Market Conduct Examination of Health Insurance Carrier for Compliance With Coverage Requirements for Mental Health or Alcoholism or Drug Dependency Services
Market Conduct Examination of Health Insurance Carrier for Compliance With Coverage Requirements for Mental Health or Alcoholism or Drug Dependency Services
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Whenever the commissioner performs a market conduct examination of a health insurance carrier that issues a health benefit plan under the jurisdiction of the department of commerce and insurance for compliance with § 56-7-2360, the examination shall include, but not be limited to, the following information:
A description of the process used to develop or select the medical necessity criteria for mental health or alcoholism or drug dependency benefits and the process used to develop or select the medical necessity criteria for medical and surgical benefits;
Identification of all non-quantitative treatment limitations (NQTLs) that are applied to both mental health or alcoholism or drug dependency benefits and medical and surgical benefits; and
The results of any analysis that may have been performed by a health insurance carrier that demonstrates that for the medical necessity criteria described in subdivision (a)(1) and for each NQTL identified in subdivision (a)(2), as written and in operation, the processes, strategies, evidentiary standards, or other factors used to apply the medical necessity criteria and each NQTL to mental health or alcoholism or drug dependency benefits are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used to apply the medical necessity criteria and each NQTL, as written and in operation, to medical and surgical benefits. The results of the analysis may:
Identify the factors used to determine that an NQTL will apply to a benefit, including factors that were considered but rejected;
Identify and define the specific evidentiary standards used to define the factors and any other evidentiary standards relied upon in designing each NQTL;
Identify and describe the methods and analyses used, including the results of any relevant analyses, to determine that the processes and strategies used to design each NQTL as written for mental health or alcoholism or drug dependency benefits are comparable to, and no more stringent than, the processes and strategies used to design each NQTL as written for medical and surgical benefits;
Identify and describe the methods and analyses used, including the results of any relevant analyses, to determine that processes and strategies used to apply each NQTL in operation for mental health or alcoholism or drug dependency benefits are comparable to, and no more stringent than, the processes or strategies used to apply each NQTL in operation for medical and surgical benefits;
Disclose the specific findings and conclusions reached by the health insurance carrier that the results of any relevant analyses under this subsection indicate that the health insurance carrier is in compliance with this section and the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) (Pub.L. No. 110-343), and its implementing regulations, including 45 CFR 146.136 and any other applicable regulations; and
Identify any other information necessary to clarify data provided in accordance with this section requested by the commissioner, including information that may be “proprietary” or have “commercial value.” Any information submitted that is proprietary shall not be made a public record under title 10, chapter 7.
The health insurance carrier's chief executive officer and chief medical officer shall sign a certification that affirms that the health insurance carrier has completed a comprehensive review of its administrative practices for the prior calendar year for compliance with the necessary provisions of this section and §§ 56-7-2601 and 56-7-2602, and the MHPAEA.
Separate NQTLs that apply to mental health or alcohol or drug dependency benefits but do not apply to medical and surgical benefits within any classification of benefits are not permitted.