2023 Vermont Statutes › Title 8 - Banking and Insurance › Chapter 107 - Health Insurance › § 4089b. Health insurance coverage, mental health, and substance use disorder

§ 4089b. Health insurance coverage, mental health, and substance use disorder
(a) It is the goal of the General Assembly that treatment for mental conditions be recognized as an integral component of health care, that health insurance plans cover all necessary and appropriate medical services without imposing practices that create barriers to receiving appropriate care, and that integration of health care be recognized as the standard for care in this State.
(b) As used in this section:
(1) “Health insurance plan” means any health insurance policy or health benefit plan offered by a health insurer, as defined in 18 V.S.A. § 9402, except a benefit plan providing coverage for a specific disease or other limited benefit coverage. Health insurance plan includes any health benefit plan offered or administered by the State, or any subdivision or instrumentality of the State.
(2) “Mental condition” means any condition or disorder involving psychiatric disabilities or alcohol or substance use that falls under any of the diagnostic categories listed in the mental disorders section of the International Classification of Diseases, as periodically revised.
(3) “Rate, term, or condition” means any lifetime or annual payment limits, deductibles, copayments, coinsurance, and any other cost-sharing requirements, out-of-pocket limits, visit limits, and any other financial component of health insurance coverage that affects the insured.
(c) A health insurance plan shall provide coverage for treatment of a mental condition and shall:
(1) not establish any rate, term, or condition that places a greater burden on an insured for access to treatment for a mental condition than for access to treatment for other health conditions, including no greater co-payment for primary mental health care or services than the co-payment applicable to care or services provided by a primary care provider under an insured’s policy and no greater co-payment for specialty mental health care or services than the co-payment applicable to care or services provided by a specialist provider under an insured’s policy;
(2) not exclude from its network or list of authorized providers any licensed mental health or substance abuse provider located within the geographic coverage area of the health benefit plan if the provider is willing to meet the terms and conditions for participation established by the health insurer;
(3) make any deductible or out-of-pocket limits required under a health insurance plan comprehensive for coverage of both mental and physical health conditions; and
(4) if the plan provides prescription drug coverage, ensure that at least one medication from each drug class approved by the U.S. Food and Drug Administration for the treatment of substance use disorder is available on the lowest cost-sharing tier of the plan’s prescription drug formulary.
(d)(1)(A) A health insurance plan that does not otherwise provide for management of care under the plan, or that does not provide for the same degree of management of care for all health conditions, may provide coverage for treatment of mental conditions through a managed care organization, provided that the managed care organization is in compliance with the rules adopted by the Commissioner that ensure that the system for delivery of treatment for mental conditions does not diminish or negate the purpose of this section. In reviewing rates and forms pursuant to section 4062 of this title, the Commissioner or the Green Mountain Care Board established in 18 V.S.A. chapter 220, as appropriate, shall consider the compliance of the policy with the provisions of this section.
(B) The rules adopted by the Commissioner shall ensure that:
(i) timely and appropriate access to care is available;
(ii) the quantity, location, and specialty distribution of health care providers is adequate;
(iii) administrative or clinical protocols do not serve to reduce access to medically necessary treatment for any insured;
(iv) utilization review and other administrative and clinical protocols do not deter timely and appropriate care, including emergency hospital admissions;
(v) in the case of a managed care organization that contracts with a health insurer to administer the insurer’s mental health benefits, the portion of a health insurer’s premium rate attributable to the coverage of mental health benefits is reviewed under section 4062, 4513, 4584, or 5104 of this title to determine whether it is excessive, inadequate, unfairly discriminatory, unjust, unfair, inequitable, misleading, or contrary to the laws of this State;
(vi) the health insurance plan is consistent with the Blueprint for Health with respect to mental conditions, as determined by the Commissioner under 18 V.S.A. § 9414(b)(2);
(vii) a quality improvement project is completed annually as a joint project between the health insurance plan and its mental health managed care organization to implement policies and incentives to increase collaboration among providers that will facilitate clinical integration of services for medical and mental conditions, including:
(I) evidence of how data collected from the quality improvement project are being used to inform the practices, policies, and future direction of care management programs for mental conditions; and
(II) demonstration of how the quality improvement project is supporting the incorporation of best practices and evidence-based guidelines into the utilization review of mental conditions;
(viii) an up-to-date list of active mental health care providers in the plan’s network who are available to the general membership is available on the health insurer’s and managed care organization’s websites and provided to consumers upon request; and
(ix) the health insurers and managed care organizations make accessible to consumers the toll-free telephone number for the Vermont Health Care Administration’s consumer protection help line.
