HB3259 Summary

• Requires insurers offering group or individual accident and health insurance policies amended, delivered, issued, or renewed on or after January 1, 2022 to provide coverage for medically necessary treatment of mental health and substance use disorders.

• Prohibits insurers from rescinding or modifying treatment authorizations after a provider renders health care services in good faith, and requires coverage of out-of-network services when in-network mental health treatment is unavailable within geographic and timely access standards, with cost-sharing equal to in-network rates.

• Prohibits insurers from limiting benefits based on availability of public entitlement programs (Medicaid, Medicare, special education, etc.) and requires medical necessity determinations for substance use disorders to follow American Society of Addiction Medicine treatment criteria.

• Mandates insurers provide at no cost the clinical review criteria to providers and patients, conduct interrater reliability testing to ensure consistent utilization review decisions, and achieve at least 90% interrater reliability pass rates with staff retraining requirements if not met.

• Requires insurers to sponsor education programs by clinical specialty associations for staff and third-party reviewers, and prohibit prior authorization and step therapy requirements for FDA-approved substance use disorder medications except those established under ASAM criteria.