ACT NO. 142
Health insurance; mental health; BISHCA
This act identifies as goals of the general assembly the recognition of mental health conditions as an integral component of health care, coverage by health insurance plans of all necessary and appropriate medical services without the imposition of practices that create barriers to receiving appropriate care, and recognition of integration of health care as the standard for care in Vermont. It expands a provision prohibiting health insurance plans from placing a greater financial burden on access to treatment for mental health conditions than they do on treatment for physical health conditions. When reviewing insurance rates and forms, the act requires the commissioner of banking, insurance, securities, and health care administration (BISHCA) also to look at a health insurance policys compliance with mental health parity.
Existing law allows a health insurance plan that does not otherwise provide for managed care or that does not provide for the same degree of managed care for all conditions to use a managed care organization for coverage of mental health treatment as long as the organization complies with rules adopted by the BISHCA commissioner. The act requires the commissioner to adopt additional rules to ensure that (1) utilization review and other administrative and clinical protocols do not deter timely and appropriate care, including emergency hospital admissions; (2) for a managed care organization that administers an insurers mental health benefits, the portion of the insurers premium rate attributable to coverage of the mental health benefits is reviewed to determine whether it is excessive, inadequate, unfairly discriminatory, unjust, unfair, inequitable, misleading, or contrary to Vermont law; (3 the health insurance plan is consistent with the Blueprint for Health with respect to mental health conditions; (4) a joint quality improvement project is completed between the insurance plan and its mental health managed care organization annually to implement policies and incentives to increase collaboration among providers that will facilitate clinical integration of services for medical and mental health conditions; (5) an up-to-date list of active mental health care providers in the plans network who are available to the general membership is on the insurers and managed care organizations websites and provided to consumers upon request; and (6) health insurers and managed care organizations make accessible to consumers the toll-free telephone number for BISHCAs health care consumer protection help line. Before adopting these rules, the act requires the BISHCA commissioner to consult with the commissioner of mental health and with a task force established under existing law to develop performance quality measures and address oversight issues for managed behavioral health care organizations about (1) addressing the availability of mental health providers; (2) incorporating best practices and evidence-based guidelines into utilizations reviews; and (3) establishing benefit design, infrastructure support, and payment methodology standards for evaluating a plans consistency with the Blueprint for Health.
The act requires managed care organizations providing or administering coverage for treatment of mental health conditions on behalf of a health insurance plan to comply with Vermont laws on mental health parity, mental health services review, unfair insurance trade practices, and quality assurance for managed care organizations, as well as with all other obligations of the health insurance plan and the health insurer on behalf of which the review agent is providing or administering coverage. It specifies that a violation of the mental health parity statute constitutes an unfair act or practice in the business of insurance.
The act makes a health insurer that contracts with a managed care organization to provide or administer coverage for mental health treatment fully responsible for the acts and omissions of the managed care organization. In addition to other remedies provided by law and after notice and an opportunity to be heard, if the BISHCA commissioner finds that a health insurance plan or managed care organization has violated the mental health parity statute or a related rule, the act allows the commissioner to (1) assess a penalty on the health insurer or managed care organization; (2) order the health insurer or managed care organization to cease and desist in further violations; (3) order the health insurer or managed care organization to remediate the violation, including issuing an order to the health insurer to terminate its contract with the managed care organization; and (4) revoke or suspend the license of the health insurer or managed care organization, or allow continued licensure subject to conditions. These remedies are applicable to legal and regulatory violations that occur before or after passage of the act.
The act reinstates a previously repealed provision requiring health insurance companies doing business in Vermont whose individual share comprises at least five percent of the commercially insured Vermont market to file annually with the commissioner the plans revenue loss and expense ratio relating to the care and treatment of mental health conditions covered under the plan, listing separately the amounts paid in claims for services and for administrative costs.
The act requires the task force established by the commissioner under existing law to develop performance quality measures and address oversight issues for managed behavioral health care organizations also to review the results of any mental health and substance abuse care and treatment quality improvement projects undertaken by managed care organizations as long as they are not otherwise confidential or privileged. It also adds to the list of required task force members the deputy commissioner of the department of health for alcohol and drug abuse programs or a designee.
In addition to other remedies provided by law and after notice and an opportunity to be heard, if the commissioner determines that a managed care organization has violated or failed to comply with any provisions of the laws or rules on quality assurance for managed care organization, the act allows the commissioner to order the managed care organization to cease and desist further violations and order the managed care organization to remediate the violation, including ordering the managed care organization to terminate its contract with any person or entity which administers claims or coverage of benefits on the managed care organizations behalf. These remedies are applicable to legal and regulatory violations that occur before or after passage of the act. The act makes a managed care organization that contracts with a person or entity to administer claims or provide coverage of health benefits fully responsible for that persons or entitys acts or omissions and requires the person or entity to comply with all obligations of the health insurance plan and health insurer on behalf of which the person or entity provides or administers coverage. The act specifies that a violation of these provisions or related rules constitutes an unfair act or practice in the business of insurance.
Upon review of a managed care organizations clinical data, or after consideration of claims or other data, the act allows the commissioner to identify quality issues in need of improvement and direct the managed care organization to propose quality improvement initiatives to remediate those issues.
Effective Date: Upon passage.
The Vermont General Assembly
115 State Street