Section 33-1-27 - Insurance coverage for mental health and substance abuse disorders; compliance with mental health parity requirements; complaints and violations; appointment of mental health parity officer(a) As used in this Code section, the term: (1) "Addictive disease" has the same meaning as in Code Section 37-1-1.(2) "Generally accepted standards of mental health or substance use disorder care" means evidence based independent standards of care and clinical practice that are generally recognized by health care providers practicing in relevant clinical specialties such as psychiatry, psychology, clinical sociology, addiction medicine and counseling, and behavioral health treatment. Valid, evidence based sources reflecting generally accepted standards of mental health or substance use disorder care may include peer reviewed scientific studies and medical literature, consensus guidelines and recommendations of nonprofit health care provider professional associations and specialty societies, and nationally recognized clinical practice guidelines, including, but not limited to, patient placement criteria and clinical practice guidelines; guidelines or recommendations of federal government agencies; and drug labeling approved by the United States Food and Drug Administration.(3) "Health care plan" means any hospital or medical insurance policy or certificate, health care plan contract or certificate, qualified higher deductible health plan, or health maintenance organization or other managed care subscriber contract.(4) "Health insurer" means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the Commissioner, that contracts, offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including those of an accident and sickness insurance company, a health maintenance organization, a health care plan, a managed care plan, or any other entity providing a health insurance plan, a health benefit plan, or a health care plan.(5) "Medically necessary" means, with respect to the treatment of a mental health or substance use disorder, a service or product addressing the specific needs of that patient for the purpose of screening, preventing, diagnosing, managing or treating an illness, injury, condition, or its symptoms, including minimizing the progression of an illness, injury, condition, or its symptoms, in a manner that is: (A) In accordance with the generally accepted standards of mental health or substance use disorder care;(B) Clinically appropriate in terms of type, frequency, extent, site, and duration; and(C) Not primarily for the economic benefit of the insurer, purchaser, or for the convenience of the patient, treating physician, or other health care provider.(6) "Mental health or substance use disorder" means a mental illness or addictive disease.(7) "Mental illness" has the same meaning as in Code Section 37-1-1.(8) "Nonquantitative treatment limitation" or "NQTL" means limitations that are not expressed numerically, but otherwise limit the scope or duration of benefits for treatment. NQTLs include, but are not limited to, the following: (A) Medical management standards limiting or excluding benefits based on whether the treatment is medically necessary or whether the treatment is experimental or investigative;(B) Formulary design for prescription drugs;(C) Standards for provider admission to participate in a network, including average time to obtain, verify, and assess the qualifications of a health practitioner for purposes of credentialing;(D) Criteria utilized for determining usual, customary, and reasonable charges for out-of-network services, including the threshold percentile utilized and any industry software or other billing, charges, and claims tools utilized;(E) Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for in-network and out-of-network services;(F) Standards for providing access to out-of-network providers;(G) Provider reimbursement rates, including rates of reimbursement for mental health or substance use services in primary care; and(H) Such other limitations as identified by the commissioner.(b) Every health insurer that provides coverage for mental health or substance use disorders as part of a health care plan shall provide coverage for the treatment of mental health or substance use disorders in accordance with the Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C. Section 300gg-26, and its implementing and related regulations in any such health care plan it offers and shall: (1) Provide such coverage for children, adolescents, and adults;(2) In addition to the requirements of Chapter 46 of this title, apply the definitions of "generally accepted standards of mental health or substance use disorder care," "medically necessary," and "mental health or substance use disorder" contained in subsection (a) of this Code section in making any medical necessity, prior authorization, or utilization review determinations under such coverage;(3) Ensure that any subcontractor or affiliate responsible for management of mental health and substance use disorder care on behalf of the health insurer complies with the requirements of this Code section; and(4) No later than January 1, 2023, and annually thereafter, submit a report to the Commissioner that contains the designated comparative analyses and other information designated by the Commissioner for that reporting year for insurers under the Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C. Section 300gg-26(a)(8)(A) and which delineates the comparative analysis and written processes and strategies used to apply benefits for children, adolescents, and adults. No later than January 1, 2024, and annually thereafter, the Commissioner shall publish on the department's website in a prominent location the reports submitted to the Commissioner pursuant to this paragraph and a list of the designated NQTLs, comparative analyses, and other information required by the Commissioner to be reported in the upcoming reporting year.