Florida Senate - 2018              PROPOSED COMMITTEE SUBSTITUTE
       Bill No. CS for SB 1422
       
       
       
       
       
                               Ì243598YÎ243598                          
       
       576-03511-18                                                    
       Proposed Committee Substitute by the Committee on Appropriations
       (Appropriations Subcommittee on Health and Human Services)
    1                        A bill to be entitled                      
    2         An act relating to insurance coverage parity for
    3         mental health and substance use disorders; amending s.
    4         409.967, F.S.; requiring contracts between the Agency
    5         for Health Care Administration and certain managed
    6         care plans to require the plans to submit a specified
    7         annual report to the agency relating to parity between
    8         mental health and substance use disorder benefits and
    9         medical and surgical benefits; amending s. 627.6675,
   10         F.S.; conforming a provision to changes made by the
   11         act; transferring, renumbering, and amending s.
   12         627.668, F.S.; deleting certain provisions that
   13         require insurers, health maintenance organizations,
   14         and nonprofit hospital and medical service plan
   15         organizations transacting group health insurance or
   16         providing prepaid health care to offer specified
   17         optional coverage for mental and nervous disorders;
   18         requiring such entities transacting individual or
   19         group health insurance or providing prepaid health
   20         care to comply with specified provisions prohibiting
   21         the imposition of less favorable benefit limitations
   22         on mental health and substance use disorder benefits
   23         than on medical and surgical benefits; revising the
   24         standard for defining substance use disorders;
   25         requiring such entities to submit a specified annual
   26         report relating to parity between such benefits to the
   27         Office of Insurance Regulation; requiring the office
   28         to implement and enforce specified federal provisions,
   29         guidance, and regulations; specifying actions the
   30         office must take relating to such implementation and
   31         enforcement; requiring the office to issue a specified
   32         annual report to the Legislature; repealing s.
   33         627.669, F.S., relating to optional coverage required
   34         for substance abuse impaired persons; providing an
   35         appropriation; providing an effective date.
   36          
   37  Be It Enacted by the Legislature of the State of Florida:
   38  
   39         Section 1. Paragraph (p) is added to subsection (2) of
   40  section 409.967, Florida Statutes, to read:
   41         409.967 Managed care plan accountability.—
   42         (2) The agency shall establish such contract requirements
   43  as are necessary for the operation of the statewide managed care
   44  program. In addition to any other provisions the agency may deem
   45  necessary, the contract must require:
   46         (p) Annual reporting relating to parity in mental health
   47  and substance use disorder benefits.Every managed care plan
   48  shall submit an annual report to the agency, on or before July
   49  1, which contains all of the following information:
   50         1.A description of the process used to develop or select
   51  the medical necessity criteria for:
   52         a. Mental or nervous disorder benefits;
   53         b. Substance use disorder benefits; and
   54         c. Medical and surgical benefits.
   55         2.Identification of all nonquantitative treatment
   56  limitations (NQTLs) applied to both mental or nervous disorder
   57  and substance use disorder benefits and medical and surgical
   58  benefits. Within any classification of benefits, there may not
   59  be separate NQTLs that apply to mental or nervous disorder and
   60  substance use disorder benefits but do not apply to medical and
   61  surgical benefits.
