Connecticut

The sections of the state insurance law related to parity will change on January 1, 2016. Here is what you will find below, in separate parts:

• A summary of the current sections of the law
• A summary of how the law will be different on January 1, 2016
• A summary of the current sections of the insurance law about autism coverage
• A summary of how the sections of the insurance law about autism coverage will change on January 1, 2016

There are two sections of the insurance law related to parity. One section is for individual plans, and another section is for small employer fully-insured plans and large employer fully-insured plans. Both sections are identical except for the wording about to which kind of insurance plan they apply.

These sections of the law require insurance plans to cover all behavioral health conditions that are in the Diagnostic and Statistical Manual of Mental Disorders (DSM) except for the following:

(1) Intellectual disabilities

(2) Specific learning disorders

(3) Motor disorders

(4) Communication disorders

(5) Caffeine-related disorders

(6) Relational problems

(7) Other conditions that may be a focus of clinical attention, but are not in the DSM

These sections of the law also state that they do not apply to autism and that insurance plans are required to comply with the sections of the law about autism coverage (summarized below).

Insurance plans are forbidden from using “any terms, conditions or benefits that place a greater financial burden” on plan enrollees for behavioral health coverage than they do for other medical coverage.

Insurance plans are required to cover services from the following list of providers:

1. Psychologists
2. Licensed clinical social workers
3. Independent social workers
4. Licensed marital and family therapists
5. Licensed or certified alcohol and drug counselors
6. Licensed professional counselor

Insurance plans are required to cover services in the following treatment facilities:

1. Child guidance clinics
2. Residential treatment facilities
3. Non-profit community mental health center
4. Adult psychiatric clinic

Insurance plans are required to cover residential treatment if a provider does not think the patient can be treated safely by a lesser form of treatment.

The parity sections of the insurance law will change beginning in January 2016 because of SB 1085 (pdf | Get Adobe® Reader®) that was signed by the Governor on 6/30, 2015. (However, SB 1502 slightly amended some of the provisions of SB 1085; the relevant sections are sections 43-46) Here is how the law will be different:

• There is no longer any language stating that these sections do not apply to people diagnosed with autism spectrum disorders.
• There is language that further defines “benefits payable” as “usual, customary, and reasonable charges for treatment deemed medically necessary under generally accepted medical standards.”
• It defines “acute treatment services” as “twenty-four-hour medically supervised treatment for a substance use disorder , that is provided in a medically managed or medically monitored inpatient facility”
• It defines “clinical stabilization services” as “twenty-four-hour clinically managed post-detoxification treatment, including, but not limited to, relapse prevention, family outreach, aftercare planning and addiction education and counseling.”
• It updates the wording to reflect the appropriate title of the treatment criteria from the American Society of Addiction Medicine
• It specifically mentions 25 forms of treatment that now must be covered by insurance plans:

(1) General inpatient hospitalization, including at state-operated facilities

(2) Medically necessary acute treatment services and medically necessary clinical stabilization services

(3) General hospital outpatient services , including at state-operated facilities

(4) Psychiatric inpatient hospitalization, including in state-operated facilities

(5) Psychiatric outpatient hospital services, including at state-operated facilities

(6) Intensive outpatient services, including at state-operated facilities

(7) Partial hospitalization , including at state-operated facilities

(8) Evidence-based maternal, infant and early childhood home visitation services, as described in Section 2951 of the Affordable Care Act

(9) Intensive, home-based services designed to address specific mental health conditions in a child

(10) Evidence-based family-focused therapy that specializes in the treatment of juvenile substance use disorders

(11) Short-term family therapy intervention

(12) Non-hospital inpatient detoxification

(13) Medically monitored detoxification

(14) Ambulatory detoxification

(15) Inpatient services at psychiatric residential treatment facilities

(16) Rehabilitation services provided in residential treatment facilities, general hospitals, psychiatric hospitals or psychiatric facilities

(17) Observation beds in acute hospital settings

(18) Psychological and neuropsychological testing conducted by an appropriately licensed health care provider

(19) Trauma screening conducted by a licensed behavioral health professional

(20) Depression screening, including maternal depression screening, conducted by a licensed behavioral health professional

(21) Substance use screening conducted by a licensed behavioral health professional

(22) Intensive, family-based and community-based treatment programs that focus on addressing environmental systems that impact chronic and violent juvenile offenders (not in effect until 1/2017)

(23) Other home-based therapeutic interventions for children (not in effect until 1/2017)

(24) Chemical maintenance treatment (not in effect until 1/2017)

(25) Extended day treatment programs (not in effect until 1/2017)

• Requires insurance plans to cover multiple screening tests as part of one visit
• Requires insurance plans to cover services performed by an advance practice registered nurse
• Requires the Insurance Commissioner and the Office of the Healthcare Advocate to create a working group comprised of insurance company representatives, behavioral health providers, and consumers of behavioral health services. This group will give recommendations to the Insurance Commissioner and the Office of the Healthcare Advocate to improve the utilization review process
• Requires the Insurance Commissioner to convene a working group to develop recommendations for collecting behavioral health data from state agencies and insurers for the purposes of “protecting behavioral health parity for youths and other populations”. The recommendations were to address:

1. Coverage for behavioral health services
2. The adequacy of coverage for behavioral health conditions, including, but not limited to, autism spectrum disorders and substance use disorders
3. The alignment of medical necessity criteria and utilization management
4. The adequacy of health care provider networks
5. The overall availability of behavioral health care providers in this state
6. The percentage of behavioral health care providers in this state that are participating providers in various plans
7. The adequacy of services available for behavioral health conditions, including, but not limited to, autism spectrum disorders and substance use disorders

There are two sections of the insurance law about coverage for autism. One section is for individual plans and another section is for small employer fully-insured plans and large employer fully-insured plans.

The one for individual plans is very brief. It only requires insurance plans to cover physical therapy, speech therapy and occupational therapy “to the extent such services are a covered benefit for other diseases and conditions.”

The section for small employer plans and large employer plans is much more detailed.

It requires plans to cover autism and defines autism spectrum disorder as pervasive developmental disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), including but not limited to:

1. Autistic disorder
2. Asperger’s disorder
3. Rhett’s disorder
4. Childhood disintegrative disorder
5. Pervasive developmental disorder not otherwise specified

It requires plans to cover the following treatments:

1. Behavioral therapy (includes applied behavior analysis)
2. Prescription drugs
3. Psychiatric therapy
4. Psychological therapy
5. Physical therapy
6. Occupational therapy
7. Speech and language pathology services

It requires plans to cover these treatments from the following providers:

1. Physician (psychiatrist)
2. Psychologist
3. Licensed clinical social worker

It requires insurance plans to have annual maximums that are at least the following:

1. $50,000 for children under 9
2. $36,000 for children 9-12
3. $25,000 for children 13 and 14

Financial requirements must be the same as what they are for other medical services.

Insurance plans are not allowed to limit outpatient visits unless it is because a medical necessity review determines that visits may be limited.

Insurance plans can only use utilization review once every 6 months.

The autism sections of the insurance law will change beginning in January 2016 because of SB 1502 Here is how the law will be different:

• The section for individual plans will mirror the one for large employer fully-insured plans and small employer fully-insured plans
• Simplifies the definition of autism spectrum disorder to the definition “most recent edition of the American Psychiatric Association’s ”Diagnostic and Statistical Manual of Mental Disorders “
• Extends coverage through age 20
• Eliminates annual maximums