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This page lists some of the action toward parity compliance undertaken by Missouri regulatory agencies since 2008.

Are we missing any actions taken by state regulatory agencies? Let us know at info@paritytrack.org

Action in the Regulatory Arena

The DIFP website contains a Mental Health Parity and Autism frequently asked questions (FAQ) sections. The Mental Health Parity FAQ contains infromation on the behavioral health conditions that fall under the parity law, coverage of residential treatment and anti-depressants, and self-insured plans. Among other topics, the Autism FAQ discusses when the coverage mandate went into effect, insurance plans impacted, covered treatments, and limits on applied behavior analysis treatment.

4/2016

The Missouri Department of Insurance, Financial Institutions and Professional Registration (DIFP) released a report (pdf | Get Adobe® Reader®) about complaints it had received from 2013-2015. During that time, the DIFP received 0 complaints in 2013, 2 complaints in 2014, and 4 complaints in 2015 that it it labeled as “mental health parity” (found on page 13). It is possible that other complaints, such as medical necessity, for example, may have been relevant to parity, but it is not possible to know that given the information that is in this report.

2/2016

The DIFP released its fifth annual report (pdf | Get Adobe® Reader®) about the effects and outcomes of the state law that mandates autism coverage for small employer plans and large employer fully-insured plans. Autism coverage is optional for individual plans. Below is a brief summary of the report’s findings:

  • The number of ABA treatments delivered increased from 14,505 in 2013 to 32,997 in 2015
  • Autism services represent only 0.25 percent of total claims. Given this small percentage of total premiums, it is unlikely that autism services will impact changes in insurance premiums
  • Because of the essential health benefit requirements of the Affordable Care Act, the percentage of individual plans covering autism services increased to 90%; in 2012 and 2013 the percentage was less than 33%.
  • The report pointed out that because DIFP has no jurisdiction over large employer self-insured plans it does not know how many people received autism coverage from these plans
  • The report summaries the settlements reached with Aetna, Chesapeake Life Insurance Company, the Mega Life and Health Insurance Company, and Mid-West National Life Insurance Company of Tennessee summarized below

10/2015

The DIFP reached a settlement agreement with Chesapeake Life Insurance Company, the Mega Life and Health Insurance Company and Mid-West National Life Insurance Company of Tennessee for their failure to provide coverage for autism services in compliance with state law and make their required payments to the First Steps Program from 2011-2014. First Steps offers coordinated services and assistance to children from birth to age 3 with delayed development or diagnosed conditions with associated developmental disabilities. In the settlement, the health insurers agreed to take the following actions:

  • Pay a joint $106,706 to the First Steps Program
  • Review their health plan compliance with state law
  • Review their claim files since 2011 to determine if any claims for autism coverage were improperly denied and then pay those claims identified in the review
  • Notify policyholders that coverage for autism is available
  • Make a $15,000 donation to the Thompson Foundation for Autism at the University of Missouri

5/2015

The DIFP took action against aetna for its continued failure to provide coverage for autism services in compliance with state law. The DIFP and Aetna reached a $4.5 million settlement that also allows the DIFP to suspend Aetna from doing business in Missouri for one year if the insurer violates the settlement during a three-year monitoring period. $1.5 million of the settlement will be suspended if Aetna complies with the agreement. This fine is the largest ever in Missouri for an insurance law violation. The DIFP previously fined Aetna $1.5 million in 2012 for non-compliance with the section of state law about autism coverage. As part of this settlement Aetna admitted that it did not perform a compliance audit after the 2012 settlement.

5/2015

The DIFP released a report (pdf | Get Adobe® Reader®) about complaints it had received from 2012-2014. During that time, the DIFP only received one complaint that it labeled as “mental health parity” (found on page 13). It is possible that other complaints, such as “medical necessity,” for example, may have been relevant to parity, but it is not possible to know that given the information that is in this report.