   62         3.The results of an analysis demonstrating that for the
   63  medical necessity criteria described in subparagraph 1. and for
   64  each NQTL identified in subparagraph 2., as written and in
   65  operation, the processes, strategies, evidentiary standards, or
   66  other factors used to apply the criteria and NQTLs to mental or
   67  nervous disorder and substance use disorder benefits are
   68  comparable to, and are applied no more stringently than, the
   69  processes, strategies, evidentiary standards, or other factors
   70  used to apply the criteria and NQTLs, as written and in
   71  operation, to medical and surgical benefits. At a minimum, the
   72  results of the analysis must:
   73         a.Identify the factors used to determine that an NQTL will
   74  apply to a benefit, including factors that were considered but
   75  rejected;
   76         b.Identify and define the specific evidentiary standards
   77  used to define the factors and any other evidentiary standards
   78  relied upon in designing each NQTL;
   79         c.Identify and describe the methods and analyses used,
   80  including the results of the analyses, to determine that the
   81  processes and strategies used to design each NQTL, as written,
   82  for mental or nervous disorder and substance use disorder
   83  benefits are comparable to, and no more stringently applied
   84  than, the processes and strategies used to design each NQTL, as
   85  written, for medical and surgical benefits;
   86         d.Identify and describe the methods and analyses used,
   87  including the results of the analyses, to determine that
   88  processes and strategies used to apply each NQTL, in operation,
   89  for mental or nervous disorder and substance use disorder
   90  benefits are comparable to, and no more stringently applied
   91  than, the processes or strategies used to apply each NQTL, in
   92  operation, for medical and surgical benefits; and
   93         e.Disclose the specific findings and conclusions reached
   94  by the managed care plan that the results of the analyses
   95  indicate that the insurer, health maintenance organization, or
   96  nonprofit hospital and medical service plan corporation is in
   97  compliance with this section, the federal Paul Wellstone and
   98  Pete Domenici Mental Health Parity and Addiction Equity Act of
   99  2008 (MHPAEA), and any federal guidance or regulations relating
  100  to MHPAEA, including, but not limited to, 45 C.F.R. s. 146.136,
  101  45 C.F.R. s. 147.160, and 45 C.F.R. s. 156.115(a)(3).
  102         Section 2. Paragraph (b) of subsection (8) of section
  103  627.6675, Florida Statutes, is amended to read:
  104         627.6675 Conversion on termination of eligibility.—Subject
  105  to all of the provisions of this section, a group policy
  106  delivered or issued for delivery in this state by an insurer or
  107  nonprofit health care services plan that provides, on an
  108  expense-incurred basis, hospital, surgical, or major medical
  109  expense insurance, or any combination of these coverages, shall
  110  provide that an employee or member whose insurance under the
  111  group policy has been terminated for any reason, including
  112  discontinuance of the group policy in its entirety or with
  113  respect to an insured class, and who has been continuously
  114  insured under the group policy, and under any group policy
  115  providing similar benefits that the terminated group policy
  116  replaced, for at least 3 months immediately prior to
  117  termination, shall be entitled to have issued to him or her by
  118  the insurer a policy or certificate of health insurance,
  119  referred to in this section as a “converted policy.” A group
  120  insurer may meet the requirements of this section by contracting
  121  with another insurer, authorized in this state, to issue an
  122  individual converted policy, which policy has been approved by
  123  the office under s. 627.410. An employee or member shall not be
  124  entitled to a converted policy if termination of his or her
  125  insurance under the group policy occurred because he or she
  126  failed to pay any required contribution, or because any
  127  discontinued group coverage was replaced by similar group
  128  coverage within 31 days after discontinuance.
  129         (8) BENEFITS OFFERED.—
  130         (b) An insurer shall offer the benefits specified in s.
  131  627.4193 s. 627.668 and the benefits specified in s. 627.669 if
  132  those benefits were provided in the group plan.
  133         Section 3. Section 627.668, Florida Statutes, is
  134  transferred, renumbered as section 627.4193, Florida Statutes,
  135  and amended, to read:
  136         627.4193 627.668Requirements for mental health and
  137  substance use disorder benefits; reporting requirements Optional
  138  coverage for mental and nervous disorders required; exception.—
  139         (1) Every insurer, health maintenance organization, and
  140  nonprofit hospital and medical service plan corporation
  141  transacting individual or group health insurance or providing
  142  prepaid health care in this state must comply with the federal
  143  Paul Wellstone and Pete Domenici Mental Health Parity and
  144  Addiction Equity Act of 2008 (MHPAEA) and any regulations
  145  relating to MHPAEA, including, but not limited to, 45 C.F.R. s.
  146  146.136, 45 C.F.R. s. 147.160, and 45 C.F.R. s. 156.115(a)(3);
  147  and must provide shall make available to the policyholder as
  148  part of the application, for an appropriate additional premium
  149  under a group hospital and medical expense-incurred insurance
  150  policy, under a group prepaid health care contract, and under a
  151  group hospital and medical service plan contract, the benefits
  152  or level of benefits specified in subsection (2) for the
  153  necessary care and treatment of mental and nervous disorders,
  154  including substance use disorders, as defined in the Diagnostic
  155  and Statistical Manual of Mental Disorders, Fifth Edition,
  156  published by standard nomenclature of the American Psychiatric
  157  Association, subject to the right of the applicant for a group
  158  policy or contract to select any alternative benefits or level
  159  of benefits as may be offered by the insurer, health maintenance
  160  organization, or service plan corporation provided that, if
  161  alternate inpatient, outpatient, or partial hospitalization
  162  benefits are selected, such benefits shall not be less than the
  163  level of benefits required under paragraph (2)(a), paragraph
  164  (2)(b), or paragraph (2)(c), respectively.
