New or Modified Benefits Required to be Provided - Public Act No. 15-5 (June special session)

STATE OF CONNECTICUT INSURANCE DEPARTMENT BULLETIN HC-115 JULY 29,2016 TO: ALL INSURANCE COMPANIES, FRATERNAL BENEFIT SOCIETIES, HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS AND HEALTH CARE CENTERS THAT DELIVER OR ISSUE INDIVIDUAL AND GROUP HEALTH INSURANCE POLICIES IN CONNECTICUT RE: NEW OR MODIFIED BENEFITS REQUIRED TO BE PROVIDED- PUBLIC ACT NO. 15-5 (June Special Session) In June 2015, the Governor signed into law the implementer bill Public Act No. 15-5 of the June Special Session, partially codified at sections 38a-488a(b) and 38a-514(b) ofthe 2016 Supplement to the Connecticut General Statutes, which contained provisions regarding new benefits to be offered for the January 1, 2017 plan year. This public act impacts individual and group health insurance policies delivered or issued for delivery in Connecticut. All entities are reminded that all policy forms are subject to prior approval. Policies are reviewed in the order of date received by the Insurance Department. • For policy forms that are already approved, you are asked to file an endorsement or amendatory rider to be attached to the approved policy in order to expedite the review process. • For new benefits on policies that require rates be filed, a rate filing should be made at the same time as the form filing even if there is no adjustment to the rates. The rate filing shall provide the per member per month (PMPM) cost separately for each newly required benefit. Section 1311(d)(3)(B) of the Affordable Care Act permits a state to require Qualified Health Plans (to be sold through the Exchange) to offer benefits in addition to the Essential Health Benefits already selected by Connecticut, but it requires the state to defray the cost of these additional benefits. The U.S. Department ofHealth and Human Services (HHS) issued a final rule on February 25, 2013 that recognizes only those mandated benefits that were enacted on or before December 31, 2011 to be considered Essential Health Benefits (EHB). The State of Connecticut would be required to make payment to the enrollee or insurance carrier to defray the cost of any new benefits specific to care, treatment and services which are enacted this session. On or after January 1, 2017, Section 38a-488a of the 2016 Supplement to the Connecticut General Statutes provides in relevant part: "(b) Each individual health insurance policy providing coverage ofthe type specified in subdivisions (1 ), (2), ( 4), (11) and (12) of section 38a-469 delivered, issued for delivery, www.ct.gov/cid P.O. Box 816 • Hartford, CT 06142-0816 An Equal Opportunity Employer renewed, amended or continued in this state shall provide benefits for the diagnosis and treatment of mental or nervous conditions. Benefits payable include, but need not be limited to: (8) Evidence-based maternal, infant and early childhood home visitation services, as described in Section 2951 ofthe Patient Protection and Affordable Care Act, P .L. 111 ­ 148, as amended from time to time, that are designed to improve health outcomes for pregnant women, postpartum mothers and newborns and children, including, but not limited to, for maternal substance use disorders or depression and relationship-focused interventions for children with mental or nervous conditions or substance use disorders; (22) Intensive, family-based and community-based treatment programs that focus on addressing environmental systems that impact chronic and violent juvenile offenders; (23) Other home-based therapeutic interventions for children; (25) Extended day treatment programs, as described in section 17a-22. Identical benefits are required for group health plans under section 38a-514(b) ofthe 2016 Supplement to the Connecticut General Statutes (P A 15-5 § 46), also effective for plan years beginning January 1, 2017. Each listed benefit above will be taken individually: (8) Evidence-based maternal, infant and early childhood home visitation services, as described in Section 2951 of the Patient Protection and Affordable Care Act, P.L. 111-148, as amended from time to time, that are designed to improve health outcomes for pregnant women, postpartum mothers and newborns and children, including, but not limited to, for maternal substance use disorders or depression and relationship-focused interventions for children with mental or nervous conditions or substance use disorders · Family therapy offered in a provider's office has always been covered under the Benchmark plan and therefore is a part ofthe EHB. Home based treatment has not been covered. Behavioral therapy for autism spectrum disorder are covered under the EHB, but not relationship-focused interventions. Relationship-focused interventions and other services that fall under this category that are not already considered EHB and covered by the benchmark plan would be new benefits and would need to be included in policies beginning January 1, 2017. These additional benefits would also be new mandates for which the State is responsible to defray the cost. (22) Intensive, family-based and community-based treatment programs that focus on addressing environmental systems that impact chronic and violent juvenile offenders Diagnoses ofbehavioral health and family therapy have always been covered under EHB when provided by licensed behavioral health professionals in a provider's office. Any other services beyond those that fall under this category would be new benefits and would need to be included in policies beginning January 1, 2017. These additional benefits would also be new mandates for which the State is responsible to defray the cost. (23) Other home-based therapeutic interventions for children Medically Necessary home health services provided by a home health agency are part ofEHB if a plan ofhome health care is ordered by a physician and approved by the carrier. There is no coverage for custodial care or educational services. Custodial care includes services to assist an individual to maintain activities ofdaily living including but not limited to: bathing, dressing, walking, eating, toileting and maintaining personal hygiene. Custodial care is also any care that can be provided by non-medical professionals with a reasonable amount oftraining. Educational services include: Screening and treatment associated with learning disabilities, Special education and related services, and Testing and training. Any home based therapeutic intervention for children not already covered by the benchmark plan would be a new benefit and would need to be included in policies beginning January 1, 2017. These additional benefits would also be new mandates for which the State is responsible to defray the cost. (25) Extended day treatment programs, as described in section 17a-22. Under the EHB, there is coverage for outpatient therapy by licensed behavioral health providers, but there is no coverage for custodial care or educational services. Custodial care includes services to assist an individual to maintain activities ofdaily living including but not limited to: bathing, dressing, walking, eating, toileting and maintaining personal hygiene. Custodial care is also any care that can be provided by non-medical professionals with a reasonable amount of training. Educational services include: Screening and treatment associated with learning disabilities, Special education and related services, and Testing and training. Coverage for custodial care and educational services provided by extended day treatment programs as described in 17a-22 would need to be included in policies beginning January 1, 2017 because they are not in the EHB. This additional benefit would be a new mandate for which the State is responsible to defray the cost. QUESTIONS Please contact the Insurance Department Life and Health Division at cid.lh@ ct.gov with any questions regarding this bulletin. Insurance Commissioner