The bill enacts the "Behavioral Health Care Coverage Modernization Act" to address issues related to coverage of behavioral, mental health, and substance use disorder services under private health insurance and the state medical assistance program (medicaid).
With regard to health insurance, the bill:
- Specifies that mandatory insurance coverage for behavioral, mental health, and substance use disorders includes coverage for the prevention of, screening for, and treatment of those disorders and must comply with the federal "Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008" (MHPAEA) ( section 3 of the bill);
- Requires services for behavioral, mental health, and substance use disorders to continue while a claim for coverage of those services is under review until the carrier notifies the covered person of the claim determination ( section 3 );
- Requires carriers to comply with treatment limitation requirements specified in federal regulations and precludes carriers from applying nonquantitative treatment limitations to behavioral, mental health, and substance use disorder services that do not apply to medical and surgical benefits ( section 3 );
- Requires carriers toestablish procedures to authorize treatment by nonparticipating providers when a participating provider is not available under network adequacy requirements and to reimburse treatment or services for behavioral, mental health, or substance use disorders obtained from a nonparticipating provider because the covered service was not available within established time and distance standards using the same methodology the carrier uses to reimburse covered medical services provided by nonparticipating providers ( section 3 );
- Requires the commissioner of insurance (commissioner) to adopt rules to establish reasonable time periods for visits with a provider for treatment of a behavioral, mental health, or substance use disorder after an initial visit with a provider ( section 3 );
- Modifies the definition of "behavioral, mental health, and substance use disorder" to include diagnostic categories listed in the mental disorders section of the International Statistical Classification of Diseases and Related Health Problems, the Diagnostic and Statistical Manual of Mental Disorders, or the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood ( section 3 );
- Updates the required coverage related to alcohol use and behavioral health screenings to reflect the current requirements of that coverage as specified in recommendations of the United States preventive services task force ( section 3 );
- Requires the commissioner to disallow a carrier's requested rate increase for failure to demonstrate compliance with the MHPAEA in accordance with rules adopted by the commissioner ( section 5 );
- For purposes of denials of reimbursement for behavioral, mental health, or substance use disorder services, other than denials based on nonpayment of premiums, requires carriers to include specified information about the protections included in the MHPAEA, how to contact the division of insurance or the office of the ombudsman for behavioral health access to care (office) related to possible violations of the MHPAEA, and the right to request medical necessity criteria from the carrier free of charge ( section 6 );
- For health benefit plans issued or renewed on or after January 1, 2020, requires carriers that provide coverage for an annual physical examination as a preventive health care service to also cover and reimburse for behavioral health screenings using a validated screening tool for behavioral health to the same extent the physical examination is covered ( section 8 );
- Requires carriers to submit an annual parity report to the commissioner ( section 9 );
- Starting January 1, 2020, for a carrier that provides prescription drug benefits for the treatment of substance use disorders, with regard to prescription medications that are on the carrier's formulary, requires the carrier to provide coverage of any FDA-approved prescription medication for treating substance use disorders without prior authorization or step therapy requirements and to place at least one covered substance use disorder prescription medication on the lowest tier of the drug formulary, and precludes those carriers from excluding coverage for those medications and related services solely on the grounds that they were court ordered ( section 10 ); and
- Requires the commissioner to provide a report to specified legislative committees regarding the effects of the bill on premiums ( section 10 ).
With regard to medicaid, the bill:
- Requires the department of health care policy and financing (department) to ensure that medicaid covers behavioral, mental health, and substance use disorder services to the extent that medicaid covers a physical illness and complies with the MHPAEA ( section 11 );
- Requires the medical services board (state board) to establish a procedure, by rule, to allow for reimbursements of medically necessary state plan behavioral, mental health, or substance use services under medicaid when a managed care entity (MCE) denies coverage of the service based on diagnosis ( section 11 );
- Requires the statewide system of community behavioral health care in the managed care system to require MCEs to provide an adequate network of providers of behavioral, mental health, and substance use disorder services and to cover all medically necessary covered treatments for covered behavioral health diagnoses, regardless of any co-occurring conditions ( section 12 );
- Requires the department to include utilization management guidelines for the MCEs in state board managed care rules and to provide information on its website specifying how the public may request the network adequacy plans and quarterly network reports for an MCE ( section 12 );
- Requires the department to examine complaints received from the office regarding compliance with the requirements of the bill or the MHPAEA upon the request of the office ( section 12 );
- Requires MCEs to include specified statements regarding the applicability of the MHPAEA to the managed care system in medicaid and how to contact the office regarding possible violations of the MHPAEA ( section 14 );
- Requires the department to submit an annual parity report to the specified committees of the general assembly and to contract with an external quality review organization annually to monitor MCEs' utilization management programs and policies to ensure compliance with the MHPAEA ( section 15 ); and
- Starting January 1, 2020, requires an MCE that provides prescription drug benefits for the treatment of substance use disorders to provide coverage of any FDA-approved prescription medication for treating substance use disorders without prior authorization or step therapy requirements and precludes those MCEs from excluding coverage for those medications and related services solely on the grounds that they were court ordered ( section 15 ).
The bill appropriates $181,751 to the department of health care policy and financing and $88,248 to the department of regulatory agencies to implement the bill.
(Note: This summary applies to the reengrossed version of this bill as introduced in the second house.)