GENERAL ASSEMBLY OF NORTH CAROLINA

SESSION 1999

H	1 

HOUSE BILL 714

Short Title:  Substance Abuse/Direct Pay.	(Public)

─────────────────────────────────────── 
Sponsors: Representatives Alexander; Earle, Easterling, Luebke, Melton, Miller, and Wainwright.

─────────────────────────────────────── 
Referred to:  Insurance.

─────────────────────────────────────── 

March 30, 1999

A BILL TO BE ENTITLED
AN ACT TO PROVIDE FOR DIRECT PAYMENT OF CERTIFIED SUBSTANCE ABUSE PROFESSIONALS UNDER HEALTH INSURANCE POLICIES AND PLANS.
The General Assembly of North Carolina enacts:
Section 1.  G.S. 58-50-30 reads as rewritten:
"§ 58-50-30. Discrimination forbidden; right to choose services of optometrist, podiatrist, certified clinical social worker, certified substance abuse professional, dentist, chiropractor, psychologist, pharmacist, certified fee-based practicing pastoral counselor, or advanced practice registered nurse.
(a)	Discrimination between individuals of the same class in the amount of premiums or rates charged for any policy of insurance covered by Articles 50 through 55 of this Chapter, or in the benefits payable thereon, or in any of the terms or conditions of the policy, or in any other manner whatsoever, is prohibited.
Whenever any policy of insurance governed by Articles 1 through 64 of this Chapter provides for payment of or reimbursement for any service rendered in connection with a condition or complaint which is within the scope of practice of a duly licensed optometrist, a duly licensed podiatrist, a duly licensed dentist, a duly licensed chiropractor, a duly certified clinical social worker, a duly certified substance abuse professional, a duly licensed psychologist, a duly licensed pharmacist, a duly certified fee-based practicing pastoral counselor, or an advanced practice registered nurse, the insured or other persons entitled to benefits under the policy shall be entitled to payment of or reimbursement for the services, whether the services be performed by a duly licensed physician, a duly licensed optometrist, a duly licensed podiatrist, a duly licensed dentist, a duly licensed chiropractor, a duly certified clinical social worker, a duly certified substance abuse professional, a duly licensed psychologist, a duly licensed pharmacist, a duly certified fee-based practicing pastoral counselor, or an advanced practice registered nurse, notwithstanding any provision contained in the policy. Whenever any policy of insurance governed by Articles 1 through 64 of this Chapter provides for certification of disability that is within the scope of practice of a duly licensed physician, a duly licensed optometrist, a duly licensed podiatrist, a duly licensed dentist, a duly licensed chiropractor, a duly certified clinical social worker, a duly certified substance abuse professional, a duly licensed psychologist, a duly certified fee-based practicing pastoral counselor, or an advanced practice registered nurse, the insured or other persons entitled to benefits under the policy shall be entitled to payment of or reimbursement for the disability whether the disability be certified by a duly licensed physician, a duly licensed optometrist, a duly licensed podiatrist, a duly licensed dentist, a duly licensed chiropractor, a duly certified clinical social worker, a duly certified substance abuse professional, a duly licensed psychologist, a duly certified fee-based practicing pastoral counselor, or an advanced practice registered nurse, notwithstanding any provisions contained in the policy. The policyholder, insured, or beneficiary shall have the right to choose the provider of the services notwithstanding any provision to the contrary in any other statute.
Whenever any policy of insurance provides coverage for medically necessary treatment, the insurer shall not impose any limitation on treatment or levels of coverage if performed by a duly licensed chiropractor acting within the scope of the chiropractor's practice as defined in G.S. 90-151 unless a comparable limitation is imposed on the medically necessary treatment if performed or authorized by any other duly licensed physician.
(b)	For the purposes of this section, a "duly licensed psychologist"shall be defined only to include a psychologist who is duly licensed in the State of North Carolina and has a doctorate degree in psychology and at least two years clinical experience in a recognized health setting, or has met the standards of the National Register of Health Service Providers in Psychology. After January 1, 1995, a duly licensed psychologist shall be defined as a licensed psychologist who holds permanent licensure and certification as a health services provider psychologist issued by the North Carolina Psychology Board.
(c)	For the purposes of this section, a "duly certified clinical social worker"is a "certified clinical social worker"as defined in G.S. 90B-3(2) and certified by the North Carolina Certification Board for Social Work pursuant to Chapter 90B of the General Statutes.
