GENERAL ASSEMBLY OF NORTH CAROLINA
SESSION 2025
H 1
HOUSE BILL 634
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Short Title: Parity Enhancement for Addiction Recovery. |
(Public) |
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Sponsors: |
Representatives T. Brown, White, Alston, and Huneycutt (Primary Sponsors). For a complete list of sponsors, refer to the North Carolina General Assembly web site. |
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Referred to: |
Health, if favorable, Insurance, if favorable, Finance, if favorable, Rules, Calendar, and Operations of the House |
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April 2, 2025
A BILL TO BE ENTITLED
AN ACT to update by conforming to federal law the laws related to health benefit plan mental health benefits coverage and to enhance coverage parity for addiction recovery.
The General Assembly of North Carolina enacts:
SECTION 1.(a) Subsections (b), (c), (d), and (j) of G.S. 58‑3‑220 are repealed.
SECTION 1.(b) Subsection (h) of G.S. 58‑3‑220 is recodified as subsection (a1) of G.S. 58‑3‑220.
SECTION 2.(a) G.S. 58‑3‑220, as amended by Section 1 of this act, reads as rewritten:
"§ 58‑3‑220. Mental illness health benefits
coverage.
(a) Mental Health Equity
Requirement. – Except as provided in subsection (b), an insurer shall
provide in each group health benefit plan benefits for All health
benefit plans shall provide coverage for the necessary care and treatment
of mental illnesses health conditions that are no less favorable
than benefits for the necessary care and treatment of physical illness
generally, including application of the same limits. For purposes of this
subsection, mental illnesses are as diagnosed and defined in the Diagnostic and
Statistical Manual of Mental Disorders, DSM‑5, or a subsequent edition
published by the American Psychiatric Association, except those mental
disorders coded in the DSM‑5 or subsequent edition as autism spectrum
disorder (299.00), substance‑related disorders (291.0 through 292.2 and
303.0 through 305.9), those coded as sexual dysfunctions not due to organic
disease (302.70 through 302.79), and those coded as "V" codes. For
purposes of this subsection, "limits" includes deductibles,
coinsurance factors, co‑payments, maximum out‑of‑pocket
limits, annual and lifetime dollar limits, and any other dollar limits or fees
for covered services.health conditions.
(a1) Definitions. – As used
The following definitions apply in this section:
(1) "Health benefit
plan" has the same meaning as Health benefit plan. – As defined in
G.S. 58‑3‑167.
(2) "Insurer"
has the same meaning as Insurer. – As defined in G.S. 58‑3‑167.
(3) Medical necessity. – As defined in G.S. 58‑50‑61.
(4) "Mental illness" has the same meaning
as in G.S. 122C‑3(21), with a Mental health condition. – A mental
disorder defined in the Diagnostic and Statistical Manual of Mental Disorders,
DSM‑5, or subsequent editions published by the American Psychiatric
Association, except this term does not include those mental disorders
coded in the DSM‑5 or subsequent editions as autism spectrum disorder
(299.00), substance‑related disorders (291.0 through 292.9 and 303.0
through 305.9), those coded as sexual dysfunctions not due to organic
disease (302.70 through 302.79), and those coded as "V" codes.
…
(i) Federal Law Applies.
– Notwithstanding any other provisions of this section, a group health
benefit plan that covers both medical and surgical benefits and mental health
benefits shall, with respect to the mental health benefits, comply with all All
applicable standards of Subtitle B of Title V of Public Law 110‑343,
known as the Paul Wellstone and Pete Domenici Mental Health Parity and
Addiction Equity Act of 2008, and the applicable regulations, as amended.amended,
and other relevant federal law shall apply to health benefit plans."
SECTION 2.(b) G.S. 58‑50‑61 reads as rewritten:
"§ 58‑50‑61. Utilization review.
…
(d) Program Operations. Clinical
Review Criteria, Generally. – In every utilization review program, an
insurer or URO shall use documented clinical review criteria that are based on
sound clinical evidence and that are periodically evaluated to assure ongoing
efficacy. An Except as otherwise provided, an insurer may develop
its own clinical review criteria or purchase or license clinical review
criteria.
(d1) Criteria for determining when a patient needs to be
placed in a substance abuse treatment program shall be either (i) the
diagnostic criteria contained in Clinical Review Criteria, Substance Use
Treatment. – Clinical review criteria and assessment of medical necessity for a
treatment modality for any mental health condition, including substance use
disorders, shall be consistent with the criteria used for, and the manner of
assessment applied to, the medical necessity of non‑mental health
conditions. For substance use disorders, medical necessity determinations shall
rely solely on the most recent revision of the American Society of
Addiction Medicine Patient Placement Criteria for the Treatment of Substance‑Related
Disorders or (ii) criteria adopted by the insurer or its URO. criteria. The
Department, in consultation with the Department of Health and Human Services,
may require proof of compliance with this subsection by a plan an
insurer or URO.
(d2) Administration of Program. – All of the following shall apply in the administration of a utilization review program under this section:
(1) Qualified health care professionals shall administer the utilization review program and oversee review decisions under the direction of a medical doctor. A medical doctor licensed to practice medicine in this State shall evaluate the clinical appropriateness of noncertifications.
(2) Compensation to persons involved in utilization review shall not contain any direct or indirect incentives for them to make any particular review decisions.
(3) Compensation to utilization reviewers shall not be directly or indirectly based on the number or type of noncertifications they render.
a. Obtain all information required to make the
decision, including pertinent clinical information; employ information.
b. Employ a process to ensure that utilization
reviewers apply clinical review criteria consistently; and issue consistently.
c. Apply the decision in a timely manner pursuant to this section.
…."
SECTION 2.(c) In accordance with G.S. 135‑48.24(b) and G.S. 135‑48.30(a)(7) which require the State Treasurer to implement procedures that are substantially similar to the provisions of G.S. 58‑50‑61 for the North Carolina State Health Plan for Teachers and State Employees (State Health Plan), the State Treasurer and the Executive Administrator of the State Health Plan shall review all practices of the State Health Plan and all contracts with, and practices of, any third party conducting any utilization review on behalf of the State Health Plan to ensure compliance with subsection (b) of this section no later than the start of the next plan year.
SECTION 3.(a) The Revisor of Statutes shall replace the phrase "chemical dependency" with the phrase "substance use disorder" in all of the following statutes:
(1) G.S. 58‑51‑16(a).
(2) G.S. 58‑51‑40(a).
(3) G.S. 58‑51‑55(b).
(4) G.S. 58‑65‑90(b).
(5) G.S. 58‑67‑75(b).
SECTION 3.(b) All of the following are repealed:
(1) G.S. 58‑51‑50.
(2) Subdivision (a)(2) and subsection (c) of G.S. 58‑51‑55.
(3) G.S. 58‑65‑75.
(4) Subdivision (a)(2) and subsection (c) G.S. 58‑65‑90.
(5) G.S. 58‑67‑70.
(6) Subdivision (a)(2) and subsection (c) G.S. 58‑67‑75.
SECTION 3.(c) G.S. 58‑3‑192(a)(2) reads as rewritten:
"(2) Autism spectrum
disorder. – As defined by the most recent edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM) or the most recent edition of the
International Statistical Classification of Diseases and Related Health
Problems. Autism spectrum disorder is not considered a mental illness health
condition, as defined in G.S. 58‑3‑220, 58‑51‑55,
or a mental illness, as defined in G.S. 58‑51‑55, 58‑65‑90,
or 58‑67‑75."
SECTION 4. This act is effective October 1, 2025, and applies to insurance contracts issued, renewed, or amended on or after that date.