Connecticut Statutes

This bill amends the CT General Statutes by adding a new section that requires health carriers to submit an annual report to the Insurance Commissioner, Attorney General, Health Care Advocate and Executive Director of the Office of Health Strategy that details compliance with parity in terms of medical necessity determinations and NQTLs. The bill requires the Insurance Commissioner to submit to the joint standing committee (having cognizance of matters related to insurance) of the General Assembly each of the health carriers’ reports. Additionally, the bill requires the joint standing committee to hold an annual public hearing concerning the health carriers’ reports. Such hearing must be attended by the Insurance Commissioner, Attorney General, Health Care Advocate and Executive Director of the Office of Health Strategy (or their designees). These entities must inform the committee if they feel each report is satisfactory and indicates compliance with parity requirements.

Furthermore, the bill adds new sections to the CT General Statutes to prohibit individual and group health insurance policies from applying NQTLs on MH/SUD benefits that are not also equally applied to med/surgical benefits. Additionally, the bill prohibits plans from excluding coverage of SUD services and prescriptions solely because the drug or services were prescribed pursuant to a court order.

Enacted through HB 7125

Public Act No. 18-10 requires individual and group health insurance policies to cover essential health benefits, which the statute defines to include mental health and substance use disorders including, but not limited to, behavioral health treatment.

Public Act No. 18-10 §§ 1-2 pertain to coverage of essential mental health benefits.

Public Act No. 17-157 requires reimbursement for behavioral health treatment covered under the insured’s policy but provided by an out-of-network provider to be paid directly to the provider if the provider is otherwise eligible for reimbursement. Providers cannot bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from or have any recourse against the insured for such services, except that such provider may collect any copayments, deductibles or other out-of-pocket expenses that the insured is required to pay under the policy. The insured who received behavioral health services shall be deemed to have made an assignment to such provider of such insured’s coverage reimbursement benefits.

Public Act No. 17-157 adopted the provisions set out in HB 5140 which amended CONN. GEN. STAT. §§ 38a-488a, 38a-514

Section 38a-514 defines “mental or nervous conditions” as those provided for in the most recent edition of the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders.” The statute requires group health insurance policies to provide benefits for the diagnosis and treatment of mental or nervous conditions, and such benefits must include, but are not limited to, the following:

(1) General inpatient hospitalization, including in state-operated facilities;
(2) Medically necessary acute treatment services and medically necessary clinical stabilization services;
(3) General hospital outpatient services, including at state-operated facilities;
(4) Psychiatric inpatient hospitalization, including in state-operated facilities;
(5) Psychiatric outpatient hospital services, including at state-operated facilities;
(6) Intensive outpatient services, including at state-operated facilities;
(7) Partial hospitalization, including at state-operated facilities;
(8) Intensive, home-based services designed to address specific mental or nervous conditions in a child;
(9) Evidence-based family-focused therapy that specializes in the treatment of juvenile substance use disorders;
(10) Short-term family therapy intervention;
(11) Nonhospital inpatient detoxification;
(12) Medically monitored detoxification;
(13) Ambulatory detoxification;
(14) Inpatient services at psychiatric residential treatment facilities;
(15) Rehabilitation services provided in residential treatment facilities, general hospitals, psychiatric hospitals or psychiatric facilities;
(16) Observation beds in acute hospital settings;
(17) Psychological and neuropsychological testing conducted by an appropriately licensed health care provider;
(18) Trauma screening conducted by a licensed behavioral health professional;
(19) Depression screening, including maternal depression screening, conducted by a licensed behavioral health professional; and
(20) Substance use screening conducted by a licensed behavioral health professional.

Policies may not place a greater financial burden on an insured for access to diagnosis or treatment of mental or nervous conditions than that for diagnosis or treatment of medical, surgical, or other physical health conditions, or prohibit and insured from obtaining or a health care provider from being reimbursed for multiple screening services as part of a single-day visit. The statute also provides that benefits payable for services of a licensed physician or psychologist should be payable for the same services when rendered by licensed psychologists, social workers, family and marital therapists, drug or alcohol counselors, professional counselors, and advanced practice registered nurses. The statute provides additional specific examples of how certain benefits payable for certain services must be the payable in the same way when provided for mental or nervous conditions.

