Amendment ID: S2572-15

Amendment 15

Continuity of Care

Ms. Comerford, Messrs. Eldridge, Timilty and Gomez, Ms. Rausch, Ms. Jehlen, Messrs. Montigny and O'Connor move that the proposed new draft be amended by inserting after section 39 the following section:-

“SECTION 39A. Section 1 of chapter 176O of the General Laws is hereby amended by inserting after the definition of “Concurrent review” the following definition:-

“Continuing course of treatment”, having at least 1 visit in the past 4 months for the same or similar mental health diagnosis or set of symptoms.”

and by inserting after section 47 the following sections:-

“SECTION 47A. Subsection (e) of section 15 of said chapter 176O is hereby amended by striking out the words “that could have been imposed if the provider had not been disenrolled;” and inserting in place thereof the following words:- permitted under this section;.

SECTION 47B. The second sentence of said subsection (e) of said section 15 of said chapter 176O is hereby further amended by striking out the word “remained” and inserting in place thereof the following words:- had been.

SECTION 47C. Section 15 of said chapter 176O 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 eligible for coverage under the plan, and 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 care professional 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 non-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 of health care finance and policy 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 of health care finance and policy.

(3) No additional charges, costs or deductibles may be levied due to the exercise of the out-of-network option. The amount of any additional co-payment charged by the carrier for the additional cost of the creation and maintenance of coverage described in subsection (1) shall be paid by the covered person unless it is paid by an employer or other person through agreement with the carrier.

(4) The commissioner may by regulation limit the amount of time that an insured may continue treatment with the provider through an out-of-network option under this section; provided, that any time limit shall be consistent with recommendations made by the office of behavioral health promotion established under section 16DD of chapter 6A. In making its recommendations, the office shall prioritize the needs of people accessing mental health care and shall seek to improve care quality and health outcomes. Before making its recommendations, the office shall convene a listening session to receive evidence and opinions from mental health clinicians, organizations representing people receiving mental health treatment, insurers, and members of the public.”.