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North Carolina House Bill H634

North Carolina 2025-2026 Regular Session

North Carolina House Bill H634 Compare Versions

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11 GENERAL ASSEMBLY OF NORTH CAROLINA
22 SESSION 2025
3-H 1
4-HOUSE BILL 634
3+H D
4+HOUSE BILL DRH40297-MR-81
5+
56
67
78 Short Title: Parity Enhancement for Addiction Recovery. (Public)
8-Sponsors: Representatives T. Brown, White, Alston, and Huneycutt (Primary Sponsors).
9-For a complete list of sponsors, refer to the North Carolina General Assembly web site.
10-Referred to: Health, if favorable, Insurance, if favorable, Finance, if favorable, Rules,
11-Calendar, and Operations of the House
12-April 2, 2025
13-*H634 -v-1*
9+Sponsors: Representative T. Brown.
10+Referred to:
11+
12+*DRH40297 -MR-81*
1413 A BILL TO BE ENTITLED 1
1514 AN ACT TO UPDATE BY CONFORMING TO FEDERAL LAW THE LAWS RELATED TO 2
1615 HEALTH BENEFIT PLAN MENTAL HEALTH BENEFITS COVERAGE AND TO 3
1716 ENHANCE COVERAGE PARITY FOR ADDICTION RECOVERY. 4
1817 The General Assembly of North Carolina enacts: 5
1918 SECTION 1.(a) Subsections (b), (c), (d), and (j) of G.S. 58-3-220 are repealed. 6
2019 SECTION 1.(b) Subsection (h) of G.S. 58-3-220 is recodified as subsection (a1) of 7
2120 G.S. 58-3-220. 8
2221 SECTION 2.(a) G.S. 58-3-220, as amended by Section 1 of this act, reads as 9
2322 rewritten: 10
2423 "§ 58-3-220. Mental illness health benefits coverage. 11
2524 (a) Mental Health Equity Requirement. – Except as provided in subsection (b), an insurer 12
2625 shall provide in each group health benefit plan benefits for All health benefit plans shall provide 13
2726 coverage for the necessary care and treatment of mental illnesses health conditions that are no 14
2827 less favorable than benefits for the necessary care and treatment of physical illness generally, 15
2928 including application of the same limits. For purposes of this subsection, mental illnesses are as 16
3029 diagnosed and defined in the Diagnostic and Statistical Manual of Mental Disorders, DSM-5, or 17
3130 a subsequent edition published by the American Psychiatric Association, except those mental 18
3231 disorders coded in the DSM-5 or subsequent edition as autism spectrum disorder (299.00), 19
3332 substance-related disorders (291.0 through 292.2 and 303.0 through 305.9), those coded as sexual 20
3433 dysfunctions not due to organic disease (302.70 through 302.79), and those coded as "V" codes. 21
3534 For purposes of this subsection, "limits" includes deductibles, coinsurance factors, co-payments, 22
3635 maximum out-of-pocket limits, annual and lifetime dollar limits, and any other dollar limits or 23
3736 fees for covered services.health conditions. 24
3837 (a1) Definitions. – As used The following definitions apply in this section: 25
3938 (1) "Health benefit plan" has the same meaning as Health benefit plan. – As 26
4039 defined in G.S. 58-3-167. 27
4140 (2) "Insurer" has the same meaning as Insurer. – As defined in G.S. 58-3-167. 28
4241 (3) Medical necessity. – As defined in G.S. 58-50-61. 29
4342 (4) "Mental illness" has the same meaning as in G.S. 122C-3(21), with a Mental 30
4443 health condition. – A mental disorder defined in the Diagnostic and Statistical 31
4544 Manual of Mental Disorders, DSM-5, or subsequent editions published by the 32
4645 American Psychiatric Association, except this term does not include those 33
47-mental disorders coded in the DSM-5 or subsequent editions as autism 34 General Assembly Of North Carolina Session 2025
48-Page 2 House Bill 634-First Edition
49-spectrum disorder (299.00), substance-related disorders (291.0 through 292.9 1
50-and 303.0 through 305.9), those coded as sexual dysfunctions not due to 2
51-organic disease (302.70 through 302.79), and those coded as "V" codes. 3
52-… 4
53-(g) Utilization Review. – Nothing in this section prevents an insurer from applying 5
54-utilization review criteria to determine medical necessity as defined in G.S. 58-50-61 as long as 6
55-it does so in accordance with all requirements for utilization review programs and medical 7
56-necessity determinations specified in that section, including the offering of an insurer appeal 8
57-process and, where applicable, health benefit plan external review as provided for in Part 4 of 9
58-Article 50 of Chapter 58 of the General Statutes.in accordance with G.S. 58-50-61. Clinical 10
59-review criteria and assessment of medical necessity for a treatment modality for any mental 11
60-health condition, including substance use disorders, shall be consistent with the criteria used for, 12
61-and the manner of assessment applied to, the medical necessity of non-mental health conditions. 13
62-For substance use disorders, medical necessity determinations shall rely solely on the most recent 14
63-American Society of Addiction Medicine criteria. 15
64-(i) Federal Law Applies. – Notwithstanding any other provisions of this section, a group 16
65-health benefit plan that covers both medical and surgical benefits and mental health benefits shall, 17
66-with respect to the mental health benefits, comply with all All applicable standards of Subtitle B 18
67-of Title V of Public Law 110-343, known as the Paul Wellstone and Pete Domenici Mental 19
68-Health Parity and Addiction Equity Act of 2008, and the applicable regulations, as 20
69-amended.amended, and other relevant federal law shall apply to health benefit plans." 21
70-SECTION 2.(b) G.S. 58-50-61 reads as rewritten: 22
71-"§ 58-50-61. Utilization review. 23
72-… 24
73-(d) Program Operations. Clinical Review Criteria, Generally. – In every utilization 25
74-review program, an insurer or URO shall use documented clinical review criteria that are based 26
75-on sound clinical evidence and that are periodically evaluated to assure ongoing efficacy. An 27
76-Except as otherwise provided, an insurer may develop its own clinical review criteria or purchase 28
77-or license clinical review criteria. 29
78-(d1) Criteria for determining when a patient needs to be placed in a substance abuse 30
79-treatment program shall be either (i) the diagnostic criteria contained in Clinical Review Criteria, 31
80-Substance Use Treatment. – Clinical review criteria and assessment of medical necessity for a 32
81-treatment modality for any mental health condition, including substance use disorders, shall be 33
82-consistent with the criteria used for, and the manner of assessment applied to, the medical 34
83-necessity of non-mental health conditions. For substance use disorders, medical necessity 35
84-determinations shall rely solely on the most recent revision of the American Society of Addiction 36
85-Medicine Patient Placement Criteria for the Treatment of Substance-Related Disorders or (ii) 37
86-criteria adopted by the insurer or its URO. criteria. The Department, in consultation with the 38
87-Department of Health and Human Services, may require proof of compliance with this subsection 39
88-by a plan an insurer or URO. 40
89-(d2) Administration of Program. – All of the following shall apply in the administration of 41
90-a utilization review program under this section: 42
91-(1) Qualified health care professionals shall administer the utilization review 43
92-program and oversee review decisions under the direction of a medical doctor. 44
93-A medical doctor licensed to practice medicine in this State shall evaluate the 45
94-clinical appropriateness of noncertifications. 46
95-(2) Compensation to persons involved in utilization review shall not contain any 47
96-direct or indirect incentives for them to make any particular review decisions. 48
97-(3) Compensation to utilization reviewers shall not be directly or indirectly based 49
98-on the number or type of noncertifications they render. 50 General Assembly Of North Carolina Session 2025
99-House Bill 634-First Edition Page 3
100-(4) In issuing a utilization review decision, an insurer shall: obtain or its URO 1
101-shall do all of the following: 2
102-a. Obtain all information required to make the decision, including 3
103-pertinent clinical information; employ information. 4
104-b. Employ a process to ensure that utilization reviewers apply clinical 5
105-review criteria consistently; and issue consistently. 6
106-c. Apply the decision in a timely manner pursuant to this section. 7
107-…." 8
108-SECTION 2.(c) In accordance with G.S. 135-48.24(b) and G.S. 135-48.30(a)(7) 9
109-which require the State Treasurer to implement procedures that are substantially similar to the 10
110-provisions of G.S. 58-50-61 for the North Carolina State Health Plan for Teachers and State 11
