2005 Vermont Code - § 4089b. — Health insurance coverage, mental health and substance abuse

§ 4089b. Health insurance coverage, mental health and substance abuse

(a) As used in this section:

(1) "Health insurance plan" means any health insurance policy or health benefit plan offered by a health insurer, as defined in 18 V.S.A. § 9402(7). Health insurance plan includes any health benefit plan offered or administered by the state, or any subdivision or instrumentality of the state.

(2) "Mental health condition" means any condition or disorder involving mental illness or alcohol or substance abuse that falls under any of the diagnostic categories listed in the mental disorders section of the international classification of disease, as periodically revised.

(3) "Rate, term or condition" means any lifetime or annual payment limits, deductibles, copayments, coinsurance and any other cost-sharing requirements, out-of-pocket limits, visit limits and any other financial component of health insurance coverage that affects the insured.

(b) A health insurance plan shall provide coverage for treatment of a mental health condition and shall:

(1) not establish any rate, term, or condition that places a greater financial burden on an insured for access to treatment for a mental health condition than for access to treatment for a physical health condition;

(2) not exclude from its network or list of authorized providers any licensed mental health or substance abuse provider located within the geographic coverage area of the health benefit plan if the provider is willing to meet the terms and conditions for participation established by the health insurer;

(3) make any deductible or out-of-pocket limits required under a health insurance plan comprehensive for coverage of both mental health and physical health conditions.

(c) A health insurance plan that does not otherwise provide for management of care under the plan, or that does not provide for the same degree of management of care for all health conditions, may provide coverage for treatment of mental health conditions through a managed care organization provided that the managed care organization is in compliance with the rules adopted by the commissioner that assure that the system for delivery of treatment for mental health conditions does not diminish or negate the purpose of this section. The rules adopted by the commissioner shall assure that timely and appropriate access to care is available; that the quantity, location and specialty distribution of health care providers is adequate and that administrative or clinical protocols do not serve to reduce access to medically necessary treatment for any insured.

(d) A health insurance plan shall be construed to be in compliance with this section if at least one choice for treatment of mental health conditions provided to the insured within the plan has rates, terms and conditions that place no greater financial burden on the insured than for access to treatment of physical conditions. The commissioner may disapprove any plan that the commissioner determines to be inconsistent with the purposes of this section.

(e) To be eligible for coverage under this section the service shall be rendered:

(1) For treatment of mental illness:

(A) by a licensed or certified mental health professional, or (B) in a mental health facility qualified pursuant to rules adopted by the secretary of human services or in an institution, approved by the secretary of human services, that provides a program for the treatment of a mental health condition pursuant to a written plan. A nonprofit hospital or a medical service corporation may require a mental health facility or licensed or certified mental health professional to enter into a contract as a condition of providing benefits.

(2) For treatment of alcohol or substance abuse:

(A) by a substance abuse counselor or other person approved by the secretary of human services based on rules adopted by the secretary that establish standards and criteria for determining eligibility under this subdivision; or

(B) in an institution, approved by the secretary of human services, that provides a program for the treatment of alcohol or substance dependency pursuant to a written plan.

(f) On or before July 15 of each year, health insurance companies doing business in Vermont, and whose individual share of the commercially-insured Vermont market, as measured by covered lives, comprises at least five percent of the commercially-insured Vermont market, shall file with the commissioner, in accordance with standards, procedures, and forms approved by the commissioner:

(1) A report card on the health insurance plan's performance in relation to quality measures for the care, treatment, and treatment options of mental health and substance abuse conditions covered under the plan, pursuant to standards and procedures adopted by the commissioner by rule, and without duplicating any reporting required of such companies pursuant to Rule 10 of the division of health care administration, "Quality Assurance Standards and Consumer Protections for Managed Care Plans," and regulation 95-2, "Mental Health Review Agents," of the division of insurance, as amended, including:

(A) the discharge rates from inpatient mental health and substance abuse care and treatment of insureds;

(B) the average length of stay and number of treatment sessions for insureds receiving inpatient and outpatient mental health and substance abuse care and treatment;

(C) the percentage of insureds receiving inpatient and outpatient mental health and substance abuse care and treatment;

(D) the number of insureds denied mental health and substance abuse care and treatment;

(E) the number of denials appealed by patients reported separately from the number of denials appealed by providers;

(F) the rates of readmission to inpatient mental health and substance abuse care and treatment for insureds with a mental health condition;

(G) the level of patient satisfaction with the quality of the mental health and substance abuse care and treatment provided to insureds under the health insurance plan; and

(H) any other quality measure established by the commissioner.

(2) [Repealed.]

(g) The commissioner shall establish a task force to develop performance quality measures and address oversight issues for managed behavioral health care organizations. The task force shall report to the committees on health and welfare of the senate and the house of representatives on or before January 15 of each year with a report on the activities and recommendations of the task force. The task force shall include the following:

(1) the commissioner of developmental and mental health services or a designee;

(2) the director of the office of Vermont health access or a designee;

(3) the commissioner of banking, insurance, securities, and health care administration or a designee;

(4) fourteen additional members appointed by the commissioner of banking, insurance, securities, and health care administration, including:

(A) four representatives of the health insurance and behavioral managed care organization industry;

(B) two consumers, after consultation with the health care ombudsman;

(C) one psychologist, after consultation with the Vermont psychological association;

(D) one psychiatrist, after consultation with the Vermont psychiatric association;

(E) one social worker, after consultation with the National Association of Social Workers, Vermont Chapter;

(F) one mental health counselor, after consultation with the Vermont mental health counselors association;

(G) one drug and alcohol counselor, after consultation with the Vermont association of drug and alcohol counselors;

(H) one representative from a consumer or citizen's organization;

(I) one representative from the business community; and

(J) one representative of community mental health centers. (Added 1997, No. 25, §§ 2, 4, 6; amended 1999, No. 129 (Adj. Sess.), § 1; 2001, No. 32, § 1; 2001, No. 76 (Adj. Sess.), § 1, eff. March 15, 2002; 2003, No. 29, § 1; 2005, No. 129 (Adj. Sess.), § 1.)