AN ACT TO ENACT THE PSYCHOLOGY INTERJURISDICTIONAL COMPACT, ALLOW LICENSED MARRIAGE AND FAMILY THERAPISTS TO CONDUCT FIRST-LEVEL COMMITMENT EXAMINATIONS, ELIMINATE REDUNDANCY IN ADULT CARE HOME INSPECTIONS, RAISE AWARENESS OF LUPUS AND CREATE THE LUPUS ADVISORY COUNCIL, ENSURE THE PROPER ADMINISTRATION OF STEP THERAPY PROTOCOLS, ENSURE EQUAL COVERAGE FOR ORAL ANTICANCER DRUGS MODERNIZE MEDICAID TELEMEDICINE POLICIES, INCREASE ACCESS TO TELEHEALTH SERVICES, AND CREATE THE NORTH CAROLINA HEALTHCARE SOLUTIONS TASK FORCE.
House committee substitute to the 3rd edition makes the following changes.
Amends GS 122C-263.1 concerning who can perform first commitment exams, by adding that a licensed marriage and family therapist is not authorized to conduct the initial exam of an individual married to a patient of the licensed marriage and family therapist.
Deletes the proposed changes to GS 90-270.54 and GS 90-270.57, which established a license to conduct first exams and the related application fee.
Adds the following provisions.
Amends GS 58-3-221(a), which requires an insurer to take four specified steps if the insurer maintains one or more closed formularies for or restricts access to covered prescription drugs or devices. Amends the statute to also make those required steps applicable to when an insurer requires an enrollee in a plan with an open or closed formulary to use a prescription drug or sequence of prescription drugs, other than the drug the enrollee's health care provider recommends, before the insurer provides coverage for the recommended prescription drug. Amends those four required steps as follows: (1) requires the insurer to develop the formularies or protocols and any restrictions on access to covered prescription drugs or devices in consultation with and with the approval of a pharmacy and therapeutics committee (was, develop the formulary or formualries and any restrictions on access to covered prescription drugs or devices in consultation with and with the approval of a pharmacy and therapeutics committee, which was required to include participating physicians licensed to practice medicine in this State); (2) requires the insurer to also make available any utilization management program indicators; (3) requires the insurer to update protocols based on a review of new evidence, research, and newly developed treatments (deletes requirement of establishing and maintaining an expeditious process or procedure for enrollees or enrollees' physicians to obtain coverage for a specific nonformulary drug or device determined to be medically necessary and appropriate by the enrolee's participating physician without prior approval from the insurer after the enrollee's participating physician makes the specified notifications about the formulary or drug; these provisions are moved to another part of the statute and amended as discussed below); and (4) requires an insurer, or a pharmacy benefits manger under contract with an insurer, to require that its pharmacy and therapeutics committee either meet the requirements for the specified conflict of interest or meet the accreditation standards of the specified Committee or another independent accrediting organization (deletes the requirement of providing coverage for a restricted access drug or device to an enrollee without requiring prior approval or use of a nonrestricted formulary drug if an enrollee's physician certifies in writing that the enrollee has previously used an alternative nonrestricted access drug or device and the alternative drug or device has been detrimental to the enrollee's health or has been ineffective in treating the same condition and, in the opinion of the prescribing physician, is likely to be detrimental to the enrollee's health or ineffective in treating the condition again).
Moves and amends the provision related to the exception process as follows. Adds the requirement that the process or procedure be published on the insurer's website or in policies provided to health care providers. Now requires that an enrollee or the enrollee's prescribing provider be allowed to obtain, without penalty or additional cost-sharing beyond that provided for in the health benefit plan, coverage for a specific nonformulary drug or device or the drug requested by the prescribing provider, if it is determined to be medically necessary and appropriate by the enrollee's prescribing provider and the prescription drug is covered under the current health benefit plan. Requires an exception request to be granted if the prescribing provider's submitted justification and supporting clinical documentation are sufficient to demonstrate: (1) the enrollee has tried the alternate drug while covered by the current or previous health benefit plan; (2) the formulary or alternate drug has been ineffective in the treatment of the enrollee's disease or condition; (3) the formulary or alternate drug causes or is reasonably expected by the prescribing provider to cause a harmful or adverse clinical reaction in the enrollee; (4) either the drug is prescribed in accordance with any applicable clinical protocol of the insurer for the prescribing of the drug, or the drug has been approved as an exception to the clinical protocol pursuant to the insurer's exception procedure; or (5) the enrollee's prescribing provider certifies in writing that the enrollee has previously used an alternative nonrestricted access drug or device and the alternative drug or device has been detrimental to the enrollee's health or has been ineffective in treating the same condition and, in the opinion of the prescribing healthcare provider, is likely to be detrimental to the enrollee's health or ineffective in treating the condition again.
Adds that pharmaceutical drug samples or patient incentive programs are not to be considered trial and failure of a preferred prescription drug in lieu of trying the formulary-preferred prescription drug. Adds the following exception process requirements. Allows the insurer, health benefit plan, or utilization review organization to request relevant documentation from the patient or healthcare provider to support the request. Requires a licensed physician or licensed pharmacist to evaluate the clinical appropriateness of the request. Sets out the timelines for the insurer to communicate to the enrollee's healthcare provider if additional information is required and for the insurer to communicate an exception request determination with the time limits dependent on whether the request is urgent.
Adds that the statute is not to be construed to prevent the health benefit plan from requiring an enrollee to try an A-rated generic equivalent drug or a biosimilar before covering the equivalent branded prescription drug.
Effective October 1, 2019, and applies to insurance contracts issued, renewed, or amended on or after that date.
