Law: health plans must disclose coverage criteria

In a move that should increase transparency for mental health providers dealing with insurance plans, Massachusetts Governor Deval Patrick signed House Bill 3704, An Act Relative to Enhancing Access to Services for Mental Health, into law on July 2.

The bill, a follow up to legislation passed in 2012 that was designed to improve the quality of health care and to reduce costs by increasing transparency, efficiency and innovation, sought to move the date for transparency compliance up by one year to this August.

“Chapter 224 of the Acts of 2012 is a comprehensive health care reform bill that is dramatically changing how all healthcare is delivered in Massachusetts,” says Michael Goldberg, Ph.D., director of professional affairs and past president of the Massachusetts Psychological Association. “The healthcare reform bill passed in 2012 called for the transparency component to be implemented in August 2015. We sought further legislation to move that implementation up a year by 2014.”

According to MPA’s Goldberg, the 2012 Act included language from a stand-alone bill the organization had filed to increase transparency by health plans in how they create utilization management programs to evaluate services provided.

“The initiative for the original transparency legislation was the result of frustrations we experienced when a major health plan refused to provide the medical necessity criteria they were using for psychological and neuropsychological services, claiming that they were ‘proprietary,’” says Goldberg.

Massachusetts Rep. Ruth Balser, Ph.D. (D-Newton), worked with the MPA on the original bill Goldberg mentioned as well as with the legislature to craft the 2012 act and then with the Mental Health Advisory Committee to craft the latest bill. As the first psychologist to serve in the Massachusetts legislature, Balser has a history of working on legislation that deals with issues in the mental health field.

“As a result of the bill becoming law,” says Balser, “health plans are required to publicly disclose the criteria by which they make decisions regarding coverage.”

That will make the selection of health plans simpler for consumers, adds Goldberg.

“This helps consumers understand the health plan products they are purchasing and helps them understand how decisions are made about utilization management so they can advocate for themselves more effectively,” he says.

State Senator John F. Keenan (D-Quincy), who spoke in support of the bill when it came before the Senate, explains that the new law will also simplify the efforts to ensure parity between physical and mental health.

“The drive behind the bill is what I, and many other legislators, have consistently heard from patient advocate groups and medical providers,” says Keenan, “that denials of coverage for behavioral health are too frequent and that the reasons for denial are opaque both to patients and to their medical providers. This lack of information has made the achievement of parity – or even an assessment of whether we are approaching parity – very difficult.”

“The insurance companies making coverage decisions already employ utilization review criteria,” he adds, “and nothing in this bill would require a change to those criteria, simply the disclosure of more information to patients, their advocates and their medical providers.”