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Legislation Signed into Law

2017-2018

Primary Focus: Parity Enforcement
Title/Description: An Act Relating to Access and Benefits for Mental Health Conditions and Substance Use Disorders
Citation:  Tex. Gov’t Code Ann. §§ 531.02251, 531.02252.
Summary: Tex. Gov’t Code Ann. §§ 531.02251, 531.02252 established an ombudsman and parity work group to help consumers and providers resolve behavioral health care access issues and increase compliance with parity laws. Specifically, the Health and Human Services Commission shall:
(1) Identify an ombudsman to help consumers encountering obstacles when accessing behavioral health services to file the appropriate complaint for both Medicaid-CHIP and for private insurance;
(2) Create a central location with designated staff to improve consumer assistance to Texans who encounter mental health parity violations;
(3) Create a stakeholder workgroup to develop a strategy for successful compliance with parity laws which shall convene quarterly through September 1, 2021;
(4) Collect data for Medicaid and Managed Care plans related to non-quantitative treatment limitations in accessing mental health and substance use treatment.

Moreover, the Act instructs the Texas Department of Insurance to:
(1) Expand parity enforcement beyond qualitative treatment limitations, such as visit limits and copays, and to address mental health and substance use disorder service complaints that are non-qualitative in nature, such as reviews for medical necessity;
(2) More widely enforce the requirements of federal parity law and regulations for all health insurance plans regulated by the state for plans issued or renewed on or after January 1, 2018;
(3) Collect data related to non-qualitative treatment limitations in accessing behavioral health services for all health insurance plans regulated by the state in order to inform insurers, agencies, and legislators of consumer experiences when accessing behavioral health care.
Effective Date: September 1, 2017
Notes: Enacted by HB 10, which created Tex. Gov’t Code Ann. §§ 531.02251, 531.02252.

Primary Focus: Mandated Benefit: Provider
Title/Description: Coverage for Maternal Depression Screening
Citation: Tex. Health & Safety Code § 62.1511
Summary: The covered services under the child health plan must include a maternal depression screening for an enrollee’s mother.
Effective Date: September 1, 2017
Note: Enacted through HB 2466 (85th Regular session)

Primary Focus: Mandated Benefit: Provider
Title/Description: Coverage for Mental Health Conditions and Substance Use Disorders
Citation: Tex. Ins. Code § 1355.254
Summary: A health benefit plan must provide benefits and coverage for mental health conditions and substance use disorders under the same terms and conditions applicable to the plan’s medical and surgical benefits and coverage. Coverage may not impose quantitative or nonquantitative treatment limitations on benefits for a mental health condition or substance use disorder that are generally more restrictive than those imposed on coverage for medical or surgical expenses.
Effective Date: September 1, 2017 per Tex. SB 769.
Note: Enacted through HB 10 (85th Regular Session)

HB 10
Introduced: 2/2017
Sponsor: Reps. Price, Greg Bonnen, Coleman, Munoz Jr., and Rose
Status: Signed into law 6/2017
Summary: This bill changed the section of the state insurance law relevant to parity by adding several new sections to the law, creating an ombudsman for behavioral health access to care, and by creating a state parity working group. The new sections of the law add requirements that are very similar to the final regulations of the Federal Parity Law. This is important because currently, the Texas Department of Insurance does not have the authority to enforce the Federal Parity Law. These requirements entail the following:

  • Behavioral health coverage must be on the same terms and conditions as coverage for other medical conditions, generally speaking
  • Quantitative treatment limitations and non-quantitative treatment limitations on behavioral health coverage must be “no more restrictive” than those in place for other medical coverage
  • Health plans must define conditions as a mental health condition or not a mental health condition in a manner that is consistent with generally recognized independent standards of medical practice
  • Health plans must define conditions as a substance use disorder or not a substance use disorder in a manner that is consistent with generally recognized independent standards of medical practice

These new sections also require the Texas Insurance must also “collect and compare” data from health plans about behavioral health coverage and other medical coverage regarding:

  • Prior authorization and other utilization review
  • Denials based on medical necessity or because a treatment is experimental or investigational
  • Internal appeals and whether internal appeals were denied
  • External reviews including data that indicates whether the appeal was upheld

The new sections also require the state Health and Human Services Commission to collect the same data from Medicaid managed care organizations.

2013-2014

Primary Focus: Medicaid
Title/Description: Behavioral Health and Physician Health Services Network
Citation: Tex. Gov’t Code § 533.00255
Summary: The commission shall, to the greatest extent possible, integrate into the Medicaid managed care program implemented under this chapter the following services for Medicaid-eligible persons:
(1) behavioral health services, including targeted case management and psychiatric rehabilitation services; and (2) physical health services.
Effective Date: June 14, 2013
Note: Enacted through SB 58 ( 83rd Regular Session)

HB 3276
Introduced: 3/2013
Sponsor:REP. DEUELL
Status: Signed into law 6/2014
Summary: This bill changed the section of the state insurance law relevant to parity so that individual plans,small employer fully-insured plans, and large employer fully-insured plans are required to screen for autism spectrum disorders. It also specified that professionals who are working under the supervision of qualified providers may provide services for treatment of autism.
This bill also makes clear that it does not apply to qualified health plans if it is determined that complying with the provisions of this bill would require a qualified health plan to exceed the requirements of essential health benefits required by the Affordable Care Act.