Enacted through S.B. 1502 (Session Year 2017)

Section 38a-488a defines “mental or nervous conditions” as those provided for in the most recent edition of the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders.” The statute requires individual health insurance policies to provide benefits for the diagnosis and treatment of mental or nervous conditions, and such benefits must include, but are not limited to, the following:

(1) General inpatient hospitalization, including in state-operated facilities;
(2) Medically necessary acute treatment services and medically necessary clinical stabilization services;
(3) General hospital outpatient services, including at state-operated facilities;
(4) Psychiatric inpatient hospitalization, including in state-operated facilities;
(5) Psychiatric outpatient hospital services, including at state-operated facilities;
(6) Intensive outpatient services, including at state-operated facilities;
(7) Partial hospitalization, including at state-operated facilities;
(8) Intensive, home-based services designed to address specific mental or nervous conditions in a child;
(9) Evidence-based family-focused therapy that specializes in the treatment of juvenile substance use disorders;
(10) Short-term family therapy intervention;
(11) Nonhospital inpatient detoxification;
(12) Medically monitored detoxification;
(13) Ambulatory detoxification;
(14) Inpatient services at psychiatric residential treatment facilities;
(15) Rehabilitation services provided in residential treatment facilities, general hospitals, psychiatric hospitals or psychiatric facilities;
(16) Observation beds in acute hospital settings;
(17) Psychological and neuropsychological testing conducted by an appropriately licensed health care provider;
(18) Trauma screening conducted by a licensed behavioral health professional;
(19) Depression screening, including maternal depression screening, conducted by a licensed behavioral health professional; and
(20) Substance use screening conducted by a licensed behavioral health professional.

Policies may not place a greater financial burden on an insured for access to diagnosis or treatment of mental or nervous conditions than that for diagnosis or treatment of medical, surgical, or other physical health conditions, or prohibit and insured from obtaining or a health care provider from being reimbursed for multiple screening services as part of a single-day visit. The statute also provides that benefits payable for services of a licensed physician or psychologist should be payable for the same services when rendered by licensed psychologists, social workers, family and marital therapists, drug or alcohol counselors, professional counselors, and advanced practice registered nurses. The statute provides additional specific examples of how certain benefits payable for certain services must be the payable in the same way when provided for mental or nervous conditions.

Enacted through S.B. 1502 (Session Year 2017)

This bill amends state insurance laws about behavioral health coverage by requiring group and individual plans to directly reimburse out of network providers for substance use disorder services if the provider is otherwise eligible for reimbursement and prohibits the providers from directly billing consumers for out of network services.

 Among other things, this bill amends state insurance law about utilization review by allowing insurers to develop and have approved by the commissioner their own clinical review criteria in order to adjust for advancements in technology and types of care for substance use disorder that are not covered in current criteria.

• Availability of coverage
• Types of treatments
• The requirements that an enrollee must meet to qualify for treatment to be covered
• Cost-sharing requirements

This bill amends the language in SB 1502 (listed below) to expand the data that could be requested by the working group convened by the Insurance Commissioner to ensure proper implementation of parity laws. The expanded data includes the number of prior authorization requests for behavioral health services approved and denied, as well as the same information for other medical services. It also specifies that information about the percentage of claims paid for out-of-network behavioral health services as compared to claims paid for other out-of-network medical services should be considered as well.

• When performing utilization review of substance use disorder treatment, insurers are now allowed to use criteria that deviate from the criteria of the American Society on Addiction Medicine if this is warranted by advancements in technology
• When performing utilization review of mental health treatment in children, insurers are now allowed to use criteria that deviate from the guidelines of the American Academy of Child and Adolescent Psychiatry’s Child and Adolescent Service Intensity Instrument if this is warranted by advancements in technology
• When performing utilization review of mental health treatment in adults, insurers are now allowed to use criteria that deviate from the Standards and Guidelines of the Association for Ambulatory Behavioral Healthcare if this is warranted by advancements in technology
• Insurers no longer have to publicly document their justifications for deviating from any of the criteria listed above when performing utilization review

Among many other things, this bill slightly amends some of the changes to the parity section of the state insurance law made by SB 1085 (listed directly below this) and changes some of the sections of the state insurance law about autism coverage, starting on 1/1/2016 (all of these looming changes are summarized at the bottom of the page under “Connecticut Parity Law”).

