Utah Code § 31A-22-663 — Utah Code / Title 31A / Chapter 31A-22 / § 31A-22-663
§ 31A-22-663. Timely access to behavioral health services -- Single case agreement.
Status: in_force

(1) As used in this section: (a) "Covered insurer" means an insurer that offers health insurance that includes coverage for behavioral health services. (b) (i) "Behavioral health services" means: (A) mental health treatment or services; or (B) substance use treatment or services. (ii) "Behavioral health services" includes telehealth services and telemedicine services. (c) "Insurer" means the same as that term is defined in Section 31A-22-634. (d) "Mental health provider" means the same as that term is defined in Section 31A-22-658. (e) "Telehealth services" means the same as that term is defined in Section 26B-4-704. (f) "Telemedicine services" means the same as that term is defined in Section 26B-4-704. (g) "Timely manner" means: (i) no more than 15 days after the day on which an insured first attempts to access behavioral health services; and (ii) no more than 24 hours after the date and time that an insured first seeks to access urgent, emergency, or crisis behavioral health services. (2) Beginning January 1, 2027, a covered insurer shall: (a) establish a procedure to assist an enrollee to access behavioral health services from an out-of-network mental health provider when no in-network mental health provider is available in a timely manner; and (b) if an enrollee in a covered insurer's health benefit plan is unable to obtain covered behavioral health services from an in-network mental health provider in a timely manner, enter into a single case agreement that allows the enrollee to receive covered behavioral health services from an out-of-network mental health provider. (3) (a) A covered insurer shall include in a negotiated single case agreement described in Subsection (2)(b): (i) a requirement that the covered insurer reimburse the out-of-network mental health provider for the covered behavioral health services at a rate negotiated by the provider and insurer, subject to the member cost-sharing requirements imposed by the health benefit plan; (ii) a requirement that the covered insurer apply the same coinsurance, copayments, and deductibles that would apply for the behavioral health services if the behavioral health services were provided by a mental health provider that is an in-network mental health provider; (iii) any terms that a network provider is subject to under the health benefit plan; and (iv) the length and scope of the single case agreement. (b) Notwithstanding Subsection (3)(a)(ii): (i) a covered insurer's payment under a single case agreement described in Subsection (2)(b) constitutes payment in full to the provider for the behavioral health services the enrollee receives; and (ii) the provider may not seek additional payment from the enrollee except for applicable cost sharing. (4) A covered insurer shall ensure that a single case agreement described in Subsection (2)(b) only permits an insured to receive behavioral health services: (a) that are: (i) within the out-of-network mental health provider's scope of practice; and (ii) behavioral health services that are otherwise covered under the enrollee's health benefit plan; and (b) that are not experimental, unless the insurer covers experimental treatments for physical health conditions in compliance with the Mental Health Parity and Addiction Equity Act, Pub. L. No. 110-343. (5) A covered insurer shall: (a) document all payments the covered insurer makes under a health benefit plan to a mental health provider under this section; and (b) provide the documentation described in Subsection (5)(a) to the department upon request. (6) Subsections (2)(b), (3), and (4) do not apply if behavioral health services are available in a timely manner. (7) The commissioner may: (a) make rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, to implement this section; and (b) bring an action in accordance with Section 31A-2-308 and Title 63G, Chapter 4, Administrative Procedures Act, for a violation of this section.