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BILL AS INTRODUCED 2007-2008

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H.198

Introduced by Representatives Donahue of Northfield, Andrews of Rutland City, Devereux of Mount Holly, Donovan of Burlington, Evans of Essex, Fisher of Lincoln, French of Randolph, Grad of Moretown, Jerman of Essex, Koch of Barre Town, Lorber of Burlington, McAllister of Highgate, Morrissey of Bennington, Pearson of Burlington, Pellett of Chester, Pugh of S. Burlington and Sweaney of Windsor

Referred to Committee on

Date:

Subject:  Health; insurance; mental health parity

Statement of purpose:  This bill proposes to:  (1)  establish the goal of fully integrating mental health and substance abuse services with other health services, while establishing interim steps toward that goal; (2)  prohibit the imposition of any type of greater burden in accessing mental health services, instead of prohibiting only financial burdens; (3)  require deductible or

out-of-pocket limits to be comprehensive for all services; (4)  require that administrative and clinical protocols for provision of mental health and substance abuse services do not differ from those for other health services or create burdens to access; (5)  require rulemaking to ensure consistency in requiring co-payments for routine and primary mental health care; (6)  prohibit mental health carve out margins in excess of those for physical health; (7)  require health plans to engage in mental health quality improvement projects, including one joint venture between all managed care plans and mental health review agents; (8)  require health plans to demonstrate how collected data is being used to inform practices, policies, and future direction of integration of services;  (9)  require health plans to demonstrate how quality improvement projects relate to the blueprint for health and chronic care initiative; and (10)  support the priorities of the report of the Institute of Medicine, “Crossing the Quality Chasm (2006).” 

AN ACT RELATING TO ENHANCING MENTAL HEALTH PARITY

It is hereby enacted by the General Assembly of the State of Vermont:

Sec. 1.  8 V.S.A. § 4089b is amended to read:

§ 4089b.  HEALTH INSURANCE COVERAGE, MENTAL HEALTH AND

                SUBSTANCE ABUSE

(a)  It is the goal of the general assembly that access to treatment for mental health and substance abuse be fully integrated with all other health services, and that health insurance plans be required to cover all offered services without subcontracting or otherwise separating access through distinct subparts of the health insurance plan, including through separate management or through management of treatment only for mental health and substance abuse.  The exceptions in this section are established as interim steps until such clinical, financial, and management integration is fully achieved. 

(b)  As used in this section:

(1)  “Health insurance plan” means any health insurance policy or health benefit plan offered by a health insurer, as defined in 18 V.S.A. § 9402(7) 9402(9).  Health insurance plan includes any health benefit plan offered or administered by the state, or any subdivision or instrumentality of the state.

(2)  “Mental health condition” means any condition or disorder involving mental illness or alcohol or substance abuse that falls under any of the diagnostic categories listed in the mental disorders section of the international classification of disease, as periodically revised.

(3)  “Rate, term, or condition” means any lifetime or annual payment limits, deductibles, copayments, coinsurance, and any other cost-sharing requirements, out-of-pocket limits, visit limits, and any other financial component of health insurance coverage that affects the insured.

(b)(c)  A health insurance plan shall provide coverage for treatment of a mental health condition and shall:

(1)  not establish any rate, term, or condition that places a greater financial burden, financial or otherwise, on an insured for access to treatment for a mental health condition than for access to treatment for a physical any other health condition;

(2)  not exclude from its network or list of authorized providers any licensed mental health or substance abuse provider located within the geographic coverage area of the health benefit plan if the provider is willing to meet the terms and conditions for participation established by the health insurer;

(3)  make any deductible or out-of-pocket limits required under a health insurance plan comprehensive for coverage of both mental health and physical health conditions.

(c)(d)  A health insurance plan that does not otherwise provide for management of care under the plan, or that does not provide for the same degree of management of care for all health conditions, may provide coverage for treatment of mental health conditions through a managed care organization provided that the managed care organization is in compliance with the rules adopted by the commissioner under subsection (e) of this section that ensure that the system for delivery of treatment for mental health conditions does not diminish or negate the purpose of this section. 

(e)  The rules adopted by the commissioner shall ensure that:

(1)  timely and appropriate access to care is available;

(2)  that the quantity, location, and specialty distribution of health care providers is adequate and that;

(3)  administrative or clinical protocols do not serve to reduce access to medically necessary treatment for any insured differ from those that apply to other health conditions or otherwise serve to create burdens to access, or reduce access, to medically necessary treatment for any insured;

(4)  any differences in co-payments in a plan between specialty and primary care are applied in a consistent way when the treatment for the mental health condition is routine and is ongoing primary care for that condition;

(5)  coverage for care and hospital admissions rendered in an emergency is not denied retroactively, and any utilization review does not impose a greater burden on providers than for any other emergent condition;

(6)  adequate resources are available for medically necessary treatment of all health conditions through ensuring that the operating margins of the mental health management company do not exceed those of the health insurance plan; and