(c1)	For purposes of this section, a "duly certified fee-based practicing pastoral counselor"shall be defined only to include fee-based practicing pastoral counselors certified by the North Carolina State Board of Examiners of Fee-Based Practicing Pastoral Counselors pursuant to Article 26 of Chapter 90 of the General Statutes.
(c2)	For purposes of this section, a 'duly certified substance abuse professional' is a person certified by the North Carolina Substance Abuse Professionals Certification Board pursuant to Article 5C of Chapter 90 of the General Statutes.
(d)	Payment or reimbursement is required by this section for a service performed by an advanced practice registered nurse only when:
(1)	The service performed is within the nurse's lawful scope of practice;
(2)	The policy currently provides benefits for identical services performed by other licensed health care providers;
(3)	The service is not performed while the nurse is a regular employee in an office of a licensed physician;
(4)	The service is not performed while the registered nurse is employed by a nursing facility (including a hospital, skilled nursing facility, intermediate care facility, or home care agency); and
(5)	Nothing in this section is intended to authorize payment to more than one provider for the same service.
No lack of signature, referral, or employment by any other health care provider may be asserted to deny benefits under this provision.
For purposes of this section, an "advanced practice registered nurse"means only a registered nurse who is duly licensed or certified as a nurse practitioner, clinical specialist in psychiatric and mental health nursing, or nurse midwife.
(e)	Payment or reimbursement is required by this section for a service performed by a duly licensed pharmacist only when:
(1)	The service performed is within the lawful scope of practice of the pharmacist;
(2)	The service performed is not initial counseling services required under State or federal law or regulation of the North Carolina Board of Pharmacy;
(3)	The policy currently provides reimbursement for identical services performed by other licensed health care providers; and
(4)	The service is identified as a separate service that is performed by other licensed health care providers and is reimbursed by identical payment methods.
Nothing in this subsection authorizes payment to more than one provider for the same service."
Section 2. G.S. 58-65-1 reads as rewritten:
"§ 58-65-1.  Regulation and definitions; application of other laws; profit and foreign corporations prohibited.
(a)	Any corporation heretofore or hereafter organized under the general corporation laws of the State of North Carolina for the purpose of maintaining and operating a nonprofit hospital and/or medical and/or dental service plan whereby hospital care and/or medical and/or dental service may be provided in whole or in part by said corporation or by hospitals and/or physicians and/or dentists participating in such plan, or plans, shall be governed by this Article and Article 66 of this Chapter and shall be exempt from all other provisions of the insurance laws of this State, heretofore enacted, unless specifically designated herein, and no laws hereafter enacted shall apply to them unless they be expressly designated therein.
The term "hospital service plan"as used in this Article and Article 66 of this Chapter includes the contracting for certain fees for, or furnishing of, hospital care, laboratory facilities, X-ray facilities, drugs, appliances, anesthesia, nursing care, operating and obstetrical equipment, accommodations and/or any and all other services authorized or permitted to be furnished by a hospital under the laws of the State of North Carolina and approved by the North Carolina Hospital Association and/or the American Medical Association.
The term "medical service plan"as used in this Article and Article 66 of this Chapter includes the contracting for the payment of fees toward, or furnishing of, medical, obstetrical, surgical and/or any other professional services authorized or permitted to be furnished by a duly licensed physician, except that in any plan in any policy of insurance governed by this Article and Article 66 of this Chapter that includes services which are within the scope of practice of a duly licensed optometrist, a duly licensed chiropractor, a duly licensed psychologist, a duly licensed pharmacist, an advanced practice registered nurse, a duly certified clinical social worker, a duly certified substance abuse professional, a duly certified fee-based practicing pastoral counselor, and a duly licensed physician, then the insured or beneficiary shall have the right to choose the provider of the care or service, and shall be entitled to payment of or reimbursement for such care or service, whether the provider be a duly licensed optometrist, a duly licensed chiropractor, a duly licensed psychologist, a duly licensed pharmacist, an advanced practice registered nurse, a duly certified clinical social worker, a duly certified substance abuse professional, a duly certified fee-based practicing pastoral counselor, or a duly licensed physician notwithstanding any provision to the contrary contained in such policy. The term "medical services plan"also includes the contracting for the payment of fees toward, or furnishing of, professional medical services authorized or permitted to be furnished by a duly licensed provider of health services licensed under Chapter 90 of the General Statutes.
