H 4896

SECTION 1. Section 18 of chapter 15A of the General Laws, as appearing in the 2022 Official Edition, is hereby amended by adding the following paragraph:- Notwithstanding any general or special law to the contrary, any qualifying student health insurance plan authorized under this chapter shall provide coverage for coordinated specialty care services and assertive community treatment service as described under section 4FF of chapter 176G. SECTION 2. Chapter 32A of the General Laws is hereby amended by adding the following section:- Section 35. (a) For the purposes of this section, the following words shall have the following meanings unless the context clearly requires otherwise: “Assertive Community Treatment”, a team-based, evidenced-based treatment practice that offers treatment, rehabilitation, and support services, using a person-centered, recovery-based flexible treatment program, as defined by evidence-based standards, including, but not limited to, the most current guidelines issued by the federal Substance Abuse and Mental Health Services Administration. Practice may also include those modalities specifically designed for pediatric patients under the age of 19 that have been adapted from guidelines issued by the federal Substance Abuse and Mental Health Services Administration or the National Institute of Health. “Behavioral health services”, care and services for the evaluation, diagnosis, treatment or management of patients with mental health, developmental or substance use disorders.  “Coordinated Specialty Care”,  a recovery-oriented treatment program for people with first-episode psychosis,  as defined by evidence-based standards, including, but not limited to the most current guidelines issued by the  National Institute of Mental Health. Programs may also include those specifically designed for pediatric patients under the age of 19 that have been adapted from guidelines issued by the federal Substance Abuse and Mental Health Services Administration or the National Institute of Mental Health. “Evidence-based practice”, treatments that are supported by clinical research, including, but not limited to, research supporting practice modifications relevant to the treatment of pediatric patients. “First episode psychosis treatment”, treatment initiated within 74 weeks of the first time an individual experiences an episode of psychosis. “Serious emotional disturbance”, mental, behavioral or emotional disorders in children or adolescents under age 19 that have resulted in functional impairment that substantially interferes with or limits the child’s role or functioning in family, school or community activities.   “Serious mental illness”, mental, behavioral or emotional disorders resulting in serious functional impairment that substantially interferes with or limits at least 1 major life activity for an individual not less than 19 years old with a psychiatric diagnosis as defined in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. (b) Coverage offered by the commission to an active or retired employee of the commonwealth insured under the group insurance commission shall provide coverage for wrap-around coordinated specialty care services for first episode psychosis treatment and assertive community treatment for early or ongoing treatment of a person with a previous episode of psychosis who has a serious mental illness or serious emotional disturbance. Coverage under this section shall not be construed as imposing a limit on the number of visits an individual may make to a provider of any of the services under this section. (c) Payment for the services performed under the treatment models listed in this section shall be based on a bundled treatment model or payment, rather than fee-for-service payment for each separate service delivered by a treatment team member. (d) To determine medical necessity for the treatment approaches under this section, neither disability nor functional impairment shall be a precondition to receive the treatment. Medical necessity shall be presumed following a recommendation by a licensed physician, licensed clinical psychologist, licensed professional clinical counselor or licensed clinical social worker. SECTION 3. Chapter 112 of the General Laws is hereby amended by inserting after section 9K the following section:- Section 9L. To credential the mental health professionals and other members of the multidisciplinary coordinated specialty care treatment team or an assertive community treatment team as described under section 32 of chapter 32A, section 39 of chapter 176A, section 26 of chapter 176B, section 34 of chapter 176G and section 14 of chapter 176I, the credentialing of the psychiatrist or the licensed clinical leader of the treatment team shall qualify all members of the treatment team to be credentialed with the insurer.  SECTION 4. Chapter 175 of the General Laws is hereby amended by inserting before section 47CCC the following section:- Section 47AAA. (a) For the purposes of this section, the following words shall have the following meanings unless the context clearly requires otherwise: “Assertive Community Treatment”, a team-based, evidenced-based treatment practice that offers treatment, rehabilitation, and support services, using a person-centered, recovery-based flexible treatment program, as defined by evidence-based standards, including, but not limited to, the most current guidelines issued by the federal Substance Abuse and Mental Health Services Administration. Practice may also include those modalities specifically designed for pediatric patients under the age of 19 that have been adapted from guidelines issued by the federal Substance Abuse and Mental Health Services Administration or the National Institute of Health. “Behavioral health services”, care and services for the evaluation, diagnosis, treatment or management of patients with mental health, developmental or substance use disorders.  “Coordinated Specialty Care”, a recovery-oriented treatment program for people with first-episode psychosis, as defined by evidence-based standards, including, but not limited to the most current guidelines issued by the National Institute of Mental Health. Programs may also include those specifically designed for pediatric patients under the age of 19 that have been adapted from guidelines issued by the federal Substance Abuse and Mental Health Services Administration or the National Institute of Mental Health. “Evidence-based practice”, treatments that are supported by clinical research, including, but not limited to, research supporting practice modifications relevant to the treatment of pediatric patients. “First episode psychosis treatment”, treatment initiated within 74 weeks of the first time an individual experiences an episode of psychosis. “Serious emotional disturbance”, mental, behavioral or emotional disorders in children or adolescents under age 19 that have resulted in functional impairment that substantially interferes with or limits the child’s role or functioning in family, school or community activities.   “Serious mental illness”, mental, behavioral or emotional disorders resulting in serious functional impairment that substantially interferes with or limits at least 1 major life activity for an individual not less than 19 years old with a psychiatric diagnosis as defined in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. (b) An individual policy of accident and sickness insurance issued under section 108 that provides hospital expense and surgical expense insurance and any group blanket or general policy of accident and sickness insurance issued under section 110 that provides hospital expense and surgical expense insurance that is issued or renewed within or without the commonwealth shall provide coverage for wrap-around coordinated specialty care services for first episode psychosis treatment and assertive community treatment for early or ongoing treatment of person with a previous episode of psychosis who has a serious mental illness or serious emotional disturbance. Coverage under this section shall not be construed as imposing a limit on the number of visits an individual may make to a provider of any of the services under this section. (c) Payment for the services performed under the treatment models listed in this section shall be based on a bundled treatment model or payment, rather than fee-for-service payment for each separate service delivered by a treatment team member. (d) To determine medical necessity for the treatment approaches under this section, neither disability nor functional impairment shall be a precondition to receive the treatment. Medical necessity shall be presumed following a recommendation by a licensed physician, licensed clinical psychologist, licensed professional clinical counselor or licensed clinical social worker. SECTION 5. Chapter 176A of the General Laws is hereby amended by adding the following section:- Section 39. (a) For the purposes of this section, the following words shall have the following meanings unless the context clearly requires otherwise: “Assertive Community Treatment”, a team-based, evidenced-based treatment practice that offers treatment, rehabilitation, and support services, using a person-centered, recovery-based flexible treatment program, as defined by evidence-based standards, including, but not limited to, the most current guidelines issued by the federal Substance Abuse and Mental Health Services Administration. Practice may also include those modalities specifically designed for pediatric patients under the age of 19 that have been adapted from guidelines issued by the federal Substance Abuse and Mental Health Services Administration or the National Institute of Health. “Behavioral health services”, care and services for the evaluation, diagnosis, treatment or management of patients with mental health, developmental or substance use disorders.  “Coordinated Specialty Care”, a recovery-oriented treatment program for people with first-episode psychosis, as defined by evidence-based standards, including, but not limited to the most current guidelines issued by the National Institute of Mental Health. Programs may also include those specifically designed for pediatric patients under the age of 19 that have been adapted from guidelines issued by the federal Substance Abuse and Mental Health Services Administration or the National Institute of Mental Health. “Evidence-based practice”, treatments that are supported by clinical research, including, but not limited to, research supporting practice modifications relevant to the treatment of pediatric patients. “First episode psychosis treatment”, treatment initiated within 74 weeks of the first time an individual experiences an episode of psychosis. “Serious emotional disturbance”, mental, behavioral or emotional disorders in children or adolescents under age 19 that have resulted in functional impairment that substantially interferes with or limits the child’s role or functioning in family, school or community activities.   “Serious mental illness”, mental, behavioral or emotional disorders resulting in serious functional impairment that substantially interferes with or limits at least 1 major life activity for an individual not less than 19 years old with a psychiatric diagnosis as defined in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. (b) A contract between a subscriber and a nonprofit hospital service corporation under an individual or group hospital service plan shall provide coverage for wrap-around coordinated specialty care services for first-episode psychosis treatment and assertive community treatment for early or ongoing treatment of person with a previous episode of psychosis who has a serious mental illness or serious emotional disturbance. Coverage under this section shall not be construed as imposing a limit on the number of visits an individual may make to a provider of any of the services under this section. (c) Payment for the services performed under the treatment models listed in this section shall be based on a bundled treatment model or payment, rather than fee for service payment for each separate service delivered by a treatment team member. (d) To determine medical necessity for the treatment approaches under this section, neither disability nor functional impairment shall be a precondition to receive the treatment. Medical necessity shall be presumed following a recommendation by a licensed physician, licensed clinical psychologist, licensed professional clinical counselor or licensed clinical social worker. SECTION 6. Chapter 176B of the General Laws is hereby amended by adding the following section:- Section 26. (a) For the purposes of this section, the following words shall have the following meanings unless the context clearly requires otherwise: “Assertive Community Treatment”, a team-based, evidenced-based treatment practice that offers treatment, rehabilitation, and support services, using a person-centered, recovery-based flexible treatment program, as defined by evidence-based standards, including, but not limited to, the most current guidelines issued by the federal Substance Abuse and Mental Health Services Administration. Practice may also include those modalities specifically designed for pediatric patients under the age of 19 that have been adapted from guidelines issued by the federal Substance Abuse and Mental Health Services Administration or the National Institute of Health. “Behavioral health services”, care and services for the evaluation, diagnosis, treatment or management of patients with mental health, developmental or substance use disorders.  “Coordinated Specialty Care”, a recovery-oriented treatment program for people with first-episode psychosis, as defined by evidence-based standards, including, but not limited to the most current guidelines issued by the National Institute of Mental Health. Programs may also include those specifically designed for pediatric patients under the age of 19 that have been adapted from guidelines issued by the federal Substance Abuse and Mental Health Services Administration or the National Institute of Mental Health. “Evidence-based practice”, treatments that are supported by clinical research, including, but not limited to, research supporting practice modifications relevant to the treatment of pediatric patients. “First episode psychosis treatment”, treatment initiated within 74 weeks of the first time an individual experiences an episode of psychosis. “Serious emotional disturbance”, mental, behavioral or emotional disorders in children or adolescents under age 19 that have resulted in functional impairment that substantially interferes with or limits the child’s role or functioning in family, school or community activities.   “Serious mental illness”, mental, behavioral or emotional disorders resulting in serious functional impairment that substantially interferes with or limits at least 1 major life activity for an individual not less than 19 years old with a psychiatric diagnosis as defined in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. (b) A contract between a subscriber and a medical service corporation shall provide coverage for wrap-around coordinated specialty care services for first episode psychosis treatment and assertive community treatment for early or ongoing treatment of person with a previous episode of psychosis who has a serious mental illness or serious emotional disturbance. Coverage under this section shall not be construed as imposing a limit on the number of visits an individual may make to a provider of any of the services under this section. (c) Payment for the services performed under the treatment models listed in this section shall be based on a bundled treatment model or payment, rather than fee for service payment for each separate service delivered by a treatment team member. (d) To determine medical necessity for the treatment approaches under this section, neither disability nor functional impairment shall be a precondition to receive the treatment. Medical necessity shall be presumed following a recommendation by a licensed physician, licensed clinical psychologist, licensed professional clinical counselor or licensed clinical social worker. SECTION 7. Chapter 176G of the General Laws is hereby amended by adding the following section:- Section 34. (a) For the purposes of this section, the following words shall have the following meanings unless the context clearly requires otherwise: “Assertive Community Treatment”, a team-based, evidenced-based treatment practice that offers treatment, rehabilitation, and support services, using a person-centered, recovery-based flexible treatment program, as defined by evidence-based standards, including, but not limited to, the most current guidelines issued by the federal Substance Abuse and Mental Health Services Administration. Practice may also include those modalities specifically designed for pediatric patients under the age of 19 that have been adapted from guidelines issued by the federal Substance Abuse and Mental Health Services Administration or the National Institute of Health. “Behavioral health services”, care and services for the evaluation, diagnosis, treatment or management of patients with mental health, developmental or substance use disorders.  “Coordinated Specialty Care”, a recovery-oriented treatment program for people with first-episode psychosis, as defined by evidence-based standards, including, but not limited to the most current guidelines issued by the National Institute of Mental Health. Programs may also include those specifically designed for pediatric patients under the age of 19 that have been adapted from guidelines issued by the federal Substance Abuse and Mental Health Services Administration or the National Institute of Mental Health. “Evidence-based practice”, treatments that are supported by clinical research, including, but not limited to, research supporting practice modifications relevant to the treatment of pediatric patients. “First episode psychosis treatment”, treatment initiated within 74 weeks of the first time an individual experiences an episode of psychosis. “Serious emotional disturbance”, mental, behavioral or emotional disorders in children or adolescents under age 19 that have resulted in functional impairment that substantially interferes with or limits the child’s role or functioning in family, school or community activities.   “Serious mental illness”, mental, behavioral or emotional disorders resulting in serious functional impairment that substantially interferes with or limits at least 1 major life activity for an individual not less than 19 years old with a psychiatric diagnosis as defined in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. (b) A contract between a member and a health maintenance organization shall provide coverage for wrap-around coordinated specialty care services for first episode psychosis treatment and assertive community treatment for early or ongoing treatment of person with a previous episode of psychosis who has a serious mental illness or serious emotional disturbance. Coverage under this section shall not be construed as imposing a limit on the number of visits an individual may make to a provider of any of the services under this section. (c) Payment for the services performed under the treatment models listed in this section shall be based on a bundled treatment model or payment, rather than fee for service payment for each separate service delivered by a treatment team member. (d) To determine medical necessity for the treatment approaches under this section, neither disability nor functional impairment shall be a precondition to receive the treatment. Medical necessity shall be presumed following a recommendation by a licensed physician, licensed clinical psychologist, licensed professional clinical counselor or licensed clinical social worker. SECTION 8. Chapter 176I of the General Laws is hereby amended by adding the following section:- Section 14. (a) For the purposes of this section, the following words shall have the following meanings unless the context clearly requires otherwise: “Assertive Community Treatment”, a team-based, evidenced-based treatment practice that offers treatment, rehabilitation, and support services, using a person-centered, recovery-based flexible treatment program, as defined by evidence-based standards, including, but not limited to, the most current guidelines issued by the federal Substance Abuse and Mental Health Services Administration. Practice may also include those modalities specifically designed for pediatric patients under the age of 19 that have been adapted from guidelines issued by the federal Substance Abuse and Mental Health Services Administration or the National Institute of Health. “Behavioral health services”, care and services for the evaluation, diagnosis, treatment or management of patients with mental health, developmental or substance use disorders.  “Coordinated Specialty Care”, a recovery-oriented treatment program for people with first-episode psychosis, as defined by evidence-based standards, including, but not limited to the most current guidelines issued by the National Institute of Mental Health. Programs may also include those specifically designed for pediatric patients under the age of 19 that have been adapted from guidelines issued by the federal Substance Abuse and Mental Health Services Administration or the National Institute of Mental Health. “Evidence-based practice”, treatments that are supported by clinical research, including, but not limited to, research supporting practice modifications relevant to the treatment of pediatric patients. “First episode psychosis treatment”, treatment initiated within 74 weeks of the first time an individual experiences an episode of psychosis. “Serious emotional disturbance”, mental, behavioral or emotional disorders in children or adolescents under age 19 that have resulted in functional impairment that substantially interferes with or limits the child’s role or functioning in family, school or community activities.   “Serious mental illness”, mental, behavioral or emotional disorders resulting in serious functional impairment that substantially interferes with or limits at least 1 major life activity for an individual not less than 19 years old with a psychiatric diagnosis as defined in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. (b) A preferred provider contract between a covered person and an organization shall provide coverage for wrap-around coordinated specialty care services for first episode psychosis treatment and assertive community treatment for early or ongoing treatment of person with a previous episode of psychosis who has a serious mental illness or serious emotional disturbance. Coverage under this section shall not be construed as imposing a limit on the number of visits an individual may make to a provider of any of the services under this section. (c) Payment for the services performed under the treatment models listed in this section shall be based on a bundled treatment model or payment, rather than fee for service payment for each separate service delivered by a treatment team member. (d) To determine medical necessity for the treatment approaches under this section, neither disability nor functional impairment shall be a precondition to receive the treatment. Medical necessity shall be presumed following a recommendation by a licensed physician, licensed clinical psychologist, licensed professional clinical counselor or licensed clinical social worker. SECTION 9. Not later than 6 months after the effective date of this act, the division of insurance shall convene a working group of insurance companies and mental health treatment providers that deliver the bundled treatment approaches listed in section 35 of chapter 32A, section 47AAA of chapter 175, section 39 of chapter 176A, section 26 of chapter 176B, section 34 of chapter 176G and section 14 of chapter 176I to determine a coding solution to allow the bundled treatment models to be coded and paid for as a bundle of services, similar to bundled payments under a single billing code for physical health care. SECTION 10. The group insurance commission, the division of insurance and the health connector shall promulgate any regulations necessary to implement this section not later than six months after enactment. SECTION 11. All carriers must implement these benefits and demonstrate to the Division of Insurance the adequacy of their provider networks for these services by the effective date of this act. Any carrier that fails to demonstrate adequate networks of providers of these services by the effective date shall: (a) assist any plan member to find an out-of-network CSC program or ACT program and to cover those services as if they were furnished in network; and (b) report monthly to the division of insurance on the status of their networks, and pay a fine of $50,000 per month. SECTION 12. After 5 years following full implementation of this act, the health policy commission, the division of insurance and the group insurance commission shall collaborate to perform an independent analysis of the impact of the coverage of the team-based treatment models provided under this section upon savings in hospitalization costs or other costs and on any increase in cost to the group insurance commission, the division of insurance or group insurance commission members. The analysis shall review claims payment and plan and consumer cost data for the largest group insurance commission plans that comprise at least 80 per cent of the covered lives at the time of the study. SECTION 13. This act shall take effect 1 year after its passage.