(7)  health care plans are responsible for coordination and integration of services for medical and mental health conditions within clinical care, and for development of quality measures and practice standards that reduce the use of prior approval and ongoing review disproportionate to other health care treatment.  This coordination of services and reduction of prior approval shall be demonstrated through the use of health care administration Rule 10 Quality Improvement Projects, which shall include:

(A)  at least one such quality improvement project, which shall be a joint venture between, collectively, each managed care plan and each mental health review agent;

(B)  evidence of how data collected from the quality improvement projects are being used to inform the practices, policies, and the future direction of integration of services in each plan, and how data collected from the quality improvement projects are being used to inform the practices, policies, and future direction of quality review; and

(C)  demonstration of how the quality improvement projects are related to the blueprint for health and the chronic care initiative.

(d)(f)  A health insurance plan shall be construed to be in compliance with this section if at least one choice for treatment of mental health conditions provided to the insured within the plan has rates, terms, and conditions that place no greater financial burden, financial or otherwise, on the insured than for access to treatment of physical conditions.  The commissioner may disapprove any plan that the commissioner determines to be inconsistent with the purposes of this section.

(e)(g)  To be eligible for coverage under this section the service shall be rendered:

(1)  For treatment of mental illness:

(A)  by a licensed or certified mental health professional,; or

(B)  in a mental health facility qualified pursuant to rules adopted by the secretary of human services or in an institution, approved by the secretary of human services, that provides a program for the treatment of a mental health condition pursuant to a written plan.  A nonprofit hospital or a medical service corporation may require a mental health facility or licensed or certified mental health professional to enter into a contract as a condition of providing benefits.

(2)  For treatment of alcohol or substance abuse:

(A)  by a substance abuse counselor or other person approved by the secretary of human services based on rules adopted by the secretary that establish standards and criteria for determining eligibility under this subdivision; or

(B)  in an institution, approved by the secretary of human services, that provides a program for the treatment of alcohol or substance dependency pursuant to a written plan.

(f)(h)  On or before July 15 of each year, health insurance companies doing business in Vermont, and whose individual share of the commercially-insured Vermont market, as measured by covered lives, comprises at least five percent of the commercially-insured Vermont market, shall file with the commissioner, in accordance with standards, procedures, and forms approved by the commissioner:

(1)  A report card on the health insurance plan’s performance in relation to quality measures for the care, treatment, and treatment options of mental health and substance abuse conditions covered under the plan, pursuant to standards and procedures adopted by the commissioner by rule, and without duplicating any reporting required of such companies pursuant to Rule 10 of the division of health care administration, “Quality Assurance Standards and Consumer Protections for Managed Care Plans,” and regulation 95-2, “Mental Health Review Agents,” of the division of insurance, as amended, including:

(A)  the discharge rates from inpatient mental health and substance abuse care and treatment of insureds;

(B)  the average length of stay and number of treatment sessions for insureds receiving inpatient and outpatient mental health and substance abuse care and treatment;

(C)  the percentage of insureds receiving inpatient and outpatient mental health and substance abuse care and treatment;

(D)  the number of insureds denied mental health and substance abuse care and treatment;

(E)  the number of denials appealed by patients reported separately from the number of denials appealed by providers;

(F)  the rates of readmission to inpatient mental health and substance abuse care and treatment for insureds with a mental health condition;

(G)  the level of patient satisfaction with the quality of the mental health and substance abuse care and treatment provided to insureds under the health insurance plan; and

(H)  any other quality measure established by the commissioner.

(2)  [Repealed.]

(g)(i)  The commissioner shall establish a task force to develop performance quality measures and, address oversight issues for managed behavioral health care organizations, and review the integration and the quality improvement projects required under subdivision (e)(7) of this section.  The task force shall report to the committees on health and welfare of the senate and the house of representatives on or before January 15 of each year with a report on the activities and recommendations of the task force.  The task force shall include the following:

(1)  the commissioner of developmental and mental health services or a designee;

(2)  the director of the office of Vermont health access or a designee;

(3)  the commissioner of banking, insurance, securities, and health care administration or a designee;

(4)  fourteen additional members appointed by the commissioner of banking, insurance, securities, and health care administration, including:

(A)  four representatives of the health insurance and behavioral managed care organization industry;

(B)  two consumers, after consultation with the health care ombudsman;

(C)  one psychologist, after consultation with the Vermont psychological association;

(D)  one psychiatrist, after consultation with the Vermont psychiatric association;

(E)  one social worker, after consultation with the National Association of Social Workers, Vermont Chapter;

(F)  one mental health counselor, after consultation with the Vermont mental health counselors association;

(G)  one drug and alcohol counselor, after consultation with the Vermont association of drug and alcohol counselors;

(H)  one representative from a consumer or citizen’s organization;

(I)  one representative from the business community; and

(J)  one representative of community mental health centers.



Published by:

The Vermont General Assembly
115 State Street
Montpelier, Vermont


www.leg.state.vt.us