Bill > S645

This bill aims to improve the fairness of medical necessity determinations for behavioral health conditions, including substance use disorders and mental illness. Key provisions include: - Requiring insurers to base medical necessity determinations for behavioral health treatment on evidence-based clinical practice guidelines, such as those from the American Society of Addiction Medicine, and apply these consistently. - Prohibiting insurers from denying coverage for behavioral health treatment solely based on the treatment being court-ordered or from a public program. - Establishing standards for what constitutes "medically necessary" treatment of a behavioral health condition, including that it be in accordance with generally accepted standards of care. - Mandating insurers provide training on the clinical review criteria, conduct interrater reliability testing, and achieve high pass rates to ensure consistent application. - Authorizing the insurance commissioner to impose civil penalties for violations and order corrective action if insureds were improperly denied coverage. - Applying these requirements to both private insurers and public health programs like Medicaid and the state employees' insurance plan. The overall goal is to ensure individuals with behavioral health needs receive coverage for medically appropriate, evidence-based treatment without unnecessary barriers or denials.

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https://malegislature.gov/Bills/192/S645