Amendment ID: S2519-24

Amendment 24

Mental Health Continuity of Care

Ms. Comerford, Messrs. Eldridge and Timilty, Ms. Gobi, Messrs. Welch, Pacheco, Montigny, Feeney and O'Connor move that the proposed new draft be amended by adding the following sections:-

“SECTION XX. Section 1 of chapter 176O of the General Laws, as appearing in the 2018 Official Edition, is hereby amended by inserting after the definition of “Concurrent review” the following definition:-

“Continuing course of treatment”, having at least one visit in the past four months for the same or similar mental health diagnosis or set of symptoms.

SECTION XX. Section 15 of said chapter 176O, as so appearing, is hereby further amended by adding after subsection (k) the following subsection:-

(l) A carrier shall allow any insured who is engaged in a continuing course of treatment with a licensed mental health provider whose provider in connection with the mental health treatment is involuntarily or voluntarily disenrolled, other than for quality-related reasons or for fraud, or whose carrier has changed for any reason thereby placing the provider out-of-network, to continue treatment with the provider through an out-of-network option, pursuant to the following:

(1) The carrier shall reimburse the licensed mental health provider the usual network per-unit reimbursement rate for the relevant service and provider type as payment in full. If more than one reimbursement rate exists, the carrier shall use the median reimbursement rate.

(2) The out-of-network option may require that a covered person pay a higher co-payment only if the higher co-payment results from increased costs caused by the use of a non-network provider. The carrier shall provide an actuarial demonstration of the increased costs to the division at the commissioner’s request. If the increased costs are not justified, the commissioner shall require the carrier to recalculate the appropriate costs allowed and resubmit the appropriate co-payment to the division.

(3) The insured shall not be required to pay any additional charges, costs or deductibles due to the exercise of the out-of-network option, except as provided in paragraph (2). The amount of any additional co-payment charged by the carrier for the additional cost of the creation and maintenance of coverage under this subsection shall be paid by the insured unless it is paid by an employer or other person through an agreement with the carrier.

(4) A carrier may condition coverage of continued treatment by a provider under this section upon the provider's agreeing (i) to adhere to the quality assurance standards of the carrier and to provide the carrier with necessary medical information related to the care provided; and (ii) to adhere to such carrier's policies and procedures, including procedures regarding referrals, obtaining prior authorization and providing services under a treatment plan, if any, approved by the carrier. Nothing in this subsection shall be construed to require the coverage of benefits that would not have been covered if the provider involved had been a participating provider.”.