Mo. Code Regs. tit. 20 § 400-2.165

Current through Register Vol. 49, No. 23, December 2, 2024

Section 20 CSR 400-2.165 - Access to Providers for Treatment of Mental Health Conditions

PURPOSE: This rule describes timely and appropriate access to mental health care, adequate distribution of the quantity, location and specialty of mental health care providers, and administrative and clinical protocols that protect access to medically necessary mental health treatment for any insured. This rule is promulgated pursuant to section 376.1550, RSMo.

(1) Definitions.

(A) "Administrative protocols" include, but are not limited to, a provider network, referral requirements, prior authorization requirements, and utilization review.

(B) "Clinical protocols" include, but are not limited to, visit limitations, length-of-stay limitations, formularies, step-therapy requirements, and drug quantity limitations.

(C) Categories of counties-

1. Urban counties-Counties with a population of two hundred thousand (200,000) or more persons;

2. Basic counties-Counties with a population between fifty thousand (50,000) persons and one hundred ninety-nine thousand nine hundred ninety-nine (199,999) persons;

3. Rural counties-Counties with a population of fewer than fifty thousand (50,000) persons; and

4. Population figures shall be based on census data as reported in the latest edition of the Official Manual State of Missouri.

(D) "Director" means the director of the Department of Commerce and Insurance.

(E) "Health benefit plan" has the same meaning as stated at section 376.1350, RSMo.

(F) "Health carrier" has the same meaning as stated at section 376.1350, RSMo.

(G) "HMO" means health maintenance organizations licensed pursuant to Chapter 354, RSMo.

(H) "Insured" means any person entitled to benefits under a health benefit plan.

(I) "Insurer" means a health carrier that is not an HMO.

(J) "Mental health condition" means any condition or disorder defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders except for chemical dependency.

(K) "Provider" means any professional or institution which is licensed or otherwise authorized in this or any other state to furnish health care services.

(L) "Utilization review" has the same meaning as stated at section 376.1350, RSMo.

(2) Applicability.

(A) This rule shall apply to all health benefit plans, except for the types of health benefit plans covered under subsection (2)(C) of this rule.

(B) This rule shall apply to managed care organizations providing mental health benefits under a health benefit plan that does not otherwise provide for management of care under the plan or that does not provide for the same degree of management of care for all health conditions.

(C) This rule shall not apply to:

1. Health benefit plans issued by an HMO;

2. Health benefit plans issued by insurers that provide for the same degree of management of care under the plan for all health conditions;

3. Individual health benefit plans, including those that cover dependents;

4. Individually underwritten group health benefit plans;

5. Supplemental insurance policies, including life care contracts, accident-only policies, specified disease policies, hospital policies providing a fixed daily benefit only, Medicare supplement policies, long-term care policies, hospitalization-surgical care policies, or short-term major medical policies of six (6) months or less duration; and

6. Any other supplemental policy as determined by the director.

(3) Timely Access to Care-Appointments with or admissions to medical providers must be available no later than as follows:

(A) For routine care, without symptoms- within thirty (30) days from the time the enrollee contacts the provider;

(B) For routine care, with symptoms- within five (5) business days from the time the insured contacts the provider;

(C) For urgent care for situations which require immediate care, but which do not constitute emergencies as defined by section 376.1350, RSMo-within twenty-four (24) hours from the time the insured contacts the provider;

(D) For emergency care-an appropriate mental health provider or emergency care facility shall be available twenty-four (24) hours per day, seven (7) days per week for people who require emergency care as defined by section 376.1350, RSMo; and

(E) For telephone access-a licensed mental health care professional shall be available twenty-four (24) hours per day, seven (7) days per week.

(4) Adequate Quantity of Health Care Providers-A system for delivery of treatment for mental health conditions shall have sufficient quantities of mental health care providers to meet the timely access requirements stated in section (3) of this rule.

(5) Appropriate Access to Care and Adequate Location and Distribution of Health Care Providers.

(A) A health benefit plan or managed care organization may establish a system for delivery of treatment for mental health conditions that includes utilization review. Such system shall comply with the provisions of sections 376.1350 to 376.1389, RSMo.

(B) If a provider network lacks an appropriate provider or it cannot assure access to medically necessary care without unreasonable delay, then coverage of mental health treatment outside the network shall place no greater cost upon the insured than if the treatment were delivered inside the network.

(C) For purposes of subsection (5)(B) of this rule, an appropriate provider is one that is reasonably suited to provide treatment that reflects the insured's age, diagnosis, anticipated length of treatment, and any other relevant factors.

(6) Administrative and Clinical Protocols.

(A) Administrative and clinical protocols applied by an insurer, either directly or indirectly through a managed care organization shall:

1. Be clearly and completely stated in written or electronic materials distributed to any insured or prospective insured, except that merely posting the information on a website shall not by itself meet this requirement;

2. Be clearly and completely stated in written or electronic materials distributed to any provider responsible for providing treatment to an insured; and

3. Be available for review by the director within thirty (30) days of the director making a request to review protocols.

(B) Administrative and clinical protocols applied by an insurer, either directly or indirectly through a managed care organization, shall not serve to reduce access to medically necessary treatment for any insured.

(7) Filings with the Director. On October 15 of each year, all insurers shall file with the director a certification of compliance with the provisions of this rule and section 376.1550, RSMo, for all health benefit plans. The certification shall be in a format prescribed by the director, and shall contain, at a minimum, the following information:

(A) The legal name and National Association of Insurance Commissioners (NAIC) number of the insurer;

(B) The number of insureds covered by health benefit plans that the insurer believes to be subject to this rule, if any;

(C) If applicable, a statement of the reasons an insurer believes none of its health benefit plans are subject to this rule, referencing the exceptions listed in paragraphs (2)(C)1. through (2)(C)6. of this rule;

(D) The insurer's certification of compliance with all the applicable provisions of this rule, unless subsection (7)(C) applies; and

(E) If the insurer provides coverage of mental health benefits through a managed care organization, the name, address and contact information of that organization.

20 CSR 400-2.165

AUTHORITY: section 376.1550, RSMo Supp. 2005.* Original rule filed Aug. 26, 2005, effective March 30, 2006. Non-substantive change filed Sept. 11, 2019, published Oct. 31, 2019.

*Original authority: 376.1550, RSMo 2004.