Section 80: Sickle cell disease; executive office review; content of report
[Text of section added by 2022, 126, Sec. 67. See, also, Section 80 added by 2022, 177, Sec. 44, below.]
Section 80. (a) Every 2 years, not later than November 15, the executive office shall review data and report on findings from the review based on data collected for the prior 2 years. The review shall consist of: (i) the available covered medications; (ii) treatments; and (iii) whether health care services were adequate to meet the needs of enrollees, including, but not limited to, input received pursuant to subsection (c). Each report shall include, but not be limited to: (A) detailed results of the review; (B) recommendations, if any, for improvements in the delivery of health care services to enrollees with a diagnosis of sickle cell disease; and (C) recommendations, if any, on whether the division shall seek to add or facilitate access to additional medications, treatments or services.
(b) Each review pursuant to subsection (a) shall include, but not be limited to:
(i) the extent to which healthcare transitional programs or services for enrollees that are covered by the division prepare, transfer and integrate emerging adults with sickle cell disease into the adult care setting;
(ii) the extent to which providers of emergency medical services to enrollees are adequately trained and otherwise prepared to treat and manage sickle cell patients presenting with vaso-occlusive crises, including, but not limited to, the extent to which such providers follow clinically-validated algorithms and protocols regarding such treatment and management; and
(iii) the number of people with sickle cell disease who had 2 or more hospitalizations or emergency department visits with a vaso-occlusive episode or pain crisis, including the average length of stay for such visits.
(c) When conducting a review pursuant to subsection (a), the executive office shall solicit and consider input from the public, with specific emphasis on receiving input from patients with a sickle cell disease diagnosis as well as persons or groups with knowledge, experience or specialized expertise in the area of sickle cell disease treatment. Not later than April 30 of each year that the review is conducted, the executive office shall hold not less than 1 public hearing to solicit input.
(d) Each report required under this section shall be filed with the clerks of the house of representatives and the senate, the joint committee on health care financing and the house and senate committees on ways and means. The division shall post the report on the division's website in a manner accessible by the public.
[Text of section added by 2022, 177, Sec. 44. See, also, Section 80 added by 2022, 126, Sec. 67, above.]
Section 80. (a) The division, its managed care organizations, accountable care organizations or other entity contracting with the division to manage or administer mental health and substance use disorder benefits shall ensure that there are no separate non-quantitative treatment limitations that apply to mental health and substance use disorder benefits but do not apply to medical and surgical benefits within any classification of benefits as defined under the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, as amended, and applicable state mental health parity laws, including, but not limited to, section 81; provided, however, that the non-quantitative treatment limitations shall include the processes, strategies or methodologies for developing and applying the division's reimbursement rates for mental health and substance use disorder benefits and medical and surgical benefits within each classification of benefits.
(b) The division shall perform a behavioral health parity compliance examination of each Medicaid managed care organization, accountable care organization or other entity contracted with the agency that manages or administers mental health and substance use disorder benefits for the division at least once every 4 years. The examination shall include examination of entities that manage medical and surgical benefits, as necessary. The examination shall only apply where the division is the primary payer. The examination shall include, but not be limited to:
(i) non-quantitative treatment limitations, including, but not limited to, prior authorization, concurrent review, retrospective review, step-therapy, network admission standards, reimbursement rates and geographic restrictions;
(ii) approvals and denials of authorization, payment and coverage; and
(iii) any other specific criteria as may be determined by the division, including factors identified through consumer or provider complaints.
(c) The division shall require each of its managed care organizations, accountable care organizations or other entity contracting with the division to manage or administer mental health and substance use disorder benefits to submit an annual report to the division on or before July 1 that shall include:
(i) the specific plan or coverage terms or other relevant terms regarding the non-quantitative 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 non-quantitative treatment limitations shall include the processes, strategies, evidentiary standards or other factors used to develop and apply the entity'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 non-quantitative treatment limitations will apply to mental health and substance use disorder benefits and medical and surgical benefits;
(iii) the evidentiary standards used to define the factors identified in clause (ii), when applicable; provided, however, that every factor shall be defined and any other source or evidence relied upon to design and apply the non-quantitative treatment limitations to mental health and substance use disorder benefits and medical and surgical benefits;
(iv) a comparative analyses demonstrating that the processes, strategies, evidentiary standard and other factors used to apply the non-quantitative 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 non-quantitative treatment limitations to medical and surgical benefits in the benefits classification;
(v) the specific findings and conclusions reached by the entity with respect to health insurance coverage, including any results of the analysis described in clause (iv) that indicates whether the entity 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 federal guidelines and regulations relevant to the act, including, but not limited to, 42 CFR Part 457.496;
(vi) the treatment authorization data for the prior calendar year, which shall include, but not be limited to: (A) the number of inpatient days, outpatient services and total number of services requested; (B) the number and per cent of inpatient day requests authorized, inpatient day requests modified, inpatient day requests modified resulting in a lesser amount of inpatient days authorized than requested and the reason for the modification, inpatient day requests denied and the reason for the denial, inpatient day requests where an internal appeal was filed and approved, inpatient day requests where an internal appeal was filed and denied, inpatient day requests where an external appeal was filed and upheld and inpatient day requests where an external appeal was filed and overturned; and (C) the number and per cent of outpatient service requests authorized, outpatient service requests modified, outpatient service requests modified resulting in a lower amount of outpatient service authorized than requested and the reason for the modification, outpatient service requests denied and the reason for the denial, outpatient service requests where an internal appeal was filed and approved, outpatient service requests where an internal appeal was filed and denied, outpatient service requests where an external appeal or hearing before the board of hearings was filed and upheld and outpatient service requests where an external appeal was filed and overturned;
(vii) the additional information, if any, that an entity is required to provide under 42 U.S.C. 300gg–26(a)(8)(B)(ii); and
(viii) any other data or information the division deems necessary to assess an entity's compliance with mental health parity requirements.