  165         (2) Under individual or group policies or contracts,
  166  inpatient hospital benefits, partial hospitalization benefits,
  167  and outpatient benefits consisting of durational limits, dollar
  168  amounts, deductibles, and coinsurance factors may shall not be
  169  less favorable than for physical illness, in accordance with 45
  170  C.F.R. s. 146.136(c)(2) and (3) generally, except that:
  171         (a) Inpatient benefits may be limited to not less than 30
  172  days per benefit year as defined in the policy or contract. If
  173  inpatient hospital benefits are provided beyond 30 days per
  174  benefit year, the durational limits, dollar amounts, and
  175  coinsurance factors thereto need not be the same as applicable
  176  to physical illness generally.
  177         (b) Outpatient benefits may be limited to $1,000 for
  178  consultations with a licensed physician, a psychologist licensed
  179  pursuant to chapter 490, a mental health counselor licensed
  180  pursuant to chapter 491, a marriage and family therapist
  181  licensed pursuant to chapter 491, and a clinical social worker
  182  licensed pursuant to chapter 491. If benefits are provided
  183  beyond the $1,000 per benefit year, the durational limits,
  184  dollar amounts, and coinsurance factors thereof need not be the
  185  same as applicable to physical illness generally.
  186         (c) Partial hospitalization benefits shall be provided
  187  under the direction of a licensed physician. For purposes of
  188  this part, the term “partial hospitalization services” is
  189  defined as those services offered by a program that is
  190  accredited by an accrediting organization whose standards
  191  incorporate comparable regulations required by this state.
  192  Alcohol rehabilitation programs accredited by an accrediting
  193  organization whose standards incorporate comparable regulations
  194  required by this state or approved by the state and licensed
  195  drug abuse rehabilitation programs shall also be qualified
  196  providers under this section. In a given benefit year, if
  197  partial hospitalization services or a combination of inpatient
  198  and partial hospitalization are used, the total benefits paid
  199  for all such services may not exceed the cost of 30 days after
  200  inpatient hospitalization for psychiatric services, including
  201  physician fees, which prevail in the community in which the
  202  partial hospitalization services are rendered. If partial
  203  hospitalization services benefits are provided beyond the limits
  204  set forth in this paragraph, the durational limits, dollar
  205  amounts, and coinsurance factors thereof need not be the same as
  206  those applicable to physical illness generally.
  207         (3) Insurers must maintain strict confidentiality regarding
  208  psychiatric and psychotherapeutic records submitted to an
  209  insurer for the purpose of reviewing a claim for benefits
  210  payable under this section. These records submitted to an
  211  insurer are subject to the limitations of s. 456.057, relating
  212  to the furnishing of patient records.
  213         (4)Every insurer, health maintenance organization, and
  214  nonprofit hospital and medical service plan corporation
  215  transacting individual or group health insurance or providing
  216  prepaid health care in this state shall submit an annual report
  217  to the office, on or before July 1, which contains all of the
  218  following information:
  219         (a)A description of the process used to develop or select
  220  the medical necessity criteria for:
  221         1. Mental or nervous disorder benefits;
  222         2. Substance use disorder benefits; and
  223         3. Medical and surgical benefits.
  224         (b) Identification of all nonquantitative treatment
  225  limitations (NQTLs) applied to both mental or nervous disorder
  226  and substance use disorder benefits and medical and surgical
  227  benefits. Within any classification of benefits, there may not
  228  be separate NQTLs that apply to mental or nervous disorder and
  229  substance use disorder benefits but do not apply to medical and
  230  surgical benefits.
