OLR Bill Analysis
SB 1085 (File 449, as amended by Senate “A” and Senate "B")*
AN ACT CONCERNING HEALTH INSURANCE COVERAGE FOR MENTAL OR NERVOUS CONDITIONS.
This bill expands the services certain health insurance policies must cover for mental and nervous conditions (see BACKGROUND). By law, a policy must cover the diagnosis and treatment of mental or nervous conditions on the same basis as medical, surgical, or other physical conditions (i.e., parity).
The bill requires policies to cover, among other things:
1. medically necessary acute treatment and clinical stabilization services (see below);
2. general inpatient hospitalization, including at state-operated facilities;
3. services provided by advanced practice registered nurses (APRNs) for mental or nervous conditions; and
4. programs to improve health outcomes for mothers, children, and families.
Under the bill, a policy may not prohibit an insured from receiving, or a provider from being reimbursed for, multiple screening services as part of a single-day visit to a health care provider or multicare institution (e.g., hospital, psychiatric outpatient clinic, or free standing facility for substance use treatment).
The bill substitutes the term “benefits payable” for “covered expenses” as it pertains to the mental or nervous conditions coverage provisions. By law, these are the usual, customary, and reasonable charges for medically necessary treatment or, in the case of a managed care plan, the contracted rates.
The bill also requires the insurance commissioner and healthcare advocate to convene a working group to study, among other things, the use of inpatient mental health and substance use disorder services. They must report to the Insurance and Real Estate and Public Health committees by January 1, 2016.
The bill also makes technical and conforming changes.
The bill applies to individual and group health insurance policies issued, delivered, renewed, amended, or continued in Connecticut that cover (1) basic hospital expenses, (2) basic medical-surgical expenses, (3) major medical expenses, or (4) hospital or medical services, including those provided through an HMO. Due to the federal Employee Retirement Income Security Act, state insurance mandates do not apply to self-insured benefit plans.
*Senate Amendment “A”: replaces the original bill (File 449), which included similar provisions. It (1) requires policies to cover inpatient hospitalization and medically necessary acute treatment and clinical stabilization services for at least 14 days and (2) removes provisions requiring policies to cover certain services, including emergency mobile psychiatric services and certain case management services.
*Senate Amendment “B”: replaces the bill (File 449, as amended by Senate “A”). It (1) removes provisions requiring policies to cover certain acute treatment and clinical stabilization services for at least 14 days without prior authorization and (2) adds provisions creating the mental health and substance use disorder services working group.
EFFECTIVE DATE: January 1, 2016, except for the working group provisions, which are effective on passage.
COVERAGE FOR MENTAL OR NERVOUS CONDITIONS
Under the bill, policies' coverage for mental or nervous conditions must include:
1. general inpatient hospitalization and outpatient hospital services,
2. psychiatric inpatient hospitalization and outpatient hospital services,
3. intensive outpatient services, and
4. partial hospitalization.
The bill specifies that these services may be provided at state-operated facilities.
The bill requires policies to also cover:
1. evidence based maternal, infant, and early childhood home visitation services designed to improve health outcomes for pregnant women, postpartum mothers, and newborns and children, including maternal substance use disorders or depression and relationship-focused interventions for children with mental or nervous conditions or substance use disorders;
2. intensive, home-based services addressing specific mental or nervous conditions in a child while remediating problematic parenting practices and addressing other family and educational challenges that affect the child's and family's ability to function;
3. intensive, family- and community-based treatment programs that focus on environmental systems impacting chronic and violent juvenile offenders;
4. evidence-based family-focused therapy specializing in the treatment of juvenile substance use disorders and delinquency;
5. short-term family therapy intervention and juvenile diversion programs targeting at-risk children to address adolescent behavior problems, conduct disorders, substance use disorders, and delinquency;
6. other home-based therapeutic interventions for children;
7. chemical maintenance treatment (i.e., when a person is admitted for the planned use of a prescribed substance under medical supervision);
8. nonhospital inpatient, medically monitored, or ambulatory detoxification;
9. inpatient services at psychiatric residential treatment facilities;
10. extended day treatment programs for emotionally disturbed, mentally ill, behaviorally disordered, or multiply handicapped children and youth;
11. rehabilitation services provided in a residential treatment facility, general hospital, psychiatric hospital, or psychiatric facility;
12. observation beds in acute hospital settings;
13. psychological and neuropsychological testing by an appropriately licensed health care provider;
14. trauma screening by a licensed behavioral health professional;
15. depression screening, including maternal depression screening, by a licensed behavioral health professional; and
16. substance use screening by a licensed behavioral health professional.
Acute Treatment and Clinical Stabilization Services without Prior Authorization
The bill requires policies to cover medically necessary acute treatment and clinical stabilization services. “Acute treatment” is 24-hour medically supervised treatment for a substance use disorder provided in a medically managed or monitored inpatient facility. “Clinical stabilization” is 24-hour clinically managed post-detoxification treatment, including relapse prevention, family outreach, aftercare planning, and addiction education and counseling.
COVERAGE FOR SERVICES PROVIDED BY AN APRN
The bill requires policies to cover services for mental or nervous conditions provided by an APRN.
By law, policies must already cover services provided by a licensed physician, psychologist, clinical social worker, marital and family therapist, or professional counselor. Existing law also covers services from certain certified marital and family therapists and independent social workers, as well as from licensed or certified alcohol and drug counselors.
MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES WORKING GROUP
The bill requires the insurance commissioner and the healthcare advocate to convene a working group, by September 1, 2015, to study and make recommendations for the development and implementation of policies that, with respect to utilization of inpatient mental health services and substance use disorder services, improve the alignment of utilization review procedures and health insurance coverage with the clinical recommendations of treating health care providers.
The working group must include health insurance industry representatives, health care providers, and consumers.
The commissioner and healthcare advocate must submit their recommendations to the Insurance and Real Estate and Public Health committees by January 1, 2016.
Mental or Nervous Conditions
By law, “mental or nervous conditions” are mental disorders defined in the most recent edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). This does not include (1) intellectual disabilities, (2) specific learning disorders, (3) motor disorders, (4) communication disorders, (5) caffeine-related disorders, (6) relational problems, and (7) other conditions that may be a focus of clinical attention but are not defined as mental disorders in the DSM (CGS §§ 38a-488a & 38a-514).
Related Federal Law
Under the federal Patient Protection and Affordable Care Act (P.L. 111-148), a state may require health plans sold through the state's health insurance exchange to offer benefits beyond those included in the required “essential health benefits,” provided the state defrays the cost of those additional benefits. The requirement applies to benefit mandates a state enacts after December 31, 2011. Thus, the state must pay the insurance carrier or enrollee to defray the cost of any new benefits mandated after that date.
sHB 6847 (File 417), reported favorably by the Insurance and Real Estate Committee, expands coverage for autism spectrum disorder (ASD). ASD is a mental and nervous condition covered under the provisions of this bill.
SB 16 (File 42), reported favorably by the Insurance and Real Estate Committee, prohibits insurers from limiting the number of visits to assess an insured for a mental or nervous condition diagnosis, and requires insurers to cover certain consultations.
Insurance and Real Estate Committee