(c) The Commissioner shall: (1)(A) Conduct an annual data call no later than May 15, 2023, and every May 15 thereafter, of health insurers to ensure compliance with mental health parity requirements, including, but not limited to, compliance with the Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C. Section 300gg-26. Such data calls shall include a focus on the use of nonquantitative treatment limitations. In the event that information collected from a data call indicates or suggests a potential violation of any mental health parity requirement by a health insurer, the department shall initiate a market conduct examination of such health insurer to determine whether such health insurer is in compliance with mental health parity requirements. All health insurers shall timely respond to and provide to the department any and all sufficient data requested by the department; and(B) Submit an annual report to the Governor, Lieutenant Governor, and Speaker of the House of Representatives no later than August 15, 2023, and every August 15 thereafter, regarding the data call conducted pursuant to this paragraph, including details regarding any market conduct examinations initiated by the department pursuant to any such data call; and(2) Include mental health parity compliance by health insurers in the examination conducted pursuant to Code Section 33-2-11 by the Commissioner.(d) No health insurer shall implement any prohibition on same-day reimbursement for a patient who sees a mental health provider and a primary care provider in the same day.(e) The Commissioner shall implement and maintain a streamlined process for accepting, evaluating, and responding to complaints from consumers and health care providers regarding suspected mental health parity violations. Such process shall be posted on the department's website in a prominent location and clearly distinguished from other types of complaints and shall include information on the rights of consumers under Article 2 of Chapter 20A of Title 33, the "Patient's Right to Independent Review Act," and other applicable law. To the extent practicable, the Commissioner shall undertake reasonable efforts to make culturally and linguistically sensitive materials available for consumers accessing the complaint process established pursuant to this subsection.(f) No later than January 1, 2023, the department shall create a repository for tracking, analyzing, and reporting information resulting from complaints received from consumers and health care providers regarding suspected mental health parity violations. Such repository shall include complaints, department reviews, mitigation efforts, and outcomes, among other criteria established by the department.(g) Beginning January 15, 2024, and no later than January 15 annually thereafter, the Commissioner shall submit a report to the administrator of the Georgia Data Analytic Center and the General Assembly with information regarding the previous year's complaints and all elements contained in the repository.(h) The Commissioner shall appoint a mental health parity officer within the department to ensure implementation of the requirements of this Code section.(i)(1) If the Commissioner determines that a health insurer failed to submit a timely or sufficient report required under paragraph (4) of subsection (b) of this Code section or failed to submit timely and sufficient data pursuant to a data call conducted pursuant to paragraph (1) of subsection (c) of this Code section, the Commissioner may impose a monetary penalty of up to $2,000.00 for each and every act in violation, unless the insurer knew or reasonably should have known that he or she was in violation, in which case the monetary penalty may be increased to an amount of up to $5,000.00 for each and every act in violation.(2) If the Commissioner determines that an insurer failed to comply with any provision of this Code section, the Commissioner may take any action authorized, including, but not limited to, issuing an administrative order imposing monetary penalties, imposing a compliance plan, ordering the insurer to develop a compliance plan, or ordering the insurer to reprocess claims.(j) Nothing contained in this Code section shall abrogate the protections afforded by federal conscience and antidiscrimination laws as further delineated in 45 C.F.R. Part 88 in effect as of June 30, 2022, all of which shall apply to patients, health care providers, and purchasers of health care plans.Added by 2022 Ga. Laws 587,§ 1-2, eff. 7/1/2022.