Colorado § 10-16-147 - Parity reporting - commissioner - carriers - rules - examination of complaints.

§ 10-16-147. Parity reporting - commissioner - carriers - rules - examination of complaints.

(1) (a) By June 1, 2020, and by each June 1 thereafter, the commissioner shall submit a written report to the health and insurance committee and the public health care and human services committee of the house of representatives, or their successor committees, and to the health and human services committee of the senate, or its successor committee, and provide a presentation of the report to those legislative committees before the next regular legislative session that follows submittal of the report, that:

(I) Specifies the methodology the commissioner uses to verify that carriers are complying with section 10-16-104 (5.5) and rules adopted under that section and with the MHPAEA, any regulations adopted pursuant to that act, or guidance related to compliance with and oversight of that act;

(II) Identifies market conduct examinations initiated, conducted, or completed during the preceding twelve months regarding compliance with section 10-16-104 (5.5) and rules adopted under that section and with the MHPAEA and regulations adopted under that act and summarizes the outcomes of those market conduct examinations;

(III) Details any educational or corrective actions the commissioner has taken to ensure carrier compliance with section 10-16-104 (5.5) and rules adopted under that section and with the MHPAEA and regulations adopted under that act.

(b) The commissioner shall ensure that the report is written in plain language and is made available to the public by, at a minimum, posting the report on the division's website.

(c) Notwithstanding section 24-1-136 (11)(a)(I), the reporting requirement specified in this section continues indefinitely.

(2) A carrier that offers a health benefit plan that is subject to section 10-16-104 (5.5) shall submit to the commissioner and make available to the public, by March 1, 2020, and by each March 1 thereafter, a report that contains the following information for the prior calendar year:

(a) Data that demonstrates parity compliance for adverse determinations regarding claims for behavioral, mental health, or substance use disorder services and includes the total number of adverse determinations for such claims;

(b) A description of the process used to develop or select:

(I) The medical necessity criteria used in determining benefits for behavioral, mental health, and substance use disorders; and

(II) The medical necessity criteria used in determining medical and surgical benefits;

(c) Identification of all nonquantitative treatment limitations that are applied to benefits for behavioral, mental health, and substance use disorders and to medical and surgical benefits within each classification of benefits; and

(d) (I) The results of analyses demonstrating that, for medical necessity criteria described in subsection (2)(b) of this section and for each nonquantitative treatment limitation identified in subsection (2)(c) of this section, as written and in operation, the processes, strategies, evidentiary standards, or other factors used in applying the medical necessity criteria and each nonquantitative treatment limitation to benefits for behavioral, mental health, and substance use disorders within each classification of benefits are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the medical necessity criteria and each nonquantitative treatment limitation to medical and surgical benefits within the corresponding classification of benefits.

(II) A carrier's report on the results of the analyses specified in this subsection (1)(d) must, at a minimum:

(A) Identify the factors used to determine whether a nonquantitative treatment limitation will apply to a benefit, including factors that were considered but rejected;

(B) Identify and define the specific evidentiary standards used to define the factors and any other evidence relied on in designing each nonquantitative treatment limitation;

(C) Provide the comparative analyses, including the results of the analyses, performed to determine that the processes and strategies used to design each nonquantitative treatment limitation, as written, and the written processes and strategies used to apply each nonquantitative treatment limitation for benefits for behavioral, mental health, and substance use disorders are comparable to, and are applied no more stringently than, the processes and strategies used to design and apply each nonquantitative treatment limitation, as written, and the written processes and strategies used to apply each nonquantitative treatment limitation for medical and surgical benefits;

(D) Provide the comparative analyses, including the results of the analyses, performed to determine that the processes and strategies used to apply each nonquantitative treatment limitation, in operation, for benefits for behavioral, mental health, and substance use disorders are comparable to, and are applied no more stringently than, the processes and strategies used to apply each nonquantitative treatment limitation, in operation, for medical and surgical benefits; and

(E) Disclose the specific findings and conclusions reached by the carrier that the results of the analyses indicate that each health benefit plan offered by the carrier complies with section 10-16-104 (5.5) and the MHPAEA.

(3) The commissioner shall adopt rules as necessary to implement the reporting requirements of subsection (2) of this section, including rules to specify the form and manner of carrier reports.

(4) If the commissioner receives a complaint from the office of the ombudsman for behavioral health access to care established pursuant to part 3 of article 80 of title 27 that relates to a possible violation of section 10-16-104 (5.5) or the MHPAEA, the commissioner shall examine the complaint, as requested by the office, and shall report to the office in a timely manner any action taken by the commissioner related to the complaint.

Source: L. 2018: Entire section added, (HB 18-1357), ch. 252, p. 1552, § 3, effective August 8. L. 2019: IP(1)(a) and (2) amended and (3) and (4) added, (HB 19-1269), ch. 195, p. 2129, § 9, effective May 16.

Cross references: For the short title ("Behavioral Health Care Coverage Modernization Act") in HB 19-1269, see section 1 of chapter 195, Session Laws of Colorado 2019.