111-Employees (State Health Plan), the State Treasurer and the Executive Administrator of the State 12
112-Health Plan shall review all practices of the State Health Plan and all contracts with, and practices 13
113-of, any third party conducting any utilization review on behalf of the State Health Plan to ensure 14
114-compliance with subsection (b) of this section no later than the start of the next plan year. 15
115-SECTION 3.(a) The Revisor of Statutes shall replace the phrase "chemical 16
116-dependency" with the phrase "substance use disorder" in all of the following statutes: 17
117-(1) G.S. 58-51-16(a). 18
118-(2) G.S. 58-51-40(a). 19
119-(3) G.S. 58-51-55(b). 20
120-(4) G.S. 58-65-90(b). 21
121-(5) G.S. 58-67-75(b). 22
122-SECTION 3.(b) All of the following are repealed: 23
123-(1) G.S. 58-51-50. 24
124-(2) Subdivision (a)(2) and subsection (c) of G.S. 58-51-55. 25
125-(3) G.S. 58-65-75. 26
126-(4) Subdivision (a)(2) and subsection (c) G.S. 58-65-90. 27
127-(5) G.S. 58-67-70. 28
128-(6) Subdivision (a)(2) and subsection (c) G.S. 58-67-75. 29
129-SECTION 3.(c) G.S. 58-3-192(a)(2) reads as rewritten: 30
130-"(2) Autism spectrum disorder. – As defined by the most recent edition of the 31
131-Diagnostic and Statistical Manual of Mental Disorders (DSM) or the most 32
132-recent edition of the International Statistical Classification of Diseases and 33
133-Related Health Problems. Autism spectrum disorder is not considered a 34
134-mental illness health condition, as defined in G.S. 58-3-220, 58-51-55, or a 35
135-mental illness, as defined in G.S. 58-51-55, 58-65-90, or 58-67-75." 36
136-SECTION 4. This act is effective October 1, 2025, and applies to insurance contracts 37
137-issued, renewed, or amended on or after that date. 38
46+mental disorders coded in the DSM-5 or subsequent editions as autism 34
47+spectrum disorder (299.00), substance-related disorders (291.0 through 292.9 35
48+H.B. 634
49+Mar 31, 2025
50+HOUSE PRINCIPAL CLERK General Assembly Of North Carolina Session 2025
51+Page 2 DRH40297-MR-81
52+and 303.0 through 305.9), those coded as sexual dysfunctions not due to 1
53+organic disease (302.70 through 302.79), and those coded as "V" codes. 2
54+… 3
55+(g) Utilization Review. – Nothing in this section prevents an insurer from applying 4
56+utilization review criteria to determine medical necessity as defined in G.S. 58-50-61 as long as 5
57+it does so in accordance with all requirements for utilization review programs and medical 6
58+necessity determinations specified in that section, including the offering of an insurer appeal 7
59+process and, where applicable, health benefit plan external review as provided for in Part 4 of 8
60+Article 50 of Chapter 58 of the General Statutes.in accordance with G.S. 58-50-61. Clinical 9
61+review criteria and assessment of medical necessity for a treatment modality for any mental 10
62+health condition, including substance use disorders, shall be consistent with the criteria used for, 11
63+and the manner of assessment applied to, the medical necessity of non-mental health conditions. 12
64+For substance use disorders, medical necessity determinations shall rely solely on the most recent 13
65+American Society of Addiction Medicine criteria. 14
66+(i) Federal Law Applies. – Notwithstanding any other provisions of this section, a group 15
67+health benefit plan that covers both medical and surgical benefits and mental health benefits shall, 16
68+with respect to the mental health benefits, comply with all All applicable standards of Subtitle B 17
69+of Title V of Public Law 110-343, known as the Paul Wellstone and Pete Domenici Mental 18
70+Health Parity and Addiction Equity Act of 2008, and the applicable regulations, as 19
71+amended.amended, and other relevant federal law shall apply to health benefit plans." 20
72+SECTION 2.(b) G.S. 58-50-61 reads as rewritten: 21
73+"§ 58-50-61. Utilization review. 22
74+… 23
75+(d) Program Operations. Clinical Review Criteria, Generally. – In every utilization 24
76+review program, an insurer or URO shall use documented clinical review criteria that are based 25
77+on sound clinical evidence and that are periodically evaluated to assure ongoing efficacy. An 26
78+Except as otherwise provided, an insurer may develop its own clinical review criteria or purchase 27
79+or license clinical review criteria. 28
