Delaware

There are 5 sections of the state insurance law relevant to parity. There are two identical sections for coverage of certain behavioral health conditions, and two identical sections for coverage of autism. There is also a section that requires large employer fully-insured plans to comply with the section of federal law in which the Federal Parity Law, used to reside. However, the location of the Federal Parity Law within federal law has changed and therefore this section of Delaware law no longer directly refers to the Federal Parity Law. However, this section does say that plans must comply with “any subsequent changes in federal law”, which could be interpreted as requiring plans to comply with the current Federal Parity Law.

It is not possible to provide a direct link to any of these sections. To find the sections that apply to individual plans, click here and scroll to “§ 3343 Insurance coverage for serious mental illness” for the behavioral health section and “§ 3366 Autism spectrum disorders coverage” for the autism section.

To find the sections that apply to employer plans, click here and scroll to “§ 3578 Insurance coverage for serious mental illness” for the behavioral health section and click here and scroll to “§ 3570A Autism spectrum disorders coverage” for the autism section.

To find the section that requires large employer fully-insured plans to comply with the section of federal law that used to contain the Federal Parity Law, click here and scroll to “§ 3576 Mental health parity”

These sections require individual plans, small employer fully-insured plans, and large employer fully-insured plans to cover services for the following conditions, as defined in the DSM :

• Schizophrenia
• Bipolar disorder
• Obsessive-compulsive disorder
• Major depressive disorder
• Panic disorder
• Anorexia nervosa
• Bulimia nervosa
• Schizoaffective disorder
• Delusional disorder
• Substance use disorders (“drug and alcohol dependencies”)

Deductibles, copayments, coinsurance, annual maximums, lifetime maximums, inpatient day limits, outpatient visit limits, any other durational limits, and coverage for prescription medication for the listed behavioral health conditions must not “place a greater financial burden” than those in place for other medical services.

Plans are explicitly allowed to use non-quantitative treatment limitations (NQTLs) and other managed care techniques in ways that are “unique to mental health benefits.” It also states “This section shall not be interpreted to require a carrier to employ the same benefit management procedures for serious mental illnesses and drug and alcohol dependencies that are employed for the management of other illnesses”. This could be interpreted to mean that NQTLs can be used more frequently or more restrictively.

These sections do not apply to out-of-network behavioral health services.

These sections require individual plans, small employer fully-insured plans, and large employer fully-insured plans to cover autism services through age 20. Plans must cover an annual maximum of $36,000 for applied behavior analysis, which can be adjusted for inflation each year.

Plans cannot have any outpatient visit limits and financial requirements must be the same as those in place for other medical services.

Autism spectrum disorders are defined as “pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), including Autistic Disorder, Asperger’s Disorder and Pervasive Developmental Disorder Not Otherwise Specified.”

Treatments for autism are listed as (and defined in this section):

• Behavioral health treatment (applied behavior analysis )
• Pharmacy care
• Psychiatric care
• Psychological care
• Therapeutic care

Insurance plans may only review a child’s treatment plan once per year.

These sections also require the Secretary of the Department of Health and Social Services to review best practices and evidence-based research regarding medically necessary care for autism and inform the Commissioner of the Department of Insurance of these findings. The Commissioner is then required to issue a bulletin to plans informing them of the latest medically necessary treatments for autism they must cover.