Lost

AMENDMENT NO 2 PROPOSED TO

Cmte Sub for House Bill No. 1008

BY: Representative Hines

AMEND by adding following new paragraph (2) after line 1612 and renumbering the succeeding paragraphs and any references thereto:

          "(2)  Each health maintenance organization, coordinated care organization, provider-sponsored health plan, or other organization paid for services on a capitated basis by the division under any managed care program or coordinated care program implemented by the division under this subsection (H) shall use a clear set of level of care guidelines in the determination of medical necessity and in all utilization management practices, including the prior authorization process, concurrent reviews, retrospective reviews and payments, that are consistent with widely accepted professional standards of care (including the Level of Care Utilization System [LOCUS], Child and Adolescent Level of Care Utilization System [CALOCUS] and the American Society of Addiction Medicine [ASAM], Child and Adolescent Service Intensity Instrument [CASSI]).  Organizations participating in a managed care program or coordinated care program implemented by the division may not use any additional criteria that would result in denial of care that would be determined appropriate and, therefore, medically necessary by the following guidelines and principles.  The standards of care must incorporate the following eight (8) principles:

              (a)  Effective treatment requires treatment of the individual's underlying condition and is not limited to alleviation of the individual's current symptoms;

              (b)  Effective treatment requires treatment of co-occurring mental health and substance use disorders and/or medical conditions in a coordinated manner that considers the interactions of the disorders when determining the appropriate level of care;

              (c)  Patients should receive treatment for mental health and substance use disorders at the least intensive and restrictive level of care that is safe and effective;

              (d)  When there is ambiguity as to the appropriate level of care, the practitioner and insurer should err on the side of caution by placing the patient in a higher level of care that is currently available;

              (e)  Effective treatment of mental health and substance use disorders includes services needed to maintain functioning or prevent deterioration;

              (f)  The appropriate duration of treatment for mental health and substance use disorders is based on the individual needs of the patient; there is no specific limit on the duration of such treatment;

              (g)  The unique needs of children and adolescents must be taken into account when making decisions regarding the level of care involving their treatment for mental health or substance use disorders; and

              (h)  The determination of the appropriate level of care for patients with mental health or substance use disorders should be made on the basis of a multidimensional assessment that takes into account a wide variety of information about the patient."