Bill Text: FL S0360 | 2019 | Regular Session | Introduced


Bill Title: Insurance Coverage Parity for Mental Health and Substance Use Disorders

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced) 2019-01-25 - Referred to Banking and Insurance; Appropriations Subcommittee on Health and Human Services; Appropriations [S0360 Detail]

Download: Florida-2019-S0360-Introduced.html
       Florida Senate - 2019                                     SB 360
       
       
        
       By Senator Rouson
       
       
       
       
       
       19-00409-19                                            2019360__
    1                        A bill to be entitled                      
    2         An act relating to insurance coverage parity for
    3         mental health and substance use disorders; amending s.
    4         409.967, F.S.; requiring contracts between the Agency
    5         for Health Care Administration and certain managed
    6         care plans to require the plans to submit a specified
    7         annual report to the agency relating to parity between
    8         mental health and substance use disorder benefits and
    9         medical and surgical benefits; requiring the report to
   10         contain certain information; amending s. 627.6675,
   11         F.S.; conforming a provision to changes made by the
   12         act; transferring, renumbering, and amending s.
   13         627.668, F.S.; deleting certain provisions that
   14         require insurers, health maintenance organizations,
   15         and nonprofit hospital and medical service plan
   16         organizations transacting group health insurance or
   17         providing prepaid health care to offer specified
   18         optional coverage for mental and nervous disorders;
   19         requiring such entities transacting individual or
   20         group health insurance or providing prepaid health
   21         care to comply with specified provisions prohibiting
   22         the imposition of less favorable benefit limitations
   23         on mental health and substance use disorder benefits
   24         than on medical and surgical benefits; revising the
   25         standard for defining substance use disorders;
   26         requiring such entities to submit a specified annual
   27         report relating to parity between such benefits to the
   28         Office of Insurance Regulation; requiring the report
   29         to contain certain information; requiring the office
   30         to implement and enforce specified federal provisions,
   31         guidance, and regulations; specifying actions the
   32         office must take relating to such implementation and
   33         enforcement; requiring the office to issue a specified
   34         annual report to the Legislature; repealing s.
   35         627.669, F.S., relating to optional coverage required
   36         for substance abuse impaired persons; providing an
   37         effective date.
   38          
   39  Be It Enacted by the Legislature of the State of Florida:
   40  
   41         Section 1. Paragraph (p) is added to subsection (2) of
   42  section 409.967, Florida Statutes, to read:
   43         409.967 Managed care plan accountability.—
   44         (2) The agency shall establish such contract requirements
   45  as are necessary for the operation of the statewide managed care
   46  program. In addition to any other provisions the agency may deem
   47  necessary, the contract must require:
   48         (p) Annual reporting relating to parity in mental health
   49  and substance use disorder benefits.Every managed care plan
   50  shall submit an annual report to the agency, on or before July
   51  1, which contains all of the following information:
   52         1.A description of the process used to develop or select
   53  the medical necessity criteria for:
   54         a. Mental or nervous disorder benefits;
   55         b. Substance use disorder benefits; and
   56         c. Medical and surgical benefits.
   57         2.Identification of all nonquantitative treatment
   58  limitations (NQTLs) applied to both mental or nervous disorder
   59  and substance use disorder benefits and medical and surgical
   60  benefits. Within any classification of benefits, there may not
   61  be separate NQTLs that apply to mental or nervous disorder and
   62  substance use disorder benefits but do not apply to medical and
   63  surgical benefits.
   64         3.The results of an analysis demonstrating that for the
   65  medical necessity criteria described in subparagraph 1. and for
   66  each NQTL identified in subparagraph 2., as written and in
   67  operation, the processes, strategies, evidentiary standards, or
   68  other factors used to apply the criteria and NQTLs to mental or
   69  nervous disorder and substance use disorder benefits are
   70  comparable to, and are applied no more stringently than, the
   71  processes, strategies, evidentiary standards, or other factors
   72  used to apply the criteria and NQTLs, as written and in