Enacts new GS 58-3-282, concerning coverage for certain anticancer drugs, applicable to every health benefit plan offered by an insurer that provides coverage for prescribed, orally administered anticancer drugs used to kill or slow the growth of cancerous cells and that provides coverage for intravenously administered or injected anticancer drugs, requiring that such plans must provide coverage for prescribed, orally administered anticancer drugs on a basis no less favorable than the coverage provided for the intravenously administered or injected anticancer drug.
Prohibits coverage for orally administered anticancer drugs from being subject to prior authorization, dollar limit, co-payment, coinsurance, deductible provision, or any other out-of-pocket expense that does not apply to intravenously administered or injected anticancer drugs.
Prohibits achieving compliance by reclassifying drugs or increasing cost-sharing expenses imposed on anticancer drugs. Provides that if out-of-pocket expenses are increased for anticancer drugs then the same must also be applied to the majority of comparable medical or pharmaceutical benefits of the policy, contract, or plan.
Applies to insurance contracts issued, renewed, or amended on or after January 1, 2020. Provides that the statute will not become effective if it is determined by the federal government to create a state-required benefit that is in excess of the essential health benefits pursuant to 45 C.F.R. 155.170(a)(3); if such a determination is made, then requires the Department of Insurance to notify the Revisor of Statutes.
Requires the Department of Health and Human Services (DHHS) to make six specified changes to the Medicaid and NC Health Choice Clinical Coverage Policy No. 1H, Telemedicine and Telepsychiatry, regarding reimbursement, referrals, delivery of services by phone or video cell phone, same-date billing, best practices, and inclusion in the coverage policy of certain behavioral health providers. Directs DHHS to expand the billing code set available for telemedicine and telepsychiatry to include most outpatient billing codes, but not to include group-type therapies other than family therapy. Changes become effective after the completion of the process for amending policy required under GS 108A-54.2 (procedures for changing medical policy in public assistance programs).
Requires DHHS to submit to the Centers for Medicare and Medicaid Services any waivers or amendments to the NC Medicaid State Plan necessary to implement this act.
Requires the Department of Health and Human Services (DHHS) to ensure that Medicaid and NC Health Choice coverage of telemedicine and telepsychiatry services are consistent with this section and requires amending Clinical Coverage Policy No: 1H as necessary. Requires using the term "telehealth" instead of "telemedicine" in all clinical coverage policies. Defines telehealth for the purposes of Medicaid and NC Health Choice coverage, as the delivery of health care-related services by a Medicaid or NC Health Choice provider licensed in the State to a Medicaid or NC Health Choice recipient through one of the three specified types of communications and technologies. Specifies that telehealth does not include the delivery of services solely through electronic mail, text chat, or audio-communication unless either additional medical history and clinical information is communicated electronically between the provider and patient or the services delivered are behavioral health services. Specifies four actions that DHHS must take regarding Medicaid and NC Health Choice coverage of telehealth services, including promoting access to health care for Medicaid and NC Health Choice recipients through telehealth services. Prohibits DHHS from requiring seven specified items as a condition of coverage of telehealth services, including that a provider be part of a telehealth network in order to bill for Medicaid or NC Health Choice services, and that the Provider be physically present with the patient or client unless the provider determines it is medically necessary to perform the services in person. Requires DHHS to ensure that (1) Medicaid and NC Health Choice coverage and reimbursement for telehealth services are equivalent to the reimbursement and coverage for the same services if provided in person and (2) that any deductible, copayment, or coinsurance requirement is equivalent to the same service if it was provided to the patient in person. Requires DHHS to submit to the Centers for Medicare and Medicaid Services any waivers or amendments to the NC Medicaid State Plan necessary to implement the above provisions. Requires DHHS by September 1, 2020, to report on changes, expected costs, savings, and outcomes of telehealth services to the specified NCGA committee and division.
Enacts new GS 58-50-305 to prohibit a health benefit plan from excluding from coverage a covered health care service or procedure delivered by a preferred or contracted health professional to a covered patient as a telehealth service solely because the covered health care service or procedure is not provided through an in-person consultation. Allows a health benefit plan to require a deductible, a copayment, or coinsurance for a covered health care service or procedure delivered by a preferred or contracted health professional to a covered patient as a telehealth service. Prohibits the amount charged from exceeding the amount of the deductible, copayment, or coinsurance required for the covered health care service or procedure provided through an in-person consultation. Makes a conforming change to GS 135-48.51 to make new GS 58-50-305 applicable to the State Health Plan.
Effective October 1, 2019.
Requires the North Carolina Area Health Education Centers Program to convene a 15-member North Carolina Healthcare Solutions Task Force (Task Force) to make recommendations for innovative solutions to healthcare access issues in the state. Sets out membership requirements. Requires the North Carolina Area Health Education Centers to assist the Task Force by convening and facilitating meetings, providing necessary clerical and administrative support, and preparing the Task Force reports and providing technical assistance as appropriate. Requires the Task Force to conduct a 10-year, ongoing study of issues related to access to healthcare in North Carolina, with the work divided into two stages. Requires the first stage to identify metrics to provide an accurate assessment and measurement of the state of access to healthcare in North Carolina, and the second stage to identify any issues relating to access to healthcare in North Carolina and to develop innovative solutions that will increase access to healthcare and improve the state of access to healthcare in North Carolina as measured by the identified metrics. Sets out additional requirements for the two stages. Requires the Task Force's first meeting to be convened by October 1, 2019. Requires the report on stage one to be submitted to the specified NCGA committee by April 1, 2021, with annual reports on stage two activities required beginning April 1, 2022, with subsequent reports submitted annually until April 1, 2030. Terminates the Task Force on the date it submits is final report in 2030.
Amends the act's long title.
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