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Statutory Overview in Massachusetts

Legislation Signed into Law

2015-2016

H. 4056
Introduced: 3/2016
Bill Sponsor: Reps. Dempsey, Malia, Hunt, Spilka, Flanagan, and Manuel deMacedo
Status: Signed into law 3/2016
Summary: Among many things, this bill requires all insurers to:
  • Cover substance use disorder evaluations without prior authorization
  • Report:
    • Medical or surgical claims submitted to the carrier
    • Medical or surgical claims denied by the carrier
    • Mental health or substance use disorder claims submitted to the carrier
    • Mental health or substance use disorder claims denied by the carrier
    • Medical or surgical claims and mental health or substance use disorder claims denied by the carrier because:
      • The insured failed to obtain prior authorization or referral for services,
      • The service was not medically necessary
      • The service was experimental or investigational
      • The insured was not covered or eligible for benefits at the time services occurred
      • The carrier does not cover the service or the provider under the insured’s plan
      • Duplicate claims had been submitted
      • Incomplete claims had been submitted, coding errors had occurred
      • Any other specified reason
  • Provide information on the patient’s right to appeal decisions to the office of patient protection

Additionally, the health policy commission must conduct a study on the availability of health care providers that serve patients with dual diagnoses of substance use disorder and mental illness, in inpatient and outpatient settings. The study must include:

  • An inventory of health care providers with the capability of caring for patients with dual diagnoses, including the location and nature of services offered at each such provider
  • An inventory of health care providers specializing in caring for child and adolescent patients with dual diagnoses, including the location and nature of services offered
  • An assessment of the sufficiency of dual diagnosis resources considering multiple factors, including but not limited to population density, geographic barriers to access, insurance coverage and network design, incidence of mental illness and substance use disorders and the needs of individuals with dual diagnoses
  • After consideration of barriers to access to comprehensive mental health and substance use disorder treatment for adults, seniors, children and adolescents, recommendations to reduce barriers to treatment for patients with dual diagnoses, including the appropriate supply and distribution of capable health care providers

Primary Focus: Mandated Benefit: Provider
Title/Description: Coverage—Clinical Stabilization Services and Acute Treatment Services
Citation: Mass. Ann. Laws ch. 118E, § 10H
Summary: The Division of Medical Assistance and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third party administrators under contract to a Medicaid managed care organization or primary care clinician plan shall cover the cost of medically necessary acute treatment services, provide up to 14 days of clinical stabilization services, and shall not require a preauthorization prior to obtaining treatment.
Effective Date: October 1, 2015
Notes: Enacted through S.2142 (188th Legislature)

Primary Focus: Mandated Benefit: Provider
Title/Description: Insurance for Clinical Stabilization Services
Citation: Mass. Ann. Laws ch. 118E, § 10I
Summary: The Division of Medical Assistance and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third party administrators under contract to a Medicaid managed care organization or primary care clinician plan shall cover the cost of FDA approved drugs for treatment of opioid and alcohol dependence.
Effective Date: July 1, 2015
Notes: Enacted through H. 3650 (189th Legislature)

2013-2014

Primary Focus: Mandated Benefit: Provider
Title/Description: Coverage—Autism Spectrum Disorder—Medically Necessary Treatments for Persons Younger than 21 Years Old
Citation: Mass. Ann. Laws ch. 118E, § 10H
Summary: The Division of Medical Assistance shall cover treatments for persons younger than 21 years old who are receiving medical coverage under this chapter and who are diagnosed with an autism spectrum disorder If federal funds are available, coverage shall include, but shall not be limited to, services for applied behavior analysis and dedicated and non-dedicated augmentative and alternative communication devices; provided, however, that the division shall also provide coverage for augmentative and alternative communication devices not eligible for federal funds if the total cost incurred by the division for a device that is not eligible for federal funds is not more than the commonwealth’s share of a comparable device that is eligible for federal funds.
Effective Date: November 3, 2014
Notes: Enacted through H.4047 (188th Legislature)