   73  operation, to medical and surgical benefits. At a minimum, the
   74  results of the analysis must:
   75         a.Identify the factors used to determine that an NQTL will
   76  apply to a benefit, including factors that were considered but
   77  rejected;
   78         b.Identify and define the specific evidentiary standards
   79  used to define the factors and any other evidentiary standards
   80  relied upon in designing each NQTL;
   81         c.Identify and describe the methods and analyses used,
   82  including the results of the analyses, to determine that the
   83  processes and strategies used to design each NQTL, as written,
   84  for mental or nervous disorder and substance use disorder
   85  benefits are comparable to, and no more stringently applied
   86  than, the processes and strategies used to design each NQTL, as
   87  written, for medical and surgical benefits;
   88         d.Identify and describe the methods and analyses used,
   89  including the results of the analyses, to determine that the
   90  processes and strategies used to apply each NQTL, in operation,
   91  for mental or nervous disorder and substance use disorder
   92  benefits are comparable to, and no more stringently applied
   93  than, the processes or strategies used to apply each NQTL, in
   94  operation, for medical and surgical benefits; and
   95         e.Disclose the specific findings and conclusions reached
   96  by the managed care plan that the results of the analyses
   97  indicate that the insurer, health maintenance organization, or
   98  nonprofit hospital and medical service plan corporation is in
   99  compliance with this section, the federal Paul Wellstone and
  100  Pete Domenici Mental Health Parity and Addiction Equity Act of
  101  2008 (MHPAEA), and any federal guidance or regulations relating
  102  to MHPAEA, including, but not limited to, 45 C.F.R. s. 146.136,
  103  45 C.F.R. s. 147.160, and 45 C.F.R. s. 156.115(a)(3).
  104         Section 2. Paragraph (b) of subsection (8) of section
  105  627.6675, Florida Statutes, is amended to read:
  106         627.6675 Conversion on termination of eligibility.—Subject
  107  to all of the provisions of this section, a group policy
  108  delivered or issued for delivery in this state by an insurer or
  109  nonprofit health care services plan that provides, on an
  110  expense-incurred basis, hospital, surgical, or major medical
  111  expense insurance, or any combination of these coverages, shall
  112  provide that an employee or member whose insurance under the
  113  group policy has been terminated for any reason, including
  114  discontinuance of the group policy in its entirety or with
  115  respect to an insured class, and who has been continuously
  116  insured under the group policy, and under any group policy
  117  providing similar benefits that the terminated group policy
  118  replaced, for at least 3 months immediately prior to
  119  termination, shall be entitled to have issued to him or her by
  120  the insurer a policy or certificate of health insurance,
  121  referred to in this section as a “converted policy.” A group
  122  insurer may meet the requirements of this section by contracting
  123  with another insurer, authorized in this state, to issue an
  124  individual converted policy, which policy has been approved by
  125  the office under s. 627.410. An employee or member shall not be
  126  entitled to a converted policy if termination of his or her
  127  insurance under the group policy occurred because he or she
  128  failed to pay any required contribution, or because any
  129  discontinued group coverage was replaced by similar group
  130  coverage within 31 days after discontinuance.
  131         (8) BENEFITS OFFERED.—
  132         (b) An insurer shall offer the benefits specified in s.
  133  627.4193 s. 627.668 and the benefits specified in s. 627.669 if
  134  those benefits were provided in the group plan.
  135         Section 3. Section 627.668, Florida Statutes, is
  136  transferred, renumbered as section 627.4193, Florida Statutes,
  137  and amended to read:
  138         627.4193 627.668Requirements for mental health and
  139  substance use disorder benefits; reporting requirements Optional
  140  coverage for mental and nervous disorders required; exception.—
  141         (1) Every insurer, health maintenance organization, and
  142  nonprofit hospital and medical service plan corporation
  143  transacting individual or group health insurance or providing
  144  prepaid health care in this state must comply with the federal
  145  Paul Wellstone and Pete Domenici Mental Health Parity and
  146  Addiction Equity Act of 2008 (MHPAEA) and any regulations
  147  relating to MHPAEA, including, but not limited to, 45 C.F.R. s.
  148  146.136, 45 C.F.R. s. 147.160, and 45 C.F.R. s. 156.115(a)(3);
  149  and must provide shall make available to the policyholder as
  150  part of the application, for an appropriate additional premium
  151  under a group hospital and medical expense-incurred insurance
