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(h) In conducting a utilization review relating to service intensity or level of care placement
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for a mental health or substance use disorder, a payor shall exclusively apply the most recent
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version of the age-appropriate patient placement criteria developed by nonprofit professional
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provider associations of the relevant clinical specialty and shall authorize placement at the service
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intensity or level of care consistent with those criteria. If the payor’s application of the relevant
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patient placement criteria is not consistent with the service intensity or level of care placement
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requested by the patient or their provider, any adverse benefit determination notice shall include
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full details of the payor’s assessment under the relevant criteria to the provider and the patient.
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(i) Mental health and substance use disorder coverage and clinical criteria shall not deviate
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from generally accepted standards of care.
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(h)
(j)
Patients with substance use disorders shall have access to evidence-based, non-opioid
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treatment for pain, therefore coverage shall apply to medically necessary chiropractic care and
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osteopathic manipulative treatment performed by an individual licensed under § 5-37-2.
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(i)
(k)
Parity of cost-sharing requirements. Regardless of the professional license of the
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provider of care, if that care is consistent with the provider’s scope of practice and the health plan’s
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credentialing and contracting provisions, cost sharing for behavioral health counseling visits and
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medication maintenance visits shall be consistent with the cost sharing applied to primary care
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office visits.
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27-38.2-2. Definitions.
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For the purposes of this chapter, the following words and terms have the following
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meanings:
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(1) “Financial requirements” means deductibles, copayments, coinsurance, or out-of-
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pocket maximums.

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(2) “Generally accepted standards of care” means standards of care and clinical practice
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that are generally recognized by healthcare providers practicing in relevant clinical specialties such
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as psychiatry, psychology, clinical social work, addiction medicine and counseling, and behavioral
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health treatment, as reflected in sources including, but not limited to, patient placement criteria,
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service intensity determination, and clinical practice guidelines developed by nonprofit
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professional provider associations such as the Level of Care Utilization System (LOCUS), the
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Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII), and
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the Early Childhood Service Intensity Instrument.
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(2)
(3)
“Group health plan” means an employee welfare benefit plan as defined in 29 U.S.C.
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§ 1002(1) to the extent that the plan provides health benefits to employees or their dependents
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directly or through insurance, reimbursement, or otherwise. For purposes of this chapter, a group
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health plan shall not include a plan that provides health benefits directly to employees or their
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dependents, except in the case of a plan provided by the state or an instrumentality of the state.
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(3)
(4)
“Health insurance plan” means health insurance coverage offered, delivered, issued
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for delivery, or renewed by a health insurer.
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(4)
(5)
“Health insurers” means all persons, firms, corporations, or other organizations
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offering and assuring health services on a prepaid or primarily expense-incurred basis, including
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but not limited to, policies of accident or sickness insurance, as defined by chapter 18 of this title;
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nonprofit hospital or medical service plans, whether organized under chapter 19 or 20 of this title
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or under any public law or by special act of the general assembly; health maintenance organizations,
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or any other entity that insures or reimburses for diagnostic, therapeutic, or preventive services to
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a determined population on the basis of a periodic premium. Provided, this chapter does not apply
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to insurance coverage providing benefits for:
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(i) Hospital confinement indemnity;
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(ii) Disability income;
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(iii) Accident only;
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(iv) Long-term care;
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(v) Medicare supplement;
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(vi) Limited benefit health;
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(vii) Specific disease indemnity;
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(viii) Sickness or bodily injury or death by accident or both; and
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(ix) Other limited benefit policies.
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(5)
(6)
“Mental health or substance use disorder” means any mental disorder and substance
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use disorder that is listed in the most recent revised publication or the most updated volume of
:

LC005172 - Page 3 of 5
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(i) Either

either
the Diagnostic and Statistical Manual of Mental Disorders (DSM)
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published by the American Psychiatric Association or the International Classification of Disease
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Manual (ICO) published by the World Health Organization;
provided, that tobacco and caffeine
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are excluded from the definition of “substance” for the purposes of this chapter.
; or
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(ii) The Diagnostic Classification of Mental Health and Developmental Disorders of
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Infancy and Early Childhood.
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(7) “Nonprofit professional provider association” means a not-for-profit health care
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provider professional association or specialty society that is generally recognized by clinicians
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practicing in the relevant clinical specialty and issues peer-reviewed guidelines, criteria, or other
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clinical recommendations developed through a transparent process, including the American
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Psychiatric Association, American Psychological Association, American Society of Addiction
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Medicine, American Academy of Child and Adolescent Psychiatry, and the American Association
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for Community Psychiatry.
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(6)
(8)
“Non-quantitative treatment limitations” means: (i) Medical management standards;
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(ii) Formulary design and protocols; (iii) Network tier design; (iv) Standards for provider admission
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to participate in a network; (v) Reimbursement rates and methods for determining usual, customary,
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and reasonable charges; and (vi) Other criteria that limit scope or duration of coverage for services
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in the treatment of mental health and substance use disorders, including restrictions based on
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geographic location, facility type, and provider specialty.
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(7)
(9)
“Quantitative treatment limitations” means numerical limits on coverage for the
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treatment of mental health and substance use disorders based on the frequency of treatment, number
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of visits, days of coverage, days in a waiting period, or other similar limits on the scope or duration
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of treatment.
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SECTION 2. This act shall take effect upon passage.
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LC005172
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EXPLANATION
BY THE LEGISLATIVE COUNCIL
OF
A N A C T
RELATING TO INSURANCE -- INSURANCE COVERAGE FOR MENTAL ILLNESS AND
SUBSTANCE USE DISORDERS
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This act would provide that for insurance coverage for treatment of mental health and
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substance use disorders, payors would rely upon criteria which reflect generally accepted standards
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of care when developing coverage for levels of care for mental health treatment. This act would
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also provide that payors would not modify clinical criteria to reduce coverage for mental health
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treatment below the level established by the generally accepted standards of care upon which their
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clinical criteria are based. This act would also provide definitions for the terms “generally accepted
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standards of care” and “nonprofit professional provider association.”
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This act would take effect upon passage.
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