HB 4707 Insurance mandate: her depression gets covered like your broken leg

Pre-ACA, Michigan had about 35 insurance mandates. At an additional 4% cost per mandate, mandates were a major reason many were shut out of the private coverage market.

Fast forward to 2023. The mother of all mandates, HB 4707 wedges mental health parity into Michigan's insurance code.  Never mind patients in 2023 face record numbers of denials - what are a few more?!

What's the strategy here - break the insurance companies to make Michigan's single-payer bills look like a bargain?

Or perhaps this Legislature wants to be remembered for the attitude, "Forget patient health consequences, let them use pixie dust." 

Bill-reading tip: numbered lines start with "1" on each page for easy reference.

Beginning on page 13:

27 Sec. 3425. (1) Except as otherwise provided in this
28 subsection, an insurer that delivers, issues for delivery, or
29 renews in this state a health insurance policy shall provide

14
1 coverage for intermediate and outpatient care for substance use
2 disorder. medically necessary treatment of a mental health or
3 substance use disorder. This section does not apply to limited
4 classification policies.
5 (2) An insurer shall cover the full continuum of service
6 intensities and levels of care that are described in the most
7 recent versions of the following:
8 (a) The ASAM Criteria by the American Society of Addiction
9 Medicine.
10 (b) The Level of Care Utilization System by the American
11 Association of Community Psychiatrists.
12 (c) The Child and Adolescent Level of Care/Service Intensity
13 Utilization System by the American Association for Community
14 Psychiatry and the American Academy of Child and Adolescent
15 Psychiatry.
16 (d) Early Child Service Intensity Instrument by the American
17 Academy of Child and Adolescent Psychiatry.

Then on page 15 we go down the deep dark hole of government managing insurance. In turn, insurance since the 1990s has managed care instead of simply covering it. 

With all the watchers watching watchers, you'd think healthcare were a crime syndicate instead of people in the business of saving lives. But I digress.

Back to managed care:
It's constant and it interferes with care, sucking up vast amounts of clinician time advocating for patient coverage and filling out forms. Whether or not insurance employees are medically qualified, and regardless of their lack of contact with the patient - they hold the whip hand, because they hold the money.

It's an upside-down world. Is it any wonder clinicians are fleeing hospitals?

This is what managed care looks like when it's framed in law:

1 (5) In conducting utilization review of all covered health
2 care services and benefits for the diagnosis, prevention, and
3 treatment of mental health and substance use disorders in children,
4 adolescents, and adults, an insurer, and any entity acting on the
5 insurer's behalf, shall do all of the following:
6 (a) Make all medical necessity determinations consistent with
7 current generally accepted standards of mental health and substance
8 use disorder care.
9 (b) Apply exclusively the level of care placement criteria and
10 practice guidelines set forth in the most recent versions of
11 utilization review criteria and practice guidelines developed by
12 the nonprofit professional association for the relevant clinical
13 specialty within the scope of the criteria. Criteria and guidelines
14 outside the scope of the nonprofit professional association
15 criteria, including criteria described in section 2212e, may be
16 used if the criteria are fully consistent with current generally
17 accepted standards of mental health and substance use disorder
18 care.
19 (c) Not limit benefits or coverage for chronic or pervasive
20 mental health and substance use disorders to short-term or acute
21 treatment at any level of care placement.
22 (6) Except as otherwise provided in subsection (5), a prior
23 authorization determination for mental health and substance abuse
24 disorder services must be conducted under section 2212e.
25 (7) For all level of care placement decisions, the insurer
26 shall authorize placement at the level of care consistent with the
27 insured's assessment using the relevant nonprofit professional
28 association level of care placement criteria and guidelines under
29 subsection (5)(b). If that level of placement is not available, the

16
1 insurer shall authorize the next higher level of care. If there is
2 a disagreement between the insured's provider and the insurer, the
3 insurer shall provide full detail of its scoring using the relevant
4 level of care placement criteria and guidelines to the insured and
5 the insured's provider.
6 (8) If services for the medically necessary treatment of a
7 mental health or substance use disorder are not available in
8 network within the geographic and timeliness access standards under
9 law, the insurer shall arrange coverage to ensure the delivery of
10 medically necessary out-of-network services and any medically
11 necessary follow-up services that, to the maximum extent possible,
12 meet those geographic and timely access standards. The insured
13 shall pay not more in total for benefits rendered than the cost
14 sharing that the insured would pay for the same covered services
15 received from an in-network provider.
16 (9) For an adverse determination regarding a mental health or
17 substance use disorder service, including an adverse determination
18 regarding a prior authorization under section 2212e, the reviewer
19 must have the appropriate training and relevant experience in the
20 clinical specialty involved in the coverage determination. As used
21 in this subsection, "adverse determination" means that term as
22 defined in section 2213.
23 (10) An insurer shall cover mental health and substance use
24 disorder emergency services not more restrictively and using the
25 same coverage standards as for other emergency services, including,
26 but not limited to, utilizing the prudent layperson standard and
27 not applying prior authorization. The insured shall pay not more
28 than the in-network cost sharing amount regardless of provider
29 participation status.

17
1 (11) An insurer shall not limit benefits or coverage for
2 medically necessary services on the basis that those services
3 should be or could be covered by a public program, including, but
4 not limited to, special education or an individualized education
5 program, Medicaid, Medicare, Supplemental Security Income, or
6 Social Security Disability Insurance, and shall not include or
7 enforce a contract term that excludes otherwise covered benefits on
8 the basis that those services should be or could be covered by a
9 public program. As used in this subsection:
10 (a) "Medicaid" means a program for medical assistance
11 established under subchapter XIX of the social security act, 42 USC
12 1396 to 1396w-6.
13 (b) "Medicare" means the federal Medicare program established
14 under title XVIII of the social security act, 42 USC 1395 to 1395lll.
15 (c) "Social Security Disability Insurance" means disability
16 insurance under 42 USC 423 to 425.
17 (d) "Supplemental Security Income" means the program
18 authorized under title XVI of the social security act, 42 USC 1381
19 to 1383f.
20 (12) An insurer that authorizes a specific type of treatment
21 by a provider under this section shall not rescind or modify the
22 authorization after the provider renders the health care service in
23 good faith and under this authorization for any reason, including,
24 but not limited to, the insurer's subsequent rescission,
25 cancellation, or modification of the insured's or policyholder's
26 contract, or the insurer's subsequent determination that it did not
27 make an accurate determination of the insured's or policyholder's
28 eligibility.
....
7 (15) By March 1, 2024, and each March 1 after that date, an
8 insurer that delivers, issues for delivery, or renews in this state
9 a health insurance policy ...
....
the director shall
22 assess a civil penalty of $10,000.00 for each violation. The civil
23 penalties available to the director under this section are not
24 exclusive and may be sought and employed in combination with any
25 other remedies available to the director under this act.

And so on.

At this rate, Michigan's obsession with controlling care at the bedside will finish killing off healthcare sooner rather than later.

PS. One curious thing. Why would Section 14 (pg 18) not apply to contractors?

"This section does not apply to any entity or contracting provider that performs utilization review or utilization management functions on an insurer's behalf."

https://www.legislature.mi.gov/documents/2023-2024/billintroduced/House/pdf/2023-HIB-4707.pdf