  152  policy, under a group prepaid health care contract, and under a
  153  group hospital and medical service plan contract, the benefits
  154  or level of benefits specified in subsection (2) for the
  155  necessary care and treatment of mental and nervous disorders,
  156  including substance use disorders, as defined in the Diagnostic
  157  and Statistical Manual of Mental Disorders, Fifth Edition,
  158  published by standard nomenclature of the American Psychiatric
  159  Association, subject to the right of the applicant for a group
  160  policy or contract to select any alternative benefits or level
  161  of benefits as may be offered by the insurer, health maintenance
  162  organization, or service plan corporation provided that, if
  163  alternate inpatient, outpatient, or partial hospitalization
  164  benefits are selected, such benefits shall not be less than the
  165  level of benefits required under paragraph (2)(a), paragraph
  166  (2)(b), or paragraph (2)(c), respectively.
  167         (2) Under individual or group policies or contracts,
  168  inpatient hospital benefits, partial hospitalization benefits,
  169  and outpatient benefits consisting of durational limits, dollar
  170  amounts, deductibles, and coinsurance factors may shall not be
  171  less favorable than for physical illness, in accordance with 45
  172  C.F.R. s. 146.136(c)(2) and (3) generally, except that:
  173         (a) Inpatient benefits may be limited to not less than 30
  174  days per benefit year as defined in the policy or contract. If
  175  inpatient hospital benefits are provided beyond 30 days per
  176  benefit year, the durational limits, dollar amounts, and
  177  coinsurance factors thereto need not be the same as applicable
  178  to physical illness generally.
  179         (b) Outpatient benefits may be limited to $1,000 for
  180  consultations with a licensed physician, a psychologist licensed
  181  pursuant to chapter 490, a mental health counselor licensed
  182  pursuant to chapter 491, a marriage and family therapist
  183  licensed pursuant to chapter 491, and a clinical social worker
  184  licensed pursuant to chapter 491. If benefits are provided
  185  beyond the $1,000 per benefit year, the durational limits,
  186  dollar amounts, and coinsurance factors thereof need not be the
  187  same as applicable to physical illness generally.
  188         (c) Partial hospitalization benefits shall be provided
  189  under the direction of a licensed physician. For purposes of
  190  this part, the term “partial hospitalization services” is
  191  defined as those services offered by a program that is
  192  accredited by an accrediting organization whose standards
  193  incorporate comparable regulations required by this state.
  194  Alcohol rehabilitation programs accredited by an accrediting
  195  organization whose standards incorporate comparable regulations
  196  required by this state or approved by the state and licensed
  197  drug abuse rehabilitation programs shall also be qualified
  198  providers under this section. In a given benefit year, if
  199  partial hospitalization services or a combination of inpatient
  200  and partial hospitalization are used, the total benefits paid
  201  for all such services may not exceed the cost of 30 days after
  202  inpatient hospitalization for psychiatric services, including
  203  physician fees, which prevail in the community in which the
  204  partial hospitalization services are rendered. If partial
  205  hospitalization services benefits are provided beyond the limits
  206  set forth in this paragraph, the durational limits, dollar
  207  amounts, and coinsurance factors thereof need not be the same as
  208  those applicable to physical illness generally.
  209         (3) Insurers must maintain strict confidentiality regarding
  210  psychiatric and psychotherapeutic records submitted to an
  211  insurer for the purpose of reviewing a claim for benefits
  212  payable under this section. These records submitted to an
  213  insurer are subject to the limitations of s. 456.057, relating
  214  to the furnishing of patient records.
  215         (4)Every insurer, health maintenance organization, and
  216  nonprofit hospital and medical service plan corporation
  217  transacting individual or group health insurance or providing
  218  prepaid health care in this state shall submit an annual report
  219  to the office, on or before July 1, which contains all of the
  220  following information:
  221         (a)A description of the process used to develop or select
  222  the medical necessity criteria for:
  223         1. Mental or nervous disorder benefits;
  224         2. Substance use disorder benefits; and
  225         3. Medical and surgical benefits.
  226         (b) Identification of all nonquantitative treatment
  227  limitations (NQTLs) applied to both mental or nervous disorder
  228  and substance use disorder benefits and medical and surgical
  229  benefits. Within any classification of benefits, there may not
  230  be separate NQTLs that apply to mental or nervous disorder and