3/2015

The DIFP issued a letter (pdf | Get Adobe® Reader®) to out-of-state insurance plans that cover residents of Missouri. This letter informed these plans that they had to comply with certain sections of Missouri Insurance law, including the sections about mental health coverage, substance use disorder coverage, and autism coverage.

2/2015

The DIFP released its fourth annual report (pdf | Get Adobe® Reader®) about the effects and outcomes of the state law that mandates autism coverage for small employer plans and large employer fully-insured plans. Autism coverage is optional for individual plans. Here is a brief summary of the report’s findings:

  • All small employer plans and large employer fully-insured plans met the requirements of the law in 2014 and have since 2012
  • Because of the essential health benefit requirements of the Affordable Care Act, the percentage of individual plans covering autism services went up 92%; in 2012 and 2013 the percentage was less than 33%
  • 3,825 individuals received coverage for autism services in 2014
  • As of January 2013, 250 individuals were licensed as applied behavior analysts and 53 were licensed as assistant applied behavior analysts, with 247 and 41, respectively, reported as active
  • There were nearly $10 million in claims for autism coverage, with $5 million of that for coverage of applied behavior analysis
  • The average cost per month for coverage of someone diagnosed with autism spectrum disorder was $278
  • The DIFP stated that it is “very unlikely unlikely that costs for autism treatment will have an appreciable impact on insurance premiums”
  • The report pointed out that because DIFP has no jurisdiction over large employer self-insured plans it does not know how many people received autism coverage from these plans

2/2014

The DIFP released its third annual report (pdf | Get Adobe® Reader®) about the effects and outcomes of the state law that mandates autism coverage for small employer plans and large employer fully-insured plans. Autism coverage is optional for individual plans. Here is a brief summary of the report’s findings:

  • All small employer plans and large employer fully-insured plans met the requirements of the law in 2013; less than ⅓ of plans included autism coverage
  • 3,070 individuals received coverage for autism services in 2013
  • As of January 2013, 218 individuals were licensed as applied behavior analysts and 41 were licensed as assistant applied behavior analysts, with 181 and 23, respectively, reported as active
  • There were $8.3 million in claims for autism coverage, with $3.8 million of that for coverage of applied behavior analysis
  • The average cost per month for coverage of someone diagnosed with autism spectrum disorder was $255
  • The DIFP stated that it is “very unlikely unlikely that costs for autism treatment will have an appreciable impact on insurance premiums”
  • The report pointed out that because DIFP has no jurisdiction over large employer self-insured plans it does not know how many people received autism coverage from these plans

2/2014

Primary Focus: Mandated Benefit: Provider
Agency: The Department of Insurance, Financial Institutions and Professional Registration
Title/Description: Mental Health Services Allowed Out-of-Network
Citation: 20 CSR 400-2.160
Summary: Pursuant to section 376.811.4, RSMo Supp. 2012, an insurance company, health services corporation or health maintenance organization, must offer in all health insurance policies at least two (2) sessions per year for the purpose of diagnosis or assessment of mental health. This offer may not limit the choice of psychiatrist, licensed psychologist, licensed professional counselor or licensed clinical social worker, or, subject to contractual provisions, a licensed marital and family therapist who provides the service. An insured or enrollee may seek these services outside an insurer’s network if he or she is covered by an insurance company, a health services corporation, or a point of service plan provided by a health maintenance organization. 376.811 R.S.Mo. sets out the coverage required for chemical dependency by all insurance and health service corporations—minimum standards—offer of coverage may be accepted or rejected by policyholders, companies may offer as standard coverage—mental health benefits provided, when—exclusions.
Effective Date: Original rule filed Nov. 3, 1997, effective June 30, 1998. Amended: Filed Aug. 19, 2013, effective Feb. 28, 2014.
Notes: N/A