(b)	Payment or reimbursement is required by this section for a service performed by an advanced practice registered nurse only when:
(1)	The service performed is within the nurse's lawful scope of practice;
(2)	The policy currently provides benefits for identical services performed by other licensed health care providers;
(3)	The service is not performed while the nurse is a regular employee in an office of a licensed physician;
(4)	The service is not performed while the registered nurse is employed by a nursing facility (including a hospital, skilled nursing facility, intermediate care facility, or home care agency); and
(5)	Nothing in this section is intended to authorize payment to more than one provider for the same service.
No lack of signature, referral, or employment by any other health care provider may be asserted to deny benefits under this provision.
(b1)	Payment or reimbursement is required by this section for a service performed by a duly licensed pharmacist only when:
(1)	The service performed is within the lawful scope of practice of the pharmacist;
(2)	The service performed is not initial counseling services required under State or federal law or regulation of the North Carolina Board of Pharmacy;
(3)	The policy currently provides reimbursement for identical services performed by other licensed health care providers; and
(4)	The service is identified as a separate service that is performed by other licensed health care providers and is reimbursed by identical payment methods.
Nothing in this subsection authorizes payment to more than one provider for the same service.
(c)	For purposes of this section, an "advanced practice registered nurse"means only a registered nurse who is duly licensed or certified as a nurse practitioner, clinical specialist in psychiatric and mental health nursing, or nurse midwife.
For the purposes of this section, a "duly certified clinical social worker"is a "certified clinical social worker"as defined in G.S. 90B-3(2)	and certified by the North Carolina Certification Board for Social Work pursuant to Chapter 90B of the General Statutes.
For purposes of this section, a "duly certified fee-based practicing pastoral counselor"shall be defined only to include fee-based practicing pastoral counselors certified by the North Carolina State Board of Examiners of Fee-Based Practicing Pastoral Counselors pursuant to Article 26 of Chapter 90 of the General Statutes.
For the purposes of this section, a "duly licensed psychologist"shall be defined only to include a psychologist who is duly licensed in the State of North Carolina and has a doctorate degree in psychology and at least two years clinical experience in a recognized health setting, or has met the standards of the National Register of Health Providers in Psychology. After January 1, 1995, a duly licensed psychologist shall be defined as a licensed psychologist who holds permanent licensure and certification as a health services provider psychologist issued by the North Carolina Psychology Board.
For purposes of this section, a 'duly certified substance abuse professional' is a person certified by the North Carolina Substance Abuse Professionals Certification Board pursuant to Article 5C of Chapter 90 of the General Statutes.
The term "dental service plan"as used in this Article and Article 66 of this Chapter includes contracting for the payment of fees toward, or furnishing of dental and/or any other professional services authorized or permitted to be furnished by a duly licensed dentist.
The insured or beneficiary of every "medical service plan"and of every "dental service plan,"as those terms are used in this Article and Article 66 of this Chapter, or of any policy of insurance issued thereunder, that includes services which are within the scope of practice of both a duly licensed physician and a duly licensed dentist shall have the right to choose the provider of such care or service, and shall be entitled to payment of or reimbursement for such care or service, whether the provider be a duly licensed physician or a duly licensed dentist notwithstanding any provision to the contrary contained in any such plan or policy.
The term "hospital service corporation"as used in this Article and Article 66 of this Chapter is intended to mean any nonprofit corporation operating a hospital and/or medical and/or dental service plan, as herein defined. Any corporation heretofore or hereafter organized and coming within the provisions of this Article and Article 66 of this Chapter, the certificate of incorporation of which authorizes the operation of either a hospital or medical and/or dental service plan, or any or all of them, may, with the approval of the Commissioner of Insurance, issue subscribers' contracts or certificates approved by the Commissioner of Insurance, for the payment of either hospital or medical and/or dental fees, or the furnishing of such services, or any or all of them, and may enter into contracts with hospitals for physicians and/or dentists, or any or all of them, for the furnishing of fees or services respectively under a hospital or medical and/or dental service plan, or any or all of them.
