2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31E - Health Benefits Plans Behavioral Health Parity › § 31–3175.03. Reporting requirements

§ 31–3175.03. Reporting requirements.
(a) Beginning October 1, 2019, and on an annual basis thereafter, health insurers shall submit a report to the Department containing the following information:
(1)(A) The frequency with which the health insurers health benefits plan required:
(i) Prior authorization for all prescribed procedures, services, or medications for mental health condition and substance use disorder benefits during the prior calendar year; and
(ii) Prior authorization for all prescribed procedures, services, or medications for medical and surgical benefits during the prior calendar year.
(B) Health insurers shall submit the information required pursuant to paragraph (1)(A) of this subsection separately for inpatient in-network benefits, inpatient out of-network benefits, outpatient in-network benefits, inpatient out-of-network benefits, outpatient in-network benefits, outpatient out-of-network benefits, emergency care benefits, and prescription drug benefits. Frequency shall be expressed as a percentage, with the total prescribed procedures, services, or medications within each classification of benefits as the denominator and the overall number of times prior authorization was required for any prescribed procedures, services, or medications within each corresponding classification of benefits as the numerator.
(2) A description of the process used to develop and select medical necessity criteria for mental health condition and substance use disorder benefits;
(3) An identification of all non-quantitative treatment limitations that are applied to benefits provided for mental health conditions and substance use disorders;
(4) An analysis of the medical necessity criteria described in paragraph (2) of this subsection, and each non-quantitative treatment limitation identified pursuant to paragraph (3) of this subsection, that shall include:
(A) An identification of the factors used to determine whether a non-quantitative treatment limitation shall apply to the provision of a benefit, including any factors that were considered but rejected;
(B) An identification of the specific evidentiary standards that were relied upon and used to design any non-quantitative treatment limitations;
(C) An identification and description of the methodology used to determine that the processes and strategies used to design each non-quantitative treatment limitation, as written, for mental health condition and substance use disorder benefits are comparable to and no more stringent than the processes and strategies used to design each non-quantitative treatment limitation, as written, for medical and surgical benefits;
(D) An identification and description of the methodology used to determine that the processes and strategies used to apply each non-quantitative treatment limitation, in operation, for mental health condition and substance use disorder benefits are comparable to and no more stringent than the processes or strategies used to apply each non-quantitative treatment limitation, in operation, for medical and surgical benefits; and
(E) A disclosure of the specific findings and conclusions reached by the health insurer indicating that it is in compliance with the requirements of this chapter.
(5) The rates of, and reasons for, denial of claims for inpatient in-network, inpatient out-of-network, outpatient in-network, outpatient out-of-network, prescription drugs, and emergency care mental health condition and substance use disorder benefits during the prior calendar year, compared to the rates of and reasons for denial of claims in those same classifications of benefits for medical and surgical services during the prior calendar year;
(6) A certification that the health insurer has completed a comprehensive review of the administrative practices of its health benefits plan for the prior calendar year to verify compliance with the requirements of this chapter; and
(7) Any other information requested by the Commissioner of the Department.
(b) By October 1, 2019, and annually thereafter, the Department shall issue a report to the Council in non-technical, readily understandable language, that shall:
(1) Specify the methodologies used by the Department to verify compliance with the requirements of this chapter;
(2) Identify the market conduct examinations conducted by the Department during the preceding year, including:
(A) The number of market conduct examinations initiated and completed;
(B) The benefit classifications assessed by each market conduct examination;
(C) The subject matter of each market conduct examination; and
(D) A summary of the basis for the final decision rendered in each market conduct examination;
(3) A description of any educational or corrective actions the Department took to ensure health insurer compliance with the requirements of this chapter; and
(4) A description of the Department's efforts to educate the public regarding mental health condition and substance use disorder protections under MHPAEA and this chapter.
(Mar. 13, 2019, D.C. Law 22-242, § 4, 66 DCR 930.)