2/2013

The DIFP released its second annual report (pdf | Get Adobe® Reader®) about the effects and outcomes of the state law that mandates autism coverage for small employer plans and large employer fully-insured plans. Autism coverage is optional for individual plans. Here is a brief summary of the report’s findings:

  • All small employer plans and large employer fully-insured plans met the requirements of the law in 2012; less than ⅓ of plans included autism coverage
  • 2,508 individuals received coverage for autism services in 2012
  • As of January 2013, 161 individuals were licensed as applied behavior analysts, a 44% increase from the previous year
  • There were $6.6 million in claims for autism coverage, with $3 million of that for coverage of applied behavior analysis
  • The average cost per month for coverage of someone diagnosed with autism spectrum disorder was $222
  • The DIFP stated that it is “very unlikely unlikely that costs for autism treatment will have an appreciable impact on insurance premiums”
  • The report pointed out that because DIFP has no jurisdiction over large employer self-insured plans it does not know how many people received autism coverage from these plans

10/2012

The DIFP contracted a consulting firm to examine the state’s options for selecting a benchmark plan that conforms with the essential health benefits requirements mandated by the Affordable Care Act and submit a report. (pdf | Get Adobe® Reader®) The report stated that most benchmark plans in Missouri had mental health benefits at full parity. However, no further evidence or citations were provided to support this claim.

9/2012

The DIFP took action against Aetna for some of its insurance practices affecting Missouri residents covered by the insurer. One of the findings of this investigation was that Aetna had not been providing coverage for autism services, as they were required to do by state law since January 1, 2011. The DIFP and Aetna reached an agreement (pdf | Get Adobe® Reader®) under which Aetna would forfeit $1.5 million to the DIFP and donate $250,000 to autism charities in Missouri. Aetna was also required to send letters to all of its enrollees in Missouri and tell them that they could retroactively files claims for any autism treatment they or their dependents received since January 1, 2011. Aetna was also required to pay any of these back claims at a 9% interest rate. DIFP Action against Aetna for stating in plan documents that autism coverage was excluded

1/2012

The DIFP released its first annual report (pdf | Get Adobe® Reader®) about the effects and outcomes of the state law that mandates autism coverage for small employer plans and large employer fully-insured plans. Autism coverage is optional for individual plan. Here is a brief summary of the report’s findings:

  1. By the end of 2011 all small employer plans and large employer fully-insured plans met the requirements of the law
  2. 4,000 individuals received coverage for autism services in 2011
  3. 120 people held licenses as applied behavior analysts when the report was issued
  4. There were $4.3 million in claims related to autism coverage; $1.1 million were for applied behavior analysis
  5. The average cost per month for someone diagnosed with autism spectrum disorder was $143
  6. Applied behavior analysis programs were not operational for the first half of 2011
  7. The DIFP stated that it is “very unlikely unlikely that costs for autism treatment will have an appreciable impact on insurance premiums

1/2011

The DIFP issued a bulletin (pdf | Get Adobe® Reader®) to insurance plans about compliance with the section of state insurance law about autism coverage, which had just taken effect. It advised insurers of the preferred method of claims coding and asked insurers to notify autism service providers about these codes. The bulletin also advised insurance plans that the DIFP would “closely monitor the delivery of autism related services and consumer complaints to ensure no unnecessary barriers to medically necessary treatment or coverage restrictions are imposed by any insurance company.” Finally the bulletin asked insurance plans be flexible in accommodating coverage for children who could temporarily lose coverage because of procedural difficulties in transitioning to the requirements of the new requirements under state law.

9/2009

The DIFP issued a bulletin (pdf | Get Adobe® Reader®) that notified insurance plans about what was required of them under the then newly-passed Federal Parity Law and Missouri’s laws relevant to parity. This bulletin is no longer relevant and is listed on DIFP’s website in a section called “Archive of Inoperative and Obsolete Bulletins.”

Missouri Parity Law

There are multiple sections of Missouri’s insurance law that are relevant to parity:

Each section will be described separately with explanations of its relationship with other sections, when necessary.