This bill will dramatically change the parity section of the state insurance law when it takes effect in January 2016 (several provisions in this bill do not take effect until January 2017). It specifically lists 25 forms of treatment that insurance plans must cover that are not listed in the current version of the law. For a summary of the current parity law and the future parity law, scroll to the “Connecticut Parity Law” section near the bottom of this page.

This bill changed the sections of the state insurance law about the utilization review process. It changed the definition of “clinical peer” so that a clinical peer in behavioral health must have a national board certification in psychiatry or a doctoral level psychology degree AND clinical experience treating behavioral health conditions. Previously the law had not required a doctoral level psychology degree, and actual clinical experience treating behavioral health conditions was not required; it was optional.

• It requires insurance plans that cover state Medicaid behavioral health care to cover intensive case management
• It requires the Department of Social Services to change any change any procedures related to utilization management of behavioral health services, if necessary

It required the Insurance Commissioner to get stakeholder input from the Office of the Healthcare Advocate, insurance companies, behavioral health providers, and behavioral health advocacy groups about the methods the Insurance Department should use to check for insurance plan compliance with the state parity law and the Federal Parity Law.

The bill then required the Insurance Commissioner to file a report and give a presentation to the General Assembly about the following:

• The methods the Insurance Department is using to comply with the Federal Parity Law
• The methods the Insurance Department is using to comply with the state parity law
• The regulatory and educational approaches the Insurance Department is using related to financing mental health services in Connecticut

It also changed the state insurance law about utilization review and required that:

• Inpatient care, partial hospitalization services, residential treatment, and intensive outpatient services for behavioral health could be part of an “urgent care request.”
• A clinical peer reviewer of child and adolescent behavioral health services must have national board certification in child and adolescent psychiatry or psychology and have training or experience in treating children and adolescents with behavioral health conditions.
• A clinical peer reviewer of adult behavioral health services must have national board certification in adult psychiatry or psychology and have training or experience in treating adults with behavioral health conditions.
• All utilization reviews for substance use disorders to use the Patient Placement Criteria from the American Society of Addiction Medicine (ASAM) or criteria that are consistent with the ASAM criteria.
• Each plan that uses utilization review for substance use disorder services must have a document that compares its review criteria with ASAM criteria and explains any deviation from ASAM criteria.
• Utilization reviews for child mental health services must use guidelines from the American Academy of Child and Adolescent Psychiatry’s (AACAP) Child and Adolescent Service Intensity Instrument or criteria that are consistent with these guidelines.
• Each plan that uses utilization review for child mental health services must have a document that compares its review criteria with guidelines from the AACAP’s Child and Adolescent Service Intensity Instrument and explains any deviation from those guidelines.
• Utilization reviews for adult mental health services must use either the most recent guidelines from the American Psychiatric Association (APA) or criteria that are consistent with these guidelines; or the most recent Standards and Guidelines of the Association for Ambulatory Behavioral Healthcare (AABH) or criteria that are consistent with these.
• Each plan that uses utilization review for adult mental health services must have a document that compares its review criteria for adult mental health reviews with guidelines those of the APA and AABH and explains any deviation from those guidelines.

This bill changed the sections of the state insurance law about autism coverage (A more detailed summary of these sections of the law can be found near the bottom of the page). The bill forbids insurance plans from changing their coverage levels for certain people diagnosed with autism spectrum disorder after the release of the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

This bill changed the state insurance law so that it is now an unfair business practice for insurance plans to refuse to cover people because they have a behavioral health condition.

This bill changed the section of the state insurance law about autism coverage for small employer fully-insured plans and large employer fully-insured plans. This bill created most of what is currently in the law. A summary of this section of the law is at the bottom of this page.