H 815

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1H.815
2 Introduced by Representative Berbeco of Winooski
3 Referred to Committee on
4 Date:
5 Subject: Health; health insurance; Medicaid; mental health professionals;
6Department of Financial Regulation; Department of Vermont Health
7Access
8 Statement of purpose of bill as introduced: This bill proposes to limit the
9 extent to which health insurers may reduce reimbursement rates for mental
10 health services. It would also require health insurers and Vermont Medicaid to
11 provide notice and stakeholder engagement opportunities prior to
12 implementing any change to reimbursement methodology, billing policy,
13 coding alignment, supervised billing requirements, or service authorization
14 requirements affecting mental health, substance use disorder, or intellectual or
15 developmental disability services.
16    An act relating to health insurance and Medicaid reimbursement for certain
17    health care services
                                                                   VT LEG #386147 v.1
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1 It is hereby enacted by the General Assembly of the State of Vermont:
2 Sec. 1. 8 V.S.A. § 4072 is amended to read:
3 § 4072. MENTAL HEALTH AND SUBSTANCE USE DISORDER
4SERVICES
5***
6    (c) A health insurance plan shall provide coverage for treatment of a mental
7 condition and shall:
8(1) not establish any rate, term, or condition that places a greater burden
9 on a covered individual for access to treatment for a mental condition than for
10 access to treatment for other health conditions, including no greater co-
11 payment for primary mental health care or services than the co-payment
12 applicable to care or services provided by a primary care provider under a
13 covered individual’s health insurance plan and no greater co-payment for
14 specialty mental health care or services than the co-payment applicable to care
15 or services provided by a specialist provider under a covered individual’s
16 health insurance plan;
17(2) not exclude from its network or list of authorized providers any
18 licensed mental health or substance use disorder treatment provider located
19 within the geographic coverage area of the health insurance plan if the provider
20 is willing to meet the terms and conditions for participation established by the
21 health insurer;
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1(3) not reduce the reimbursement rate for more than one mental health
2 code for the same mental health professional license type in any contract year
3 below the reimbursement rate provided for that code and license type in the
4 previous contract year;
5(4) make any deductible or out-of-pocket limits required under a health
6 insurance plan comprehensive for coverage of both mental and physical health
7 conditions; and
8(4)(5) if the health insurance plan provides prescription drug coverage,
9 ensure that at least one medication in each therapeutic class approved by the
10 U.S. Food and Drug Administration for the treatment of substance use
11 disorder, including for opioid use disorder, methadone, buprenorphine, and
12 naltrexone, is available on the lowest cost-sharing tier of the plan’s
13 prescription drug formulary.
14***
15 Sec. 2. 18 V.S.A. § 9418h is added to read:
16 § 9418h. MODIFICATIONS TO REIMBURSEMENT AND CODING
17POLICIES FOR CERTAIN SERVICES AND PROVIDERS
18    (a) Notwithstanding any provision of this subchapter to the contrary, a
19 health plan shall not implement any change to reimbursement methodology,
20 billing policy, coding alignment, supervised billing requirements, or service
                                                                    VT LEG #386147 v.1
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1 authorization requirements affecting mental health, substance use disorder, or
2 intellectual or developmental disability services without first:
3(1) publicly identifying whether the change is required by federal or
4 State law and, if so, citing the specific federal or State statute, regulation, or
5 rule that requires the change;
6(2) publicly identifying which elements of the change, if any, are
7 discretionary policy choices;
8(3) publishing the proposed policy language and billing guidance on its
9 website, and sending written notice directly to providers, including
10 independent mental health providers, designated and specialized service
11 agencies, relevant advocacy organizations, and representatives of individuals
12 and families of individuals who receive services that will be affected by the
13 change, and the Department of Financial Regulation, at least 90 days prior to
14 implementation;
15(4) conducting at least one public stakeholder meeting and soliciting
16 public comments; and
17(5) publishing on its website a written response describing the ways in
18 which stakeholder input and public comments were considered and
19 incorporated.
20    (b) Prior to implementing any reimbursement or coding policy change
21 described in subsection (a) of this section, the health plan shall:
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1(1) conduct and publicly release a fiscal impact analysis;
2(2) conduct and publicly release an assessment of the impact on access
3 to care and on the provider workforce, demonstrating that the change will not
4 reduce service availability; and
5(3) consult with affected providers, the Office of the Health Care
6 Advocate, Disability Rights Vermont, and representatives of individuals and
7 families of individuals who receive services that will be affected by the
8 change.
9    (c)(1) For 12 months following implementation of a reimbursement or
10 coding policy change described in subsection (a) of this section, the health plan
11 shall monitor and shall post on its website and report to the Department of
12 Financial Regulation quarterly on access indicators, including:
13(A) provider network participation and withdrawal;
14(B) wait times for services; and
15(C) service denial rates and service reductions.