80+(d1) Criteria for determining when a patient needs to be placed in a substance abuse 29
81+treatment program shall be either (i) the diagnostic criteria contained in Clinical Review Criteria, 30
82+Substance Use Treatment. – Clinical review criteria and assessment of medical necessity for a 31
83+treatment modality for any mental health condition, including substance use disorders, shall be 32
84+consistent with the criteria used for, and the manner of assessment applied to, the medical 33
85+necessity of non-mental health conditions. For substance use disorders, medical necessity 34
86+determinations shall rely solely on the most recent revision of the American Society of Addiction 35
87+Medicine Patient Placement Criteria for the Treatment of Substance-Related Disorders or (ii) 36
88+criteria adopted by the insurer or its URO. criteria. The Department, in consultation with the 37
89+Department of Health and Human Services, may require proof of compliance with this subsection 38
90+by a plan an insurer or URO. 39
91+(d2) Administration of Program. – All of the following shall apply in the administration of 40
92+a utilization review program under this section: 41
93+(1) Qualified health care professionals shall administer the utilization review 42
94+program and oversee review decisions under the direction of a medical doctor. 43
95+A medical doctor licensed to practice medicine in this State shall evaluate the 44
96+clinical appropriateness of noncertifications. 45
97+(2) Compensation to persons involved in utilization review shall not contain any 46
98+direct or indirect incentives for them to make any particular review decisions. 47
99+(3) Compensation to utilization reviewers shall not be directly or indirectly based 48
100+on the number or type of noncertifications they render. 49
101+(4) In issuing a utilization review decision, an insurer shall: obtain or its URO 50
102+shall do all of the following: 51 General Assembly Of North Carolina Session 2025
103+DRH40297-MR-81 Page 3
104+a. Obtain all information required to make the decision, including 1
105+pertinent clinical information; employ information. 2
106+b. Employ a process to ensure that utilization reviewers apply clinical 3
107+review criteria consistently; and issue consistently. 4
108+c. Apply the decision in a timely manner pursuant to this section. 5
109+…." 6
110+SECTION 2.(c) In accordance with G.S. 135-48.24(b) and G.S. 135-48.30(a)(7) 7
111+which require the State Treasurer to implement procedures that are substantially similar to the 8
112+provisions of G.S. 58-50-61 for the North Carolina State Health Plan for Teachers and State 9
113+Employees (State Health Plan), the State Treasurer and the Executive Administrator of the State 10
114+Health Plan shall review all practices of the State Health Plan and all contracts with, and practices 11
115+of, any third party conducting any utilization review on behalf of the State Health Plan to ensure 12
116+compliance with subsection (b) of this section no later than the start of the next plan year. 13
117+SECTION 3.(a) The Revisor of Statutes shall replace the phrase "chemical 14
118+dependency" with the phrase "substance use disorder" in all of the following statutes: 15
119+(1) G.S. 58-51-16(a). 16
120+(2) G.S. 58-51-40(a). 17
121+(3) G.S. 58-51-55(b). 18
122+(4) G.S. 58-65-90(b). 19
123+(5) G.S. 58-67-75(b). 20
124+SECTION 3.(b) All of the following are repealed: 21
125+(1) G.S. 58-51-50. 22
126+(2) Subdivision (a)(2) and subsection (c) of G.S. 58-51-55. 23
127+(3) G.S. 58-65-75. 24
128+(4) Subdivision (a)(2) and subsection (c) G.S. 58-65-90. 25
129+(5) G.S. 58-67-70. 26
130+(6) Subdivision (a)(2) and subsection (c) G.S. 58-67-75. 27
131+SECTION 3.(c) G.S. 58-3-192(a)(2) reads as rewritten: 28
132+"(2) Autism spectrum disorder. – As defined by the most recent edition of the 29
133+Diagnostic and Statistical Manual of Mental Disorders (DSM) or the most 30
134+recent edition of the International Statistical Classification of Diseases and 31
135+Related Health Problems. Autism spectrum disorder is not considered a 32
136+mental illness health condition, as defined in G.S. 58-3-220, 58-51-55, or a 33
137+mental illness, as defined in G.S. 58-51-55, 58-65-90, or 58-67-75." 34
138+SECTION 4. This act is effective October 1, 2025, and applies to insurance contracts 35
139+issued, renewed, or amended on or after that date. 36