Medical Necessity Determination Insurance Coverage

The act clarifies that the health benefits coverage for the prevention of, screening for, and treatment of behavioral, mental health, and substance use disorders must be no less extensive than the coverage provided for any physical illness. The act requires that every health benefit plan provide coverage for medically necessary treatment of covered behavioral, mental health, and substance use disorder benefits, consistent with specified criteria.

The act also specifies criteria to be used for conducting utilization review, service intensity, and the level of care for covered persons. In addition, the act prohibits:

• A health benefit plan from limiting coverage for chronic behavioral, mental health, or substance use disorders to short-term symptom reduction; and
• A health insurance carrier from reversing or altering a determination of medical necessity except in the case of fraud.

The act requires carriers that provide benefits for mental health conditions or substance use disorders to offer meaningful benefits for mental health conditions and substance use disorders. The act describes how to determine whether the benefits provided are meaningful benefits.

The commissioner of insurance is authorized to adopt rules to:

• Establish carrier utilization review compliance;
• Specify data testing requirements for plan design and application of parity compliance;
• Set standard definition for coverage requirements;
• Establish timelines for carriers to provide comparative analysis information to the division of insurance; and
• Establish time periods for visits with a provider for treatment of a behavioral, mental health, or substance use disorder after an initial visit with a provider.
  (Note: This summary applies to this bill as enacted.)