  231  substance use disorder benefits but do not apply to medical and
  232  surgical benefits.
  233         (c)The results of an analysis demonstrating that for the
  234  medical necessity criteria described in paragraph (a) and for
  235  each NQTL identified in paragraph (b), as written and in
  236  operation, the processes, strategies, evidentiary standards, or
  237  other factors used to apply the criteria and NQTLs to mental or
  238  nervous disorder and substance use disorder benefits are
  239  comparable to, and are applied no more stringently than, the
  240  processes, strategies, evidentiary standards, or other factors
  241  used to apply the criteria and NQTLs, as written and in
  242  operation, to medical and surgical benefits. At a minimum, the
  243  results of the analysis must:
  244         1.Identify the factors used to determine that a NQTL will
  245  apply to a benefit, including factors that were considered but
  246  rejected;
  247         2.Identify and define the specific evidentiary standards
  248  used to define the factors and any other evidentiary standards
  249  relied upon in designing each NQTL;
  250         3.Identify and describe the methods and analyses used,
  251  including the results of the analyses, to determine that the
  252  processes and strategies used to design each NQTL, as written,
  253  for mental or nervous disorder and substance use disorder
  254  benefits are comparable to, and no more stringently applied
  255  than, the processes and strategies used to design each NQTL, as
  256  written, for medical and surgical benefits;
  257         4.Identify and describe the methods and analyses used,
  258  including the results of the analyses, to determine that the
  259  processes and strategies used to apply each NQTL, in operation,
  260  for mental or nervous disorder and substance use disorder
  261  benefits are comparable to, and no more stringently applied
  262  than, the processes or strategies used to apply each NQTL, in
  263  operation, for medical and surgical benefits; and
  264         5.Disclose the specific findings and conclusions reached
  265  by the insurer, health maintenance organization, or nonprofit
  266  hospital and medical service plan corporation that the results
  267  of the analyses indicate that the insurer, health maintenance
  268  organization, or nonprofit hospital and medical service plan
  269  corporation is in compliance with this section, MHPAEA, and any
  270  regulations relating to MHPAEA, including, but not limited to,
  271  45 C.F.R. s. 146.136, 45 C.F.R. s. 147.160, and 45 C.F.R. s.
  272  156.115(a)(3).
  273         (5)The office shall implement and enforce applicable
  274  provisions of MHPAEA and federal guidance or regulations
  275  relating to MHPAEA, including, but not limited to, 45 C.F.R. s.
  276  146.136, 45 C.F.R. s. 147.160, and 45 C.F.R. s. 156.115(a)(3),
  277  and this section, which includes:
  278         (a)Ensuring compliance by each insurer, health maintenance
  279  organization, and nonprofit hospital and medical service plan
  280  corporation transacting individual or group health insurance or
  281  providing prepaid health care in this state.
  282         (b)Detecting violations by any insurer, health maintenance
  283  organization, or nonprofit hospital and medical service plan
  284  corporation transacting individual or group health insurance or
  285  providing prepaid health care in this state.
  286         (c)Accepting, evaluating, and responding to complaints
  287  regarding potential violations.
  288         (d)Reviewing information from consumer complaints for
  289  possible parity violations regarding mental or nervous disorder
  290  and substance use disorder coverage.
  291         (e)Performing parity compliance market conduct
  292  examinations, which include, but are not limited to, reviews of
  293  medical management practices, network adequacy, reimbursement
  294  rates, prior authorizations, and geographic restrictions of
  295  insurers, health maintenance organizations, and nonprofit
  296  hospital and medical service plan corporations transacting
  297  individual or group health insurance or providing prepaid health
  298  care in this state.
  299         (6)No later than December 31 of each year, the office
  300  shall issue a report to the Legislature which describes the
  301  methodology the office is using to check for compliance with
  302  MHPAEA; any federal guidance or regulations that relate to
  303  MHPAEA, including, but not limited to, 45 C.F.R. s. 146.136, 45
  304  C.F.R. s. 147.160, and 45 C.F.R. s. 156.115(a)(3); and this
  305  section. The report must be written in nontechnical and readily
  306  understandable language and must be made available to the public
  307  by posting the report on the office’s website and by other means
  308  the office finds appropriate.
  309         Section 4. Section 627.669, Florida Statutes, is repealed.
  310         Section 5. This act shall take effect July 1, 2019.

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