The term "preferred provider"as used in this Article and Article 66 of this Chapter with respect to contracts, organizations, policies or otherwise means a health care service provider who has agreed to accept, from a corporation organized for the purposes authorized by this Article and Article 66 of this Chapter or other applicable law, special reimbursement terms in exchange for providing services to beneficiaries of a plan administered pursuant to this Article and Article 66 of this Chapter. Except to the extent prohibited either by G.S. 58-65-140 or by regulations promulgated by the Department of Insurance not inconsistent with this Article and Article 66 of this Chapter, the contractual terms and conditions for special reimbursement shall be those which the corporation and preferred provider find to be mutually agreeable.
(d)	No foreign or alien hospital or medical and/or dental service corporation as herein defined shall be authorized to do business in this State."
Section 3. G.S. 135-40.7B(c1) reads as rewritten:
"(c1)	Notwithstanding any other provisions of this Part, the following providers and no others may provide necessary care and treatment for chemical dependency under this section:
(1)	The following providers with appropriate substance abuse training and experience in the field of alcohol and other drug abuse as determined by the mental health case manager, in facilities described in subdivision (b)(2) of this section, in day/night programs or outpatient treatment facilities licensed after July 1, 1984, under Article 2 of Chapter 122C of the General Statutes or in North Carolina area programs in substance abuse services are authorized to provide treatment for chemical dependency under this section:
a.	Licensed physicians including, but not limited to, physicians who are certified in substance abuse by the American Society of Addiction Medicine (ASAM);
b.	Licensed or certified psychologists;
c.	Psychiatrists;
d.	Certified substance abuse counselors working under the direct supervision of such physicians, psychologists, or psychiatrists;
e.	Psychological associates with a masters degree in psychology working under the direct supervision of such physicians, psychologists, or psychiatrists;
f.	Nurses working under the direct supervision of such physicians, psychologists, or psychiatrists;
g.	Certified clinical social workers;
h.	Certified clinical specialists in psychiatric and mental health nursing;
i.	Licensed professional counselors; 
j.	Certified fee-based practicing pastoral counselors until July 1, 1999; and
k.	Substance abuse professionals certified under Article 5C of Chapter 90 of the General Statutes.
(2)	The following providers with appropriate substance abuse training and experience in the field of alcohol and other drug abuse as determined by the mental health case manager are authorized to provide treatment for chemical dependency in outpatient practice settings:
a.	Licensed physicians who are certified in substance abuse by the American Society of Addiction Medicine (ASAM);
b.	Licensed or certified psychologists;
c.	Psychiatrists;
d.	Certified substance abuse counselors working under the employment and direct supervision of such physicians, psychologists, or psychiatrists;
e.	Psychological associates with a masters degree in psychology working under the employment and direct supervision of such physicians, psychologists, or psychiatrists;
f.	Nurses working under the employment and direct supervision of such physicians, psychologists, or psychiatrists;
g.	Certified clinical social workers;
h.	Certified clinical specialists in psychiatric and mental health nursing;
i.	Licensed professional counselors;
j.	Licensed fee-based practicing pastoral counselors until July 1, 1999; 
k.	Substance abuse professionals certified under Article 5C of Chapter 90 of the General Statutes; and
l.	In the absence of meeting one of the criteria above, the Mental Health Case Manager could consider, on a case-by-case basis, a provider who supplies:
1.	Evidence of graduate education in the diagnosis and treatment of chemical dependency, and
2.	Supervised work experience in the diagnosis and treatment of chemical dependency (with supervision by an appropriately credentialed provider), and
3.	Substantive past and current continuing education in the diagnosis and treatment of chemical dependency commensurate with one's profession.
Provided, however, that nothing in this subsection shall prohibit the Plan from requiring the most cost-effective treatment setting to be utilized by the person undergoing necessary care and treatment for chemical dependency."
Section 4. This act becomes effective October 1, 1999, and applies to claims for payment or reimbursement for services rendered on or after that date.