The proposed Substitute Senate Bill No. 10 aims to strengthen health insurance compliance regarding mental health and substance use disorder benefits, effective October 1, 2025. It requires health carriers to file an annual certification with the Insurance Commissioner, confirming adherence to state and federal reporting requirements related to mental health benefits, signed by the chief executive officer and chief medical officer. The bill introduces a "parity advancement account" to fund initiatives supporting mental health parity enforcement and consumer education. It also establishes new penalties for non-compliance, including civil penalties of up to $100 per participant and daily late fees for missed filings, with all collected fees directed to the parity advancement account. Additionally, the bill amends existing regulations by repealing certain provisions regarding the reporting process to the General Assembly and the confidentiality of health carrier identities.

Effective January 1, 2026, the bill introduces significant changes to the utilization review process, mandating health carriers to contract with healthcare professionals for evaluating adverse determinations and ensuring the use of documented clinical review criteria based on sound clinical evidence. It establishes a rebuttable presumption that healthcare services ordered by a qualified professional are medically necessary, placing the burden of proof on the utilization review company. The bill also modifies step therapy protocols, reducing the maximum duration from thirty days to twenty days and expanding the conditions under which it can be applied. Furthermore, it mandates equal reimbursement rates for outpatient services across providers in the same geographic area and requires public hearings for rate filings, ensuring transparency and accountability in health insurance practices. Overall, the bill aims to enhance patient rights, improve access to necessary medical treatments, and ensure fair reimbursement practices.

Statutes affected:
Committee Bill:
INS Joint Favorable Substitute:
File No. 419: