HB2595 Summary: Generally Accepted Standards of Behavioral Health Care Act of 2021

• Requires insurers to provide coverage for medically necessary treatment of mental, emotional, nervous, and substance use disorders based on generally accepted standards of care established by nonprofit clinical associations, effective January 1, 2023.

• Defines "medically necessary treatment" as services addressing patient needs according to generally accepted standards, clinically appropriate in type and frequency, and not primarily for economic benefit of the insurer or convenience of parties involved.

• Mandates insurers base medical necessity determinations and utilization review criteria on current clinical practice guidelines from organizations like the American Society of Addiction Medicine, with restrictions on applying different or more restrictive criteria than those sources specify.

• Establishes requirements for insurers including staff education on utilization review criteria, interrater reliability testing with 90% pass rates, provision of criteria to providers and patients at no cost, and tracking of how criteria are used to certify or deny care.

• Imposes civil penalties of $1,000 to $5,000 per violation and requires annual reporting to the Department of Insurance with comparative analyses demonstrating compliance with parity requirements for mental health and substance use disorder benefits.