S. 2142
Introduced: 5/2014
Sponsor: None listed
Status: Signed into law 8/2014
Summary: This is a comprehensive bill that increases access to substance use disorder treatment through the following provisions:
  • It creates a commission tasked with developing a drug formulary for opiate drugs that are associated with abuse and misuse
  • It defines substance use disorder treatment as early intervention services, outpatient care including medication-assisted treatment, intensive outpatient care and partial hospitalization services, residential treatment and inpatient treatment, stabilization services, acute treatment, and medically managed inpatient services. The bill eliminates prior authorization for any of these services under state employee plans, individual plans, and group health plans
  • It requires the department of public health to publish regulations on coordinated care for individuals receiving substance use disorder treatment
  • It requires state employee plans, individual health plans and group health plans certified in Massachusetts to provide access to all opioid deterrent drugs recommended by the drug formulary commission under the same terms and conditions as prescription drugs for physical health conditions
  • It requires a commission to define voluntary standards for substance use disorder treatment providers. The commission is also tasked with creating a procedure for certifying a provider complies with the standards
  • It mandates the chief medical examiner to file a report with the federal Food and Drug Administration’s MedWatch Program any time a cause of death was fully or partially related to a controlled substance
  • It requires all corporate entities besides hospitals and clinics that treat more than 300 patients with opioid dependency treatment to be licensed by the department of public health
  • It requires the department of public health to compile a list of safe locations to dispose of prescription drugs
  • It requires the center for health information and analysis to conduct a review of the accessibility of substance use disorder treatment and adequacy of insurance coverage
  • It creates a commission to examine “substance use disorder treatment programs in correctional facilities
H. 3538
Introduced: 7/2013
Sponsor: Rep. Dempsey, Rep. Kulik, Sen. Brewer, & Sen. Flanagan
Status: Veto Overridden 7/2013
Summary: This is the appropriations bill for fiscal year 2014. Section 190 of the bill requires the Division of Insurance and the Office of Medicaid to promulgate regulations on the following topics related to parity:
  • A process for private and public insurers to certify and outline compliance
  • A requirement that insurers notify their enrollees of their rights, including the right to file a complaint or grievance
  • Information on how the Department of Insurance and the Office of Medicaid will review consumer complaints and grievances for compliance

2011-2012

Primary Focus: Mandated Benefit: Provider
Title/Description: Mental Health Parity and Addiction Equity Laws
Citation: Mass. Ann. Laws ch. 26, § 8K
Summary: The commissioner of insurance may implement and enforce applicable provisions of the federal Mental Health Parity and Addiction Equity Act, section 511 of Public Law 110-343, and applicable state mental health parity laws in regard to any carrier licensed under chapters 175, 176A, 176B and 176G.
Effective Date: November 4, 2012
Notes: Enacted through S.2400 (187th Legislature)

Primary Focus: Mandated Benefit: Provider
Title/Description: Coverage for Costs Arising from Mental or Nervous Conditions; Benefits
Citation: Mass. Ann. Laws ch. 176A, § 8A
Summary: Subsection (i) of Section 8A of chapter 176A added the definition of a licensed mental health professional. Additionally, a contract between a subscriber and the corporation under an individual or group hospital service plan which is issued or renewed within or without the commonwealth shall provide mental health benefits on a nondiscriminatory basis to residents of the commonwealth and to all individual subscribers and members and group members having a principal place of employment in the commonwealth for the diagnosis and treatment of the following biologically-based mental disorders, as described in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, referred to in this section as the DSM: (1) schizophrenia; (2) schizoaffective disorder; (3) major depressive disorder; (4) bipolar disorder; (5) paranoia and other psychotic disorders; (6) obsessive-compulsive disorder; (7) panic disorder; (8) delirium and dementia; (9) affective disorders; (10) eating disorders; (11) post traumatic stress disorder; (12) substance abuse disorders; and (13) autism. A contract between a subscriber and the corporation under an individual or group hospital service plan which is issued or renewed within or without the commonwealth shall provide mental health benefits on a nondiscriminatory basis to residents of the commonwealth and to all individual subscribers and members and group members having a principal place of employment in the commonwealth for the diagnosis and medically necessary and active treatment of any mental disorder, as described in the most recent edition of the DSM, that is approved by the commissioner of mental health.
Effective Date: October 11, 2012 and August 5, 2008, respectively.
Notes: Amended by Mass. SB 72 and Mass. HB 4423.

Primary Focus: Mandated Benefit: Provider
Title/Description: Subscription Certificates Shall Insure Against Costs Arising from Mental or Nervous Conditions; Benefits
Citation: Mass. Ann. Laws ch. 176B, § 4A
Summary: The statute was amended to include the definition of licensed mental health professional and to include that a subscription certificate under an individual or group medical service agreement which is issued or renewed within or without the commonwealth shall provide mental health benefits on a nondiscriminatory basis to residents of the commonwealth and to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment in the commonwealth for the diagnosis and treatment of the following biologically-based mental disorders, as described in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, referred to in this section as the DSM: (1) schizophrenia; (2) schizoaffective disorder; (3) major depressive disorder; (4) bipolar disorder; (5) paranoia and other psychotic disorders; (6) obsessive-compulsive disorder; (7) panic disorder; (8) delirium and dementia; (9) affective disorders; (10) eating disorders; (11) post traumatic stress disorder; (12) substance abuse disorders; and (13) autism. A subscription certificate under an individual or group medical service agreement which is issued or renewed within or without the commonwealth shall provide mental health benefits on a nondiscriminatory basis to residents of the commonwealth and to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment in the commonwealth for the diagnosis and medically necessary and active treatment of any mental disorder, as described in the most recent edition of the DSM, that is approved by the commissioner of mental health.
Effective Date: October 11, 2012 and August 5, 2008, respectively.
Notes: Amended by Mass SB 72 and Mass HB 4423.