(C) Prior to the adoption of rules pursuant to this subdivision, the Commissioner shall consult with the Commissioner of Mental Health and the task force established pursuant to subsection (h) of this section concerning:
(i) developing incentives and other measures addressing the availability of providers of care and treatment for mental conditions, especially in medically underserved areas;
(ii) incorporating nationally recognized best practices and evidence-based guidelines into the utilization review of mental conditions; and
(iii) establishing benefit design, infrastructure support, and payment methodology standards for evaluating the health insurance plan’s consistency with the Blueprint for Health with respect to the care and treatment of mental conditions.
(2) A managed care organization providing or administering coverage for treatment of mental conditions on behalf of a health insurance plan shall comply with this section, sections 4089a and 4724 of this title, and 18 V.S.A. § 9414, with rules adopted pursuant to those provisions of law, and with all other obligations, under Title 18 and under this title, of the health insurance plan and the health insurer on behalf of which the review agent is providing or administering coverage. A violation of any provision of this section shall constitute an unfair act or practice in the business of insurance in violation of section 4723 of this title.
(3) A health insurer that contracts with a managed care organization to provide or administer coverage for treatment of mental conditions is fully responsible for the acts and omissions of the managed care organization, including any violations of this section or a rule adopted pursuant to this section.
(4) In addition to any other remedy or sanction provided for by law, if the Commissioner, after notice and an opportunity to be heard, finds that a health insurance plan or managed care organization has violated this section or any rule adopted pursuant to this section, the Commissioner may:
(A) assess a penalty on the health insurer or managed care organization under section 4726 of this title;
(B) order the health insurer or managed care organization to cease and desist in further violations;
(C) order the health insurer or managed care organization to remediate the violation, including issuing an order to the health insurer to terminate its contract with the managed care organization; and
(D) revoke or suspend the license of a health insurer or managed care organization, or permit continued licensure subject to such conditions as the Commissioner deems necessary to carry out the purposes of this section.
(5) As used in this subsection, the term “managed care organization” includes any of the following entities that provide or administer the coverage of mental health benefits on behalf of a health insurance plan:
(A) a review agent as defined in section 4089a of this title;
(B) a health insurer or an affiliate of a health insurer as defined in 18 V.S.A. § 9402;
(C) a managed care organization or an affiliate of a managed care organization as defined in 18 V.S.A. § 9402; and
(D) a person or entity that should be licensed as a managed care organization.
(e) [Repealed.]
(f) To be eligible for coverage under this section, the service shall be rendered:
(1) For treatment of a mental condition:
(A) by a licensed or certified mental health professional; or
(B) in a mental health facility qualified pursuant to rules adopted by the Secretary of Human Services or in an institution, approved by the Secretary of Human Services, that provides a program for the treatment of a mental condition pursuant to a written plan. A nonprofit hospital or medical service corporation may require a mental health facility or licensed or certified mental health professional to enter into a contract as a condition of providing benefits.
(2) For treatment of alcohol or substance abuse:
(A) by a substance abuse counselor or other person approved by the Secretary of Human Services based on rules adopted by the Secretary that establish standards and criteria for determining eligibility under this subdivision; or
(B) in an institution, approved by the Secretary of Human Services, that provides a program for the treatment of alcohol or substance dependency pursuant to a written plan.
(g), (h) [Repealed.] (Added 1997, No. 25, §§ 2, 4, 6; amended 1999, No. 129 (Adj. Sess.), § 1; 2001, No. 32, § 1; 2001, No. 76 (Adj. Sess.), § 1, eff. March 15, 2002; 2003, No. 29, § 1; 2005, No. 129 (Adj. Sess.), § 1; 2007, No. 142 (Adj. Sess.), § 1, eff. May 14, 2008; 2009, No. 33, § 17; 2009, No. 128 (Adj. Sess.), § 30; 2009, No. 137 (Adj. Sess.), § 26a; 2009, No. 156 (Adj. Sess.), § I.13; 2011, No. 78 (Adj. Sess.), § 2, eff. April 2, 2012; 2011, No. 78 (Adj. Sess.), § 31, eff. April 2, 2012; 2011, No. 171 (Adj. Sess.), § 11d, eff. Jan. 1, 2014; 2011, No. 171 (Adj. Sess.), § 41(a); 2013, No. 79, § 5e, eff. Jan. 1, 2014; 2013, No. 96 (Adj. Sess.), § 19; 2015, No. 54, § 32; 2019, No. 43, § 1, eff. Jan. 1, 2020.)