PA 15-226—SB 1085

Insurance and Real Estate Committee

Appropriations Committee

AN ACT CONCERNING HEALTH INSURANCE COVERAGE FOR MENTAL OR NERVOUS CONDITIONS

SUMMARY: This act specifies the services certain health insurance policies must cover for mental and nervous conditions (see BACKGROUND). By law, a policy must cover the diagnosis and treatment of mental or nervous conditions on the same basis as medical, surgical, or other physical conditions (i. e. , parity).

The act requires policies to at least cover, among other things:

1. medically necessary acute treatment and clinical stabilization services (see below);

2. general inpatient hospitalization, including at state-operated facilities; and

3. programs to improve health outcomes for mothers, children, and families.

Under the act, a policy may not prohibit an insured from receiving, or a provider from being reimbursed for, multiple screening services as part of a single-day visit to a health care provider or multicare institution (e. g. , hospital, psychiatric outpatient clinic, or free standing facility for substance use treatment).

The act substitutes the term “benefits payable” for “covered expenses” pertaining to the mental or nervous condition coverage provisions. By law, these are the usual, customary, and reasonable charges for medically necessary treatment or, in the case of a managed care plan, the contracted rates.

The act also requires the insurance commissioner and healthcare advocate to convene a working group to study, among other things, the use of inpatient mental health and substance use disorder services. (PA 15-5, June Special Session, 515 repeals this requirement. )

The act applies to individual and group health insurance policies issued, delivered, renewed, amended, or continued in Connecticut that cover (1) basic hospital expenses, (2) basic medical-surgical expenses, (3) major medical expenses, or (4) hospital or medical services, including those provided through an HMO. Due to the federal Employee Retirement Income Security Act, state insurance mandates do not apply to self-insured benefit plans.

The act also makes technical and conforming changes.

EFFECTIVE DATE: January 1, 2016, except for the working group provisions, which are effective on passage.

COVERAGE FOR MENTAL OR NERVOUS CONDITIONS

Under the act, policies' coverage for mental or nervous conditions must at least include:

1. general inpatient hospitalization and outpatient hospital services,

2. psychiatric inpatient hospitalization and outpatient hospital services,

3. intensive outpatient services, and

4. partial hospitalization.

The act specifies that these services may be provided at state-operated facilities.

The act requires policies to also cover:

1. evidence-based maternal, infant, and early childhood home visitation services designed to improve health outcomes for pregnant women, postpartum mothers, and newborns and children, including for maternal substance use disorders or depression and relationship-focused interventions for children with mental or nervous conditions or substance use disorders;

2. intensive, home-based services designed to address specific mental or nervous conditions in a child while remediating problematic parenting practices and addressing other family and educational challenges that affect the child's and family's ability to function (PA 15-5, June Special Session, 43-46 eliminates the requirement for services to remediate problematic parenting practices and address other family and educational challenges);

3. intensive, family- and community-based treatment programs focusing on environmental systems impacting chronic and violent juvenile offenders (PA 15-5, June Special Session, 43-46 delays this requirement until January 1, 2017);

4. evidence-based, family-focused therapy specializing in juvenile substance use disorders and delinquency (PA 15-5, June Special Session, 43-46 repeals the requirement that such therapy also focus on delinquency);

5. short-term family therapy intervention and juvenile diversion programs targeting at-risk children to address adolescent behavior problems, conduct disorders, substance use disorders, and delinquency (PA 15-5, June Special Session, 43-46 repeals the (1) juvenile diversion program coverage provision and (2) requirement for coverage to target at-risk children and address adolescent behavior problems, conduct disorders, substance use disorders, and delinquency);

6. other home-based, therapeutic interventions for children (PA 15-5, June Special Session, 43-46 delays this requirement until January 1, 2017);

7. chemical maintenance treatment (i. e. , admitting a person for the planned use of a prescribed substance under medical supervision) (PA 15-5, June Special Session, 43-46 delays this requirement until January 1, 2017);

8. nonhospital inpatient, medically monitored, or ambulatory detoxification;

9. inpatient services at psychiatric residential treatment facilities;

10. extended day treatment programs for emotionally disturbed, mentally ill, behaviorally disordered, or multiply handicapped children and youth (PA 15-5, June Special Session, 43-46 delays this requirement until January 1, 2017);

1. rehabilitation services provided in a residential treatment facility, general hospital, psychiatric hospital, or psychiatric facility;

1. observation beds in acute hospital settings;

1. psychological and neuropsychological testing by an appropriately licensed health care provider;

1. trauma screening by a licensed behavioral health professional;

1. depression screening, including maternal depression screening, by a licensed behavioral health professional; and

1. substance use screening by a licensed behavioral health professional.

Acute Treatment and Clinical Stabilization Services

The act also requires policies to cover medically necessary acute treatment and clinical stabilization services. “Acute treatment” is 24-hour medically supervised treatment for a substance use disorder provided in a medically managed or monitored inpatient facility. “Clinical stabilization” is 24-hour, clinically managed post-detoxification treatment, including relapse prevention, family outreach, aftercare planning, and addiction education and counseling.

COVERAGE FOR APRN-PROVIDED SERVICES

The act requires policies to cover APRN-provided services for mental or nervous conditions. By law, policies must cover such services when provided by (1) licensed physicians, psychologists, clinical social workers, marital and family therapists, and professional counselors; (2) certain certified marital and family therapists; (3) independent social workers; (4) licensed or certified alcohol and drug counselors; and (5) under certain circumstances, certified nurse practitioners (CGS 38a-499 & 38a-526). (Certified nurse practitioners are also APRNs. )

MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES WORKING GROUP

The act requires the insurance commissioner and the healthcare advocate to convene a mental health and substance use disorder services working group by September 1, 2015. The group must study and recommend policies that, with respect to utilizing inpatient mental health services and substance use disorder services, improve the alignment of utilization review procedures and health insurance coverage with treating health care providers' clinical recommendations.

The working group must, at least, include health insurance industry representatives, health care providers, and consumers.

The commissioner and healthcare advocate must submit the group's recommendations to the Insurance and Real Estate and Public Health committees by January 1, 2016.

(PA 15-5, June Special Session, 515 repeals all of the above working group provisions. )

BACKGROUND

Mental or Nervous Conditions

By law, “mental or nervous conditions” are mental disorders defined in the most recent edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). This does not include (1) intellectual disabilities, (2) specific learning disorders, (3) motor disorders, (4) communication disorders, (5) caffeine-related disorders, (6) relational problems, and (7) other conditions that may be a focus of clinical attention but are not defined as mental disorders in the DSM (CGS 38a-488a & 38a-514).

Related Federal Law

Under the federal Patient Protection and Affordable Care Act (ACA) (P. L. 111-148), a state may require health plans sold through the state's health insurance exchange to offer benefits beyond those included in the ACA's required “essential health benefits,” provided the state defrays the cost of those additional benefits. The requirement applies to benefit mandates a state enacts after December 31, 2011. Thus, the state must pay the insurance carrier or enrollee to defray the cost of any new benefits mandated after that date.

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