The Delaware Department of Insurance issues a submission guide(pdf | Get Adobe® Reader®) for insurers who want to sell qualified health plans on the individual and small group market. This guide explains that plans must comply with the Federal Parity Law and the parity sections of the state insurance law (page 16). It informs plans that the Department will be reviewing all plans to make sure that they comply with state and federal parity laws (page 16). It also requires plans to fill out a checklist to demonstrate their compliance with the Federal Parity Law and the parity sections of the state insurance law (pages 52 and 53).
Primary Focus: Federal Compliance Agency: Delaware Health and Social Services (“Department”) / Division of Medicaid and Medical Assistance Title/Description: Title XXI CHIP Compliance with MHPAEA Citation: 21 DE Reg. 805 Summary: The Delaware Health and Social Services (“Department”) / Division of Medicaid and Medical Assistance submitted proposal DE 3290 to amend Title XXI CHIP Plan regarding MHPAEA specifically, to align the Delaware CHIP Plan with new Federal Requirements. The purpose of the proposed regulation was to ensure that coverage provided to CHIP beneficiaries for mental health and substance use disorders was no more restrictive than coverage for medical/surgical conditions. The final order for 21 DE Reg. 805 was issued on April 4, 2018 via DE 3357.
The regulation covers how the state determines whether each covered benefit is a medical/surgical, mental health, or substance use disorder. It categorizes each benefit as inpatient, outpatient, emergency care, and a prescription drug. The regulation also lists the annual and aggregate lifetime dollar limits for benefits covered under the State child health plan. In addition it ensures that NQTLs comply with parity requirements and that information on medical necessity criteria and denials of payment or reimbursements are available. Attachments cover benefits by classification, NQTL analysis, and cost-sharing methodology. Effective Date: April 11, 2018 Notes: N/A
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 an older version of the Federal Parity Law, known as the Mental Health Parity Act of 1996. However, that 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.
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.
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):
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.
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