Primary Focus: Mandated Benefit: Provider
Title/Description: Mental Health Benefits
Citation: Mass. Ann. Laws ch. 32A, § 22
Summary: Section 22 of chapter 31A was amended to include the definition of a licensed mental health professional. This section was also amended to include the provision that the commission shall provide to any active or retired employee of the commonwealth who is insured under the group insurance commission coverage on a nondiscriminatory basis for the diagnosis and treatment of the following biologically-based mental disorders, as described in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, referred to in this section as the DSM: (1) schizophrenia; (2) schizoaffective disorder; (3) major depressive disorder; (4) bipolar disorder; (5) paranoia and other psychotic disorders; (6) obsessive-compulsive disorder; (7) panic disorder; (8) delirium and dementia; (9) affective disorders; (10) eating disorders; (11) post traumatic stress disorders; (12) substance abuse disorders; and (13) autism. The commission shall also provide to any active and retired employee of the commonwealth who is insured under the group insurance commission coverage on a nondiscriminatory basis for the diagnosis and medically necessary and active treatment of any mental disorder, as described in the most recent edition of the DSM, that is approved by the commissioner of mental health.
Effective Date: October 11, 2012 and August 5, 2008, respectively.
Notes: Amended by Mass SB 72 and Mass HB 4423, respectively.

Primary Focus: Mandated Benefit: Provider
Title/Description: Coverage—Mental Health Benefits
Citation: Mass. Ann. Laws ch. 176G, § 4M
Summary: Subsection (i) of Section 4M, chapter 176G was amended to insert the definition of licensed mental health professional.
Effective Date: October 11, 2012.
Notes: Amended by Mass. SB 72.

Primary Focus: Mandated Benefit: Provider
Title/Description: Certain Accident and Sickness Insurance Policies Shall Insure Against Costs Arising from Mental or Nervous Conditions; Benefits
Citation: Mass. Ann. Laws ch. 175, § 47B
Summary: Subsection (i) of Section 47B was amended to include the definition of licensed mental health professional. Additionally, a provision was added which stated an individual policy of accident and sickness insurance issued which provides hospital expense and surgical expense insurance, and a group blanket or general policy of accident and sickness insurance issued, which provides hospital expense and surgical expense insurance, which is issued or renewed within or without the commonwealth, shall provide mental health benefits on a nondiscriminatory basis to residents of the commonwealth and to all policyholders having a principal place of employment in the commonwealth for the diagnosis and treatment of the following biologically-based mental disorders, as described in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, referred to in this section as the DSM: (1) schizophrenia; (2) schizoaffective disorder; (3) major depressive disorder; (4) bipolar disorder; (5) paranoia and other psychotic disorders; (6) obsessive-compulsive disorder; (7) panic disorder; (8) delirium and dementia;(9) affective disorders; (10) eating disorders; (11) post traumatic stress disorder; (12) substance abuse disorders; and (13) autism. An individual policy of accident and sickness insurance issued, which provides hospital expense and surgical expense insurance, and a group blanket or general policy of accident and sickness insurance issued, which provides hospital expense and surgical expense insurance, which is issued or renewed within or without the commonwealth, shall provide mental health benefits on a nondiscriminatory basis to residents of the commonwealth and to all policyholders having a principal place of employment in the commonwealth for the diagnosis and medically necessary and active treatment of any mental disorder, as described in the most recent edition of the DSM, that is approved by the commissioner of mental health.
Effective Date: August 5, 2008 and August 6, 2012, respectively
Notes: Amended by Mass HB 4423 and Mass SB 2400, respectively.