  231         (c)The results of an analysis demonstrating that for the
  232  medical necessity criteria described in paragraph (a) and for
  233  each NQTL identified in paragraph (b), as written and in
  234  operation, the processes, strategies, evidentiary standards, or
  235  other factors used to apply the criteria and NQTLs to mental or
  236  nervous disorder and substance use disorder benefits are
  237  comparable to, and are applied no more stringently than, the
  238  processes, strategies, evidentiary standards, or other factors
  239  used to apply the criteria and NQTLs, as written and in
  240  operation, to medical and surgical benefits. At a minimum, the
  241  results of the analysis must:
  242         1.Identify the factors used to determine that an NQTL will
  243  apply to a benefit, including factors that were considered but
  244  rejected;
  245         2.Identify and define the specific evidentiary standards
  246  used to define the factors and any other evidentiary standards
  247  relied upon in designing each NQTL;
  248         3.Identify and describe the methods and analyses used,
  249  including the results of the analyses, to determine that the
  250  processes and strategies used to design each NQTL, as written,
  251  for mental or nervous disorder and substance use disorder
  252  benefits are comparable to, and no more stringently applied
  253  than, the processes and strategies used to design each NQTL, as
  254  written, for medical and surgical benefits;
  255         4.Identify and describe the methods and analyses used,
  256  including the results of the analyses, to determine that
  257  processes and strategies used to apply each NQTL, in operation,
  258  for mental or nervous disorder and substance use disorder
  259  benefits are comparable to and no more stringently applied than
  260  the processes or strategies used to apply each NQTL, in
  261  operation, for medical and surgical benefits; and
  262         5.Disclose the specific findings and conclusions reached
  263  by the insurer, health maintenance organization, or nonprofit
  264  hospital and medical service plan corporation that the results
  265  of the analyses indicate that the insurer, health maintenance
  266  organization, or nonprofit hospital and medical service plan
  267  corporation is in compliance with this section; MHPAEA; and any
  268  regulations relating to MHPAEA, including, but not limited to,
  269  45 C.F.R. s. 146.136, 45 C.F.R. s. 147.160, and 45 C.F.R. s.
  270  156.115(a)(3).
  271         (5)The office shall implement and enforce applicable
  272  provisions of MHPAEA and federal guidance or regulations
  273  relating to MHPAEA, including, but not limited to, 45 C.F.R. s.
  274  146.136, 45 C.F.R. s. 147.160, and 45 C.F.R. s. 156.115(a)(3),
  275  and this section, which includes:
  276         (a)Ensuring compliance by each insurer, health maintenance
  277  organization, and nonprofit hospital and medical service plan
  278  corporation transacting individual or group health insurance or
  279  providing prepaid health care in this state.
  280         (b)Detecting violations by any insurer, health maintenance
  281  organization, or nonprofit hospital and medical service plan
  282  corporation transacting individual or group health insurance or
  283  providing prepaid health care in this state.
  284         (c)Accepting, evaluating, and responding to complaints
  285  regarding potential violations.
  286         (d)Reviewing, from consumer complaints, for possible
  287  parity violations regarding mental or nervous disorder and
  288  substance use disorder coverage.
  289         (e)Performing parity compliance market conduct
  290  examinations, which include, but are not limited to, reviews of
  291  medical management practices, network adequacy, reimbursement
  292  rates, prior authorizations, and geographic restrictions of
  293  insurers, health maintenance organizations, and nonprofit
  294  hospital and medical service plan corporations transacting
  295  individual or group health insurance or providing prepaid health
  296  care in this state.
  297         (6)No later than December 31 of each year, the office
  298  shall issue a report to the Legislature which describes the
  299  methodology the office is using to check for compliance with
  300  MHPAEA; any federal guidance or regulations that relate to
  301  MHPAEA, including, but not limited to, 45 C.F.R. s. 146.136, 45
  302  C.F.R. s. 147.160, and 45 C.F.R. s. 156.115(a)(3); and this
  303  section. The report must be written in nontechnical and readily
  304  understandable language and must be made available to the public
  305  by posting the report on the office’s website and by other means
  306  the office finds appropriate.
  307         Section 4. Section 627.669, Florida Statutes, is repealed.
  308         Section 5. For the 2018-2019 fiscal year, the sum of
  309  $69,414 in recurring funds is appropriated from the Insurance
  310  Regulatory Trust Fund to the Office of Insurance Regulation, and
  311  one full-time equivalent position with salary rate of 47,858 is
  312  authorized, for the purpose of implementing s. 627.4193, Florida
  313  Statutes.
  314         Section 6. This act shall take effect July 1, 2018.