In Illinois, SB 1707 went into effect on Jan 1, 2019, implementing some of the most consumer-friendly mental health regulations in the United States.
Appeals & Reviews
All insurance companies are required to allow policy holders to appeal a denial. However most of the time, it is an insurance company doctor, or doctor paid by the insurer, that is doing the review. (Conflict of interest?) SB 1707 states the physician reviewer must be,
“jointly selected by the patient (or the patient's next of kin or legal representative if the patient is unable to act for himself or herself), the patient's provider, and the insurer in the event of a dispute between the insurer and patients’ provider regarding the medical necessity of a treatment proposed by a patient's provider.”
Residential Treatment
Under the Federal Mental Health Parity Act, most insurance plans are required to cover treatment at residential treatment centers, and most do so. However, insurers have created obstacles to treatment by requiring that residential treatment programs meet their own criteria, (for example, 24-hour nursing, weekly psychiatric visits, accredited by a certain body). SB 1707 states that “coverage for inpatient treatment shall include coverage for treatment in a residential treatment center certified or licensed by the Department of Health And Human Services.” (Period.)
Medical Necessity Criteria
When insurance companies perform medical necessity reviews, they may choose or create their own criteria. If policyholders believe the criteria is too stringent, their option is to sue the insurance company (which has been done). SB 1707 requires that for substance abuse, medical necessity standards developed by the American Society of Addiction Medicine (ASAM) be used. No additional criteria may be used, the bill states.
It goes on. (6.5) An individual or group health benefit plan amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 100th General Assembly:
(A) shall not impose prior authorization requirements, other than those established under the Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions established by the American Society of Addiction Medicine, on a prescription medication approved by the United States Food and Drug Administration that is prescribed or administered for the treatment of substance use disorders;
(B) shall not impose any step therapy requirements, other than those established under the Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions established by the American Society of Addiction Medicine, before authorizing coverage for a prescription medication approved by the United States Food and Drug Administration that is prescribed or administered for the treatment of substance use disorders;
(C) shall place all prescription medications approved by the United States Food and Drug Administration prescribed or administered for the treatment of substance use disorders on, for brand medications, the lowest tier of the drug formulary developed and maintained by the individual or group health benefit plan that covers brand medications and, for generic medications, the lowest tier of the drug formulary developed and maintained by the individual or group health benefit plan that covers generic medications; and
(D) shall not exclude coverage for a prescription medication approved by the United States Food and Drug Administration for the treatment of substance use disorders and any associated counseling or wraparound services on the grounds that such medications and services were court ordered.
Proactive Parity Compliance
SB 1707 requires insurance plan to proactively document compliance with the Federal Parity Act and publish the outcomes. Below is some of the bill language:
Requiring that insurers submit comparative analyses, as set forth in paragraph (6) of subsection (k) of Section 370c.1, demonstrating how theydesign and apply nonquantitative treatment limitations both as written and in operation, for mental, emotional, nervous, or substance use disorder or condition benefits as compared to how they design and apply nonquantitative treatment limitations, as written and in operation, for medical and surgical benefits;
(2) evaluating all consumer or provider complaints regarding mental, emotional, nervous, or substance use disorder or condition coverage for possible parity
violations;
(3) performing parity compliance market conduct examinations or, in the case of the Department of Healthcare and Family Services, parity compliance audits of individual and group plans and policies, including, but not limited to, reviews of:
(A) nonquantitative treatment limitations, including, but not limited to, prior authorization requirements, concurrent review, retrospective review, step therapy, network admission standards, reimbursement rates, and geographic restrictions;
(B) denials of authorization, payment, and coverage; and
(C) other specific criteria as may be determined by the Department. The findings and the conclusions of the parity compliance market conduct examinations and audits shall be made public.
The Director may adopt rules to effectuate any provisions of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 that relate to the business of
Insurance.
Finally Senate Bill 682, which also went into effect 1/1/19, provides substance abusers immediate access to outpatient treatment for 72 hours (while an appeal is conducted) if an insurance company denies authorization.
(This blog was written by Cecily Ruttenberg, Chief Training Officer of Bridgeway Billing. www.bridgewaybilling.net)