S. 2400
Introduced: 7/2012
Sponsor: None Listed
Status: Signed into law 8/2012
Summary: This is a comprehensive bill that addresses many issues. The part of the bill related to parity (Section 254) orders the state insurance commissioner to issue regulations requiring insurers to comply with the Federal Parity Law and the state parity law. It also requires insurance companies to file reports with the insurance commissioner detailing how they comply with the Federal Parity Law and state law (section 254). It also allows the attorney general to have public hearings about an insurers’ parity report to the insurance commissioner (section 254). Furthermore, it authorizes the state insurance commissioner to implement and enforce the Federal Parity Law and the parity sections of state law (section 8k).
This bill also requires the state Medicaid office to issue rules to make all state Medicaid plans compliant with the Federal Parity Law and the state parity law (section 265). Additionally, the office of Medicaid is required to submit annual reports detailing Medicaid plans’ compliance (section 265).
H. 4200
Introduced: 7/2012
Sponsor: Rep. Dempsey, Rep. Kulik, Sen. deMacedo, Sen. Brewer, Sen. Flanagan, & Sen. Knapik
Status: Veto Overridden 7/2012
Summary: This is the appropriations bill for fiscal year 2013. Section 186 established an advisory committee tasked with analyzing behavioral health care services. Among other duties, the advisory committee must monitor the implementation of the Federal Parity Law and the parity sections of state law (section 8k).
H. 4935
Introduced: 7/2010
Sponsor: Rep. Murphy
Status: Signed Into Law 8/2010
Summary: This bill expands coverage for autism spectrum disorders. It requires that the group insurance plan for retired state employees provide non-discriminatory access to autism spectrum disorder treatment benefits. To do this, the plan must meet the following requirements:
  • No annual limit or lifetime limit for autism spectrum disorder benefits is more restrictive than the limits imposed for physical conditions
  • No limits on the number of visits an individual can make to an autism spectrum provider

Insurers are exempt from this requirement if they can show the annual cost associated with this coverage exceeded 1% of the premiums charged and that this would result in an increase in premiums of at least 1%.

2007-2008

Primary Focus: Mandated Benefit: Provider
Title/Description: Behavioral Health Manager—Notification by Manager
Citation: Mass. Ann. Laws ch. 176O, § 20
Summary: Mass. Ann. Laws ch. 176O, § 20 mandates that a behavioral health manager shall notify covered persons of the following services:
(1) that the insured may obtain emergency mental health services;
(2) that no insured shall be discouraged from using the local pre-hospital emergency medical service system, the 911 emergency telephone number or its local equivalent;
(3) that no insured shall be denied coverage for medical and transportation expenses incurred as a result of such emergency mental health condition; and
(4) if the behavioral health manager requires an insured to contact either the behavioral health manager, carrier or the primary care provider of the insured within 48 hours of receiving emergency services, notification already given to the behavioral health manager, carrier or primary care provider by the attending emergency physician shall satisfy that requirement.
A behavioral health manager must also notify covered persons of the process by which clinical guidelines and utilization review are developed for behavioral health services.
Effective Date: November 18, 2008
Notes: Enacted by Mass. S.B. 2804

Massachusetts Parity Law

Here are links to the sections of Massachusetts law that are relevant to parity and autism coverage:

Behavioral Health Coverage

M.G.L. c. 32A, §22; M.G.L. c. 175, §47B; M.G.L. c. 176A, §8A; M.G.L. c. 176B, §4A; M.G.L. c. 176G, §§4 4M

Autism Coverage

M.G.L. c. 32A §25; M.G.L. c. 175 §47AA; M.G.L. c. 176A §8DD; M.G.L. c. 176B §4DD; M.G.L. c. 176G §4V

Behavioral Health Coverage

These sections of the law require large employer fully-insured plans, small employer fully-insured plans, individual plans, and state employee plans to provide behavioral health treatment coverage on a “non-discriminatory basis” for certain conditions.

The law explicitly applies to the following conditions and requires that annual limits,lifetime limits, and quantitative treatment limitations for these conditions are the same as they are for other medical conditions:

  1. Schizophrenia
  2. Schizoaffective disorder
  3. Major depressive disorder
  4. Bipolar disorder
  5. Paranoia and other psychotic disorders
  6. Obsessive-compulsive disorder
  7. Panic disorder
  8. Delirium and dementia
  9. Affective disorders
  10. Eating disorders
  11. Post traumatic stress disorder
  12. Substance abuse disorders
  13. Autism

These sections of the law also require individual plans, small employer fully-insured plans, large employer fully-insured plans, and state employee plans to cover treatment of patients with conditions not listed above for at least 60 days of inpatient treatment and 24 outpatient visits, as long as the treatment is considered medically necessary .

These sections of the law also require insurance plans to provide treatment coverage on a “non-discriminatory basis” for victims of rape and assault with intent to commit rape if the costs of treatment are more than the maximum compensation awarded to the victims.

Insurance plans are also required to cover treatment for children under age 19 who do not have any of the conditions listed above who meet these criteria:

  1. They can’t attend school because of their condition
  2. The condition requires hospitalization
  3. Their behavior poses serious danger to themselves or others

The law does cover a full range of inpatient, intermediate, and outpatient services and says treatment may take place in the least restrictive clinically appropriate setting.

Autism Coverage

These sections require individual plans, small employer fully-insured plans, large employer fully-insured plans, and state employee plans to cover the following autism services:

Coverage must be provided on “a non-discriminatory basis” and cannot have any annual maximum or lifetime maximum in place for autism services that are not in place for other medical services.

Get Support

Massachusetts Insurance Division

Common Violations

In seeking care or services, be aware of the common ways parity rights can be violated.

Common Violations

Definition

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