SB 1484
Introduced: 3/2013
Sponsor: Sen. Watson, Sen. Davis, Sen. Lucio
Status: Signed into law 6/2014
Summary: This bill changed the section of the state insurance law relevant to parity so that individual plans,small employer fully-insured plans, and large employer fully-insured plans are required to provide coverage for generally recognized services for autism spectrum disorder for children beyond their tenth birthdays. Prior to this bill becoming law, insurers were only required to cover autism spectrum disorder treatment through age nine.

HB 451
Introduced: 12/2008
Sponsor: Rep. Lucio
Status: Signed into law 07/2009
Summary: This bill amended the autism section of the Insurance Code to require health plans provide coverage for enrollees from the date of diagnosis through age 9. Previously, coverage had only been required through age 6.

Texas Parity Law

There are 2 sections of the state insurance law relevant to parity. There is one section of the law that addresses mental health and autism coverage, and another that addresses substance use disorders

Because most of the autism requirements are in a separate subsection of the section on mental health and autism coverage, autism coverage will be summarized in a separate section of this page below.

Mental Health Section

This section applies to large employer fully-insured plans, small employer fully-insured plans, and local government plans. However, the coverage described below is optional for small employer fully-insured plans. Also, there is a separate subsection that applies to local government plans that is very brief (summarized below).

This section only applies coverage to the following conditions, defined in this section as “serious mental illness”:

  1. Bipolar disorders (hypomanic, manic, depressive, and mixed)
  2. Depression in childhood and adolescence
  3. Major depressive disorders (single episode or recurrent)
  4. Obsessive-compulsive disorders
  5. Paranoid and other psychotic disorders
  6. Schizo-affective disorders (bipolar or depressive)
  7. Schizophrenia

This section specifies that at least 45 inpatient days and 60 outpatient visits are required of plans affected by the law and states that plans “must include the same amount limitations, deductibles , copayments , and coinsurance factors for serious mental illness as the plan includes for physical illness.” It also states that plans “must provide coverage for an outpatient visit under the same terms as the coverage the issuer provides for an outpatient visit for the treatment of physical illness.”

This section also forbids any lifetime limitations within a plan for inpatient days and outpatient visits.

This section specifies that plans offering coverage in a hospital for a child or adolescent with a “mental or emotional illness or disorder” must provide coverage for the child in a “residential treatment center for children and adolescents or a crisis stabilization unit that is at least as favorable as the coverage the plan provides for treatment of mental or emotional illness or disorder in a hospital.” It also specifies that each two days of treatment in a residential treatment center or crisis stabilization unit are equivalent to one day of coverage for treatment in a hospital.

This section also has specific language addressing partial hospitalization. It specifies that plans that offer inpatient coverage must also provide coverage for “psychiatric day treatment.” It also specifies that each day of coverage for psychiatric day treatment is equivalent to one-half day of coverage for inpatient or hospital care.

This section explicitly allows plans to use managed care.

This section also has a small subsection that mandates that local governments may not provide coverage for serious mental illness that is that is “less extensive than the coverage provided for any other physical illness.”

Autism

The subsection within the mental health coverage section requires individual plans, small employer fully-insured plans, and large employer fully-insured plans to provide autism screening at 18 and 24 months. The subsection pertaining to autism also lists a number of “generally recognized services” for autism treatment:

  1. Evaluation and assessment services
  2. Applied behavior analysis
  3. Behavior training and behavior management
  4. Speech therapy
  5. Occupational therapy
  6. Physical therapy
  7. Medications or nutritional supplements used to address symptoms of autism spectrum disorder

This subsection defines autism spectrum disorder as “a neurological disorder that includes autism, Asperger’s syndrome, or Pervasive Developmental Disorder–Not Otherwise Specified.”

Deductibles, copayments, and coinsurance must be equivalent to those in place for other medical services. Plans are not required to pay more than $36,000 in a year for applied behavior analysis for children age 10 and older.

Substance Use Disorder Section

This section requires that treatment for chemical dependency is covered that is not “less favorable” that coverage for other medical care. It also specifies that durational limits, dollar limits, deductibles , and coinsurance must be the same as treatment coverage for other care. However, there is a significant caveat that a plan is only required to cover three separate treatment series during the lifetime of the plan for each enrollee.

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Common Violations

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

Common Violations

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