(d) 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 non-quantitative treatment limitation analysis process and reporting format that is significantly different from, contrary to or more efficient than the non-quantitative treatment limitation analysis process and reporting format requirements described in subsection (b), the division may promulgate regulations that delineate a non-quantitative treatment limitation analysis process and reporting format that may be used in lieu of the non-quantitative treatment limitation analysis and reporting requirements described in said subsection (b).
(e) Any proprietary information submitted to the general court by the division as a result of the requirements in this section shall not be a public record under clause Twenty-sixth of section 7 of chapter 4 or chapter 66; provided, however, that nothing in this section shall limit the authority of the director of Medicaid to use and, if appropriate, publish any final or preliminary examination report, examiner or company work papers or other documents or other information discovered or developed during the course of an examination in the furtherance of any legal or regulatory action that the director may, in their sole discretion, deem appropriate; provided further, that nothing in this section shall prevent the director of Medicaid from publishing any illustrative utilization review criteria, medical necessity standard, clinical guideline or other policy, procedure, criteria or standard, regardless of its origin, as an example of the type of policy, procedure, criteria or standard that contributes to a violation of state or federal law parity requirements, including any information that is subject to disclosure to plan members under the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, as amended, or under any member right to receive such guideline under applicable federal law.
(f) Annually, not later than December 1, the division shall submit a summary of the reports that the division receives from all entities under subsection (c) 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 division 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 regulations or guidance relevant to the act;
(ii) the methodology the division is using to check for compliance with section 81;
(iii) the report of each examination conducted or completed under subsection (b) 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 examinations;
(iv) a breakdown of treatment authorization data for the division, and for each Medicaid managed care organization, accountable care organization or other entity that manages or administers benefits for the division, for mental health treatment services, substance use disorder treatment services and medical and surgical treatment services for the immediately preceding calendar year indicating for each treatment service: (A) the number of inpatient days, outpatient services and total number of services requested; (B) the number and per cent of inpatient day requests authorized, inpatient day requests modified, inpatient day requests modified resulting in a lesser amount of inpatient days authorized than requested and the reason for the modification, inpatient day requests denied and the reason for the denial, inpatient day requests where an internal appeal was filed and approved, inpatient day requests where an internal appeal was filed and denied, inpatient day requests where an external review under section 47B or hearing before the board of hearings under section 48 was filed and upheld and inpatient day requests where an external review under said section 47B or hearing before the board of hearings under said section 48 was filed and overturned; and (C) the number and per cent of outpatient service requests authorized, outpatient service requests modified, outpatient service requests modified resulting in a lower amount of outpatient service authorized than requested and the reason for the modification, outpatient service requests denied and the reason for the denial, outpatient service requests where an internal appeal was filed and approved, outpatient service requests where an internal appeal was filed and denied, outpatient service requests where an external review under said section 47B or hearing before the board of hearings under said section 48 was filed and upheld and outpatient service requests where an external review under said section 47B or hearing before the board of hearings under said section 48 was filed and overturned;
(v) the number of complaints the division, or any Medicaid managed care organization, accountable care organization or other entity contracting with the division to manage or administer mental health and substance use disorder benefits, 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 division, or any Medicaid managed care organization, accountable care organization or other entity contracting with the division to manage or administer mental health and substance use disorder benefits, during that time period; and
(vi) information about any educational or corrective actions the division has taken to ensure carrier compliance with the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, as amended, and section 81.
The summary report shall be written in non-technical, readily understandable language and shall be made publicly available on the division's website.
(g) The division shall evaluate all consumer or provider complaints regarding mental health and substance use disorder coverage for possible parity violations within 3 months of receipt of the complaint.