Section 22B: Implement and enforcement of mental health parity provisions of the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008; federal guidance and regulations and state mental health parity laws and regulations; annual report
[ Introductory paragraph of subsection (a) effective until March 29, 2023. For text effective March 29, 2023, see below.]
Section 22B. (a) The commission shall implement and enforce the mental health parity provisions of the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C. 18031(j), as amended, federal guidance or regulations issued under the act, applicable state mental health parity laws and regulations and, to the degree applicable to its health benefit plans, guidance issued by the commissioner of insurance under section 8K of chapter 26 by:
[ Introductory paragraph of subsection (a) as amended by 2023, 2, Sec. 16 effective March 29, 2023. For text effective until March 29, 2023, see above.]
(a) The commission shall implement and enforce the mental health parity provisions of the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C. 300gg-26, as amended, federal guidance or regulations issued under the act, applicable state mental health parity laws and regulations and, to the degree applicable to its health benefit plans, guidance issued by the commissioner of insurance under section 8K of chapter 26 by:
(i) utilizing the commission's procurement, contracting, vendor oversight and auditing authority to ensure that the commission's health benefit plans that provide medical and surgical benefits and mental health and substance use disorder benefits are compliant with the applicable state or federal laws related to mental health and substance use disorder parity;
(ii) performing audits of each of the commission's health benefit plans at least once every 4 years, or more frequently if noncompliance is suspected, with a focus on: (A) nonquantitative treatment limitations under the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, as amended, and applicable state mental health and substance use disorder parity laws, including, but not limited to, prior authorization, concurrent review, retrospective review, step-therapy, network admission standards, reimbursement rates, network adequacy and geographic restrictions; (B) denials of authorization, payment and coverage; and (C) any other criteria determined by the commission, including factors identified through consumer or provider complaints;
(iii) requiring the commission's health benefit plans that provide medical and surgical benefits and mental health and substance use disorder benefits to comply with the annual reporting requirements under subsection (b); and
(iv) evaluating all consumer or provider complaints regarding mental health and substance use disorder coverage for possible parity violations not more than 3 months after receipt.
(b) The commission's health benefit plans that provide medical and surgical benefits and mental health and substance use disorder benefits shall submit an annual report not later than July 1 to the commission that contains:
(i) the specific plan or coverage terms or other relevant terms regarding the nonquantitative treatment limitations and a description of all mental health and substance use disorder benefits and medical and surgical benefits to which each term applies in each respective benefits classification; provided, however, that the nonquantitative treatment limitations shall include the processes, strategies, evidentiary standards or other factors used to develop and apply the health benefit plan's reimbursement rates for mental health and substance use disorder benefits and medical and surgical benefits in each respective benefits classification;
(ii) the factors used to determine that the nonquantitative treatment limitations will apply to mental health and substance use disorder benefits and medical and surgical benefits;
(iii) the evidentiary standards used for the factors identified in clause (ii), when applicable; provided, that every factor shall be defined, and any other source or evidence relied upon to design and apply the nonquantitative treatment limitations to mental health and substance use disorder benefits and medical and surgical benefits;
(iv) a comparative analysis demonstrating that the processes, strategies, evidentiary standards and other factors used to apply the nonquantitative treatment limitations to mental health and substance use disorder benefits, as written and in operation, are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards and other factors used to apply the nonquantitative treatment limitations to medical or surgical benefits in the benefits classification;
(v) the specific findings and conclusions reached by the health benefit plan with respect to health insurance coverage, including any results of the analysis described in clause (iv) that indicate whether the health benefit plan is in compliance with this section and the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, as amended, and any federal guidance or regulations relevant to the act; and
(vi) any other data or information the commission deems necessary to assess a health benefit plan's compliance with state or federal laws related to mental health and substance use disorder parity.
(c) If federal guidance, including, but not limited to, the Self-Compliance Tool for the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, as amended, is released that indicates a nonquantitative treatment limitation analysis process and reporting format that is significantly different from, contrary to or more efficient than the nonquantitative treatment limitation analysis process and reporting format requirements described in subsection (b), the commission may revise the analysis and reporting requirements described in said subsection (b).
(d) Any proprietary portions of information submitted to the commission by a health benefit plan as a result of the requirements of this section shall not be a public record under clause Twenty-sixth of section 7 of chapter 4 or chapter 66; provided, however, that the commission may produce reports summarizing any findings.
(e) Annually, not later than December 1, the commission shall submit a summary of the reports that the commission receives from all health benefit plans under subsection (b) to the clerks of the senate and house of representatives, the joint committee on mental health, substance use and recovery and the joint committee on health care financing. The summary report shall include, but not be limited to:
(i) the methodology the commission is using to check for compliance with the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, as amended, and any federal guidance or regulations relevant to the act;
(ii) the methodology the commission is using to check for compliance with applicable state mental health parity laws and regulations, including section 22 of chapter 32A, and, to the degree applicable to its health benefit plans, guidance issued by the commissioner of insurance under section 8K of chapter 26;
(iii) a summary of any audit findings for audits conducted and completed under clause (ii) of subsection (a) during the immediately preceding calendar year regarding access to behavioral health services or compliance with parity in mental health and substance use disorder benefits under state and federal laws and any actions taken as a result of such audit; and
(iv) the number of consumer complaints the commission has received in the immediately preceding calendar year regarding access to behavioral health services or compliance with parity in mental health and substance use disorder benefits under state and federal laws and a summary of all complaints resolved by the commission during that time period.
The summary report shall be written in nontechnical, readily understandable language and made available to the public by posting the report on the commission's website.