2023 CODE OF GEORGIA › Title 33 - INSURANCE (§§ 33-1-1 — 33-66-8) › Chapter 21A - MEDICAID CARE MANAGEMENT ORGANIZATIONS ACT (§§ 33-21A-1 — 33-21A-14) › Section 33-21A-13 - Coverage for mental health and substance abuse disorders; role of commissioner of community health; parity violations

(a)
As used in this Code section, the term:
(1)
"Addictive disease" has the same meaning as in Code Section
37-1-1
.
(2)
"Generally accepted standards of mental health or substance use disorder care" means evidence based independent standards of care and clinical practice that are generally recognized by health care providers practicing in relevant clinical specialties such as psychiatry, psychology, clinical sociology, addiction medicine and counseling, and behavioral health treatment. Valid, evidence based sources reflecting generally accepted standards of mental health or substance use disorder care may include peer reviewed scientific studies and medical literature, consensus guidelines and recommendations of nonprofit health care provider professional associations and specialty societies, and nationally recognized clinical practice guidelines, including, but not limited to, patient placement criteria and clinical practice guidelines; guidelines or recommendations of federal government agencies; and drug labeling approved by the United States Food and Drug Administration.
(3)
"Medically necessary" means, with respect to the treatment of a mental health or substance use disorder, a service or product addressing the specific needs of that patient for the purpose of screening, preventing, diagnosing, managing or treating an illness, injury, condition, or its symptoms, including minimizing the progression of an illness, injury, condition, or its symptoms, in a manner that is:
(A)
In accordance with the generally accepted standards of mental health or substance use disorder care;
(B)
Clinically appropriate in terms of type, frequency, extent, site, and duration; and
(C)
Not primarily for the economic benefit of the insurer, purchaser, or for the convenience of the patient, treating physician, or other health care provider.
(4)
"Mental health or substance use disorder" means a mental illness or addictive disease.
(5)
"Mental illness" has the same meaning as in Code Section
37-1-1
.
(6)
"Nonquantitative treatment limitation" or "NQTL" means limitations that are not expressed numerically, but otherwise limit the scope or duration of benefits for treatment. NQTLs include, but are not limited to, the following:
(A)
Medical management standards limiting or excluding benefits based on whether the treatment is medically necessary or whether the treatment is experimental or investigative;
(B)
Formulary design for prescription drugs;
(C)
Standards for provider admission to participate in a network, including average time to obtain, verify, and assess the qualifications of a health practitioner for purposes of credentialing;
(D)
Criteria utilized for determining usual, customary, and reasonable charges for out-of-network services, including the threshold percentile utilized and any industry software or other billing, charges, and claims tools utilized;
(E)
Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for in-network and out-of-network services;
(F)
Standards for providing access to out-of-network providers;
(G)
Provider reimbursement rates, including rates of reimbursement for mental health or substance use services in primary care; provided, however, that any proprietary information collected shall not be subject to disclosure; and
(H)
Such other limitation identified by the commissioner.
(7)
"State health care entity" means any entity that provides or arranges health care for a state health plan on a prepaid, capitated, or fee for service basis to enrollees or recipients of Medicaid or PeachCare for Kids, including any insurer, care management organization, administrative services organization, utilization management organization, or other entity.
(8)
"State health plan" means any health care benefits provided pursuant to Subpart 2 of Part 6 of Article 17 of Chapter 2 of Title 20, Subpart 3 of Part 6 of Article 17 of Chapter 2 of Title 20, Article 1 of Chapter 18 of Title 45, Article 7 of Chapter 4 of Title 49, or Article 13 of Chapter 5 of Title 49.
(b)
Every state health care entity shall provide coverage for the treatment of mental health or substance use disorders in accordance with the Mental Health Parity and Addiction Equity Act of 2008,
42 U.S.C. Section 300gg-26
, and its implementing and related regulations, which shall be at least as extensive and provide at least the same degree of coverage as that provided by the entity for the treatment of other types of physical illnesses. Such coverage shall also cover the spouse and the dependents of the insured if such insured's spouse and dependents are covered under such benefit plan, policy, or contract. Such coverage shall not contain any exclusions, reductions, or other limitations as to coverages, deductibles, or coinsurance provisions which apply to the treatment of mental health or substance use disorders unless such provisions apply generally to other similar benefits provided or paid for under the state health plan. Every such entity shall:
(1)
Provide such coverage for children, adolescents, and adults;
(2)
Apply the definitions of "generally accepted standards of mental health or substance use disorder care," "medically necessary," and "mental health or substance use disorder" contained in subsection (a) of this Code section in making any medical necessity, prior authorization, or utilization review determinations under such coverage;
(3)
Ensure that any subcontractor or affiliate responsible for management of mental health and substance use disorder care on behalf of the state health care entity complies with the requirements of this Code section;
(4)
Process hospital claims for emergency health care services for mental health or substance use disorders in accordance with this Code section regardless of whether a member is treated in an emergency department; and
(5)
No later than January 1, 2023, and annually thereafter, submit a report to the commissioner of community health that contains the comparative analysis and other information required of insurers under the Mental Health Parity and Addiction Equity Act of 2008,
42 U.S.C. Section 300gg
-
26(a)(8)(A)
and which delineates the comparative analysis and written processes and strategies used to apply benefits for children, adolescents, and adults. No later than January 1, 2024, and annually thereafter, the commissioner of community health shall publish on the Department of Community Health's website in a prominent location the reports submitted to the commissioner of community health pursuant to this paragraph.
(c)
The commissioner of community health shall annually:
(1)
Perform parity compliance reviews of all state health care entities to ensure compliance with mental health parity requirements, including, but not limited to, compliance with the Mental Health Parity and Addiction Equity Act of 2008,
42 U.S.C. Section 300gg-26
. Such parity compliance reviews shall include a focus on the use of nonquantitative treatment limitations; and
(2)
Publish on the Department of Community Health's website in a prominent location a status report of the parity compliance reviews performed pursuant to this subsection, including the results of the reviews and any corrective actions taken.
(d)
No state health care entity shall implement any prohibition on same-day reimbursement for a patient who sees a mental health provider and a primary care provider in the same day.
(e)
The commissioner of community health shall establish a process for accepting, evaluating, and responding to complaints from consumers and health care providers regarding suspected mental health parity violations. Such process shall be posted on the Department of Community Health's website in a prominent location and shall include information on the rights of consumers under Article 2 of Chapter 20A of Title 33, the "Patient's Right to Independent Review Act," and rights of care management organizations under Code Section
49-4-153
. To the extent practicable, the commissioner of community health shall undertake reasonable efforts to make culturally and linguistically sensitive materials available for consumers accessing the complaint process established pursuant to this subsection.
(f)
No later than July 1, 2023, the Department of Community Health shall create a repository for tracking, analyzing, and reporting information resulting from complaints received from consumers and health care providers regarding suspected mental health parity violations. Such repository shall include complaints, department reviews, mitigation efforts, and outcomes, among other criteria established by the department.
(g)
Beginning January 15, 2024, and no later than January 15 annually thereafter, the commissioner of community health shall submit a report to the administrator of the Georgia Data Analytic Center and the General Assembly with information regarding the previous year's complaints and all elements contained in the repository.
(h)
Nothing contained in this Code section shall abrogate the protections afforded by federal conscience and antidiscrimination laws as further delineated in 45 C.F.R. Part 88 in effect as of June 30, 2022, all of which shall apply to patients, health care providers, and purchasers or recipients of state health plans.
Added by 2022 Ga. Laws 587,§ 1-4, eff. 7/1/2022.