Section 376.1550

This section requires all small employer fully-insured plans, large employer fully-insured plans and state employee plans to cover all mental health conditions in the DSM; it specifically exempts coverage for substance use disorders instead stating that plans have to comply with 376.811. It forbids plans from having any lifetime limits, annual limits, copayments, coinsurance, outpatient visit limits for mental health services that are more expensive or restrictive than those in place for other medical services. It requires plans to have one deductible or out-of-pocket limit for both mental health services and other medical services. It does not address inpatient day limits.

This section allows plans to use managed care for mental health coverage even if they do not use managed care for other medical coverage. It also allows plans to use a more involved form of managed care for mental health coverage than what they use for other medical coverage. However, it does state that administrative and clinical procedures should “not serve to reduce access to medically necessary treatment”. This could be interpreted as addressing non-quantitative treatment limitations such as medical necessity review, prior authorization, and step therapy.

This section also allows employers to apply for a waiver exempting them from this section of the law if they can show that their plan’s compliance with this section caused premiums to increase by at least 2%.

Section 376.811

This section requires individual plans, small employer fully-insured plans, and large employer fully-insured plans to offer optional behavioral health coverage that individuals and employers can accept or reject.

Because section 376.1550 requires small employer fully-insured plans and large employer fully-insured plans to cover mental health services, the parts of this section about mental health coverage only apply to individual plans, with some possible exceptions (explained below).

The offered coverage for substance use disorder services must meet the following requirements:

  • 26 visits of outpatient care and partial hospitalization
  • 21 days of residential treatment
  • 6 days of detoxification
  • A lifetime limit of 10 episodes of treatment, with episode defined as “a distinct course of chemical dependency treatment separated by at least thirty days without treatment”
  • Financial requirements that are equal to those used for other medical services

The offered coverage for mental health services must meet the following requirements:

It is possible that the last two parts about residential treatment are relevant for small employer fully-insured plans and large employer fully-insured plans because section 376.1550 does not list any requirements about residential treatment or inpatient care.

This section of the law also has an outdated subsection that requires plans to comply with sections of the law that expired in 2011 if an individual or employer rejects the behavioral health coverage offer.

This section only applies to individual plans and requires them to cover at least 30 days of inpatient or residential treatment for alcoholism. Plans are not allowed to deny coverage for any services at a facility certified by the state’s Department of Mental Health. This section is superseded by section 376.811 if an individual accepts the offer of behavioral health coverage as part of his plan, as described in section 376.811.

Section 376.1224

This section requires autism coverage for small employer fully-insured plans, large employer fully-insured plans, self-insured governmental plans, self-insured school district plans, and several other forms of self-insured plans that are not under ERISA. Some of the most significant requirements of this section are:

  • Coverage for Autistic Disorder, Asperger’s Disorder; Pervasive Developmental Disorder not Otherwise Specified, Rett’s Disorder, and Childhood Disintegrative Disorder
  • $40,000 annual maximum for applied behavior analysis for children through age 18; other treatments are not subject to this annual maximum or age limitation (dollar amount is adjusted for inflation each year)
  • No outpatient visit limits
  • Coverage of psychiatric care, psychological care, habilitative or rehabilitative care, therapeutic care, and pharmacy care (all of these are defined in the section)
  • Insurance plans can only review a treatment plan once every six months
  • Financial requirements must be the same as what are in place for other medical services

Individual plans are not required to cover autism services, but they must offer it as optional coverage.

All plans are exempt from covering any services that are classified as a Part C early intervention program.

Small employers can apply for an exemption if they can show their premium costs increased by at least 2.5% in any 12-month period.

The section does not apply to Missouri HealthNet plans (Medicaid).

Get Support

Missouri Insurance Division

Common Violations

In seeking care or services, be aware of the common ways parity rights can be violated.

Common