16(2) If monitoring demonstrates a reduction in access, the health plan
17 shall take corrective action to restore the access levels that were in effect prior
18 to the policy change.
19    (d)(1) The Department of Financial Regulation shall provide written notice
20 to the House Committees on Health Care and on Human Services and the
21 Senate Committee on Health and Welfare at least 60 days prior to
                                                                     VT LEG #386147 v.1
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1 implementation of any policy or reimbursement change affecting mental
2 health, substance use disorder, or intellectual or developmental disability
3 services that does one more of the following:
4(A) reduces or is reasonably expected to reduce provider
5 reimbursement;
6(B) increases uncompensated administrative or supervision
7 requirements; or
8(C) is reasonably expected to increase wait times, reduce provider
9 participation, or reduce availability of services, regardless of whether the
10 change is described as coding alignment, billing clarification, compliance
11 update, policy modernization, or otherwise.
12(2) The notice shall include the fiscal analysis, access impact
13 assessment, and stakeholder engagement documentation required by this
14 section.
15 Sec. 3. 33 V.S.A. § 1905b is added to read:
16 § 1905b. MODIFICATIONS TO REIMBURSEMENT AND CODING
17POLICIES FOR CERTAIN SERVICES AND PROVIDERS
18    (a) Notwithstanding any provision of this subchapter to the contrary, the
19 Department of Vermont Health Access shall not implement any change to
20 Medicaid reimbursement methodology, billing policy, coding alignment,
21 supervised billing requirements, or service authorization requirements
                                                                    VT LEG #386147 v.1
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1 affecting mental health, substance use disorder, or intellectual or
2 developmental disability services without first:
3(1) publicly identifying whether the change is required by federal or
4 State law and, if so, citing the specific federal or State statute, regulation, or
5 rule that requires the change;
6(2) publicly identifying which elements of the change, if any, are
7 discretionary policy choices;
8(3) publishing the proposed policy language and billing guidance on the
9 Department’s website and sending written notice directly to providers,
10 including independent mental health providers, designated and specialized
11 service agencies, relevant advocacy organizations, and representatives of
12 individuals and families of individuals who receive services that will be
13 affected by the change at least 90 days prior to implementation;
14(4) conducting at least one public stakeholder meeting and soliciting
15 public comments; and
16(5) publishing on the Department’s website a written response
17 describing the ways in which stakeholder input and public comments were
18 considered and incorporated.
19    (b) Prior to implementing any Medicaid reimbursement or coding policy
20 change described in subsection (a) of this section, the Department of Vermont
21 Health Access shall:
                                                                       VT LEG #386147 v.1
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1(1) conduct and publicly release a fiscal impact analysis;
2(2) conduct and publicly release an assessment of the impact on access
3 to care and on the provider workforce, demonstrating that the change will not
4 reduce service availability; and
5(3) consult with affected providers, the Office of the Health Care
6 Advocate, Disability Rights Vermont, and representatives of individuals and
7 families of individuals who receive services that will be affected by the
8 change.
9    (c)(1) For 12 months following implementation of a reimbursement or
10 coding policy change described in subsection (a) of this section, the
11 Department of Vermont Health Access shall post quarterly reports on its
12 website showing updated access indicators, including:
13(A) provider network participation and withdrawal;
14(B) wait times for services; and
15(C) service denial rates and service reductions.
16(2) If monitoring demonstrates a reduction in access, the Department
17 shall take corrective action to restore the access levels that were in effect prior
18 to the policy change.
19    (d)(1) The Department of Vermont Health Access shall provide written
20 notice to the House Committees on Health Care and on Human Services and
21 the Senate Committee on Health and Welfare at least 60 days prior to
                                                                     VT LEG #386147 v.1
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1 implementation of any Medicaid policy or reimbursement change affecting
2 mental health, substance use disorder, or intellectual or developmental
3 disability services that does one more of the following:
4(A) reduces or is reasonably expected to reduce provider
5 reimbursement;
6(B) increases uncompensated administrative or supervision
7 requirements; or
8(C) is reasonably expected to increase wait times, reduce provider
9 participation, or reduce availability of services, regardless of whether the
10 change is described as coding alignment, billing clarification, compliance
11 update, policy modernization, or otherwise.
12(2) The notice shall include the fiscal analysis, access impact
13 assessment, and stakeholder engagement documentation required by this
14 section.
15 Sec. 4. EFFECTIVE DATES
16    (a) Sec. 1 (8 V.S.A. § 4072; mental health reimbursement rates) shall take
17 effect on January 1, 2027.
18    (b) The remaining sections shall take effect on passage.
                                                                    VT LEG #386147 v.1