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SECTION 1.(a)  Subsections (b), (c), (d), and (j) of G.S. 58‑3‑220 are repealed.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 health benefits coverage.
(a)	Mental Health Equity Requirement. – All health benefit plans shall provide coverage for the necessary care and treatment of mental health conditions that are no less favorable than benefits for the necessary care and treatment of physical health conditions.
(a1)	Definitions. – The following definitions apply in this section:
(1)	Health benefit plan. – As defined in G.S. 58‑3‑167.
(2)	Insurer. – As defined in G.S. 58‑3‑167.
(3)	Medical necessity. – As defined in G.S. 58‑50‑61.
(4)	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), those coded as sexual dysfunctions not due to organic disease (302.70 through 302.79), and those coded as "V" codes.
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(g)	Utilization Review. – Nothing in this section prevents an insurer from applying utilization review criteria to determine medical necessity in accordance with G.S. 58‑50‑61. 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 American Society of Addiction Medicine criteria.
(i)	Federal Law Applies. – 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, 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.
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(d)	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. Except as otherwise provided, an insurer may develop its own clinical review criteria or purchase or license clinical review criteria.
(d1)	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 American Society of Addiction Medicine criteria. The Department, in consultation with the Department of Health and Human Services, may require proof of compliance with this subsection by 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.
(4)	In issuing a utilization review decision, an insurer or its URO shall do all of the following:
a.	Obtain all information required to make the decision, including pertinent clinical information.
b.	Employ a process to ensure that utilization reviewers apply clinical review criteria consistently.
c.	Apply the decision in a timely manner pursuant to this section.
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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 health condition, as defined in G.S. 58‑3‑220, 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.