The proposed bill introduces the Mental Health and Substance Use Disorders Insurance Coverage Protection Act, which mandates that certain insurance policies provide coverage for medically necessary treatment of mental health and substance use disorders. Effective January 1, 2026, the bill requires insurers to adhere to specific coverage standards, including following generally accepted standards of care for medical necessity determinations and ensuring access to out-of-network services when in-network options are unavailable. It also prohibits insurers from denying coverage based on the potential availability of public entitlement programs and imposes civil penalties for violations. Additionally, insurers are required to educate their staff and providers on clinical review criteria.

A significant aspect of the bill is the inclusion of a new clause that clarifies the permissible scope of contract provisions related to decision-making processes, ensuring that insured individuals are informed about how contract terms are applied in eligibility determinations and claims handling. This provision is designed to protect the rights of insured individuals by preventing the creation of a deferential standard of review by courts. Overall, the bill aims to enhance the clarity and fairness of insurance contracts concerning mental health and substance use disorder coverage, thereby strengthening protections for individuals seeking treatment under their insurance plans.

Statutes affected:
Introduced Version: 5-16-15a, 33-15-4y, 33-16-3ii, 33-24-7z, 33-25-8w, 33-25A-8z, 33-57A-1, 33-57A-2, 33-57A-3, 33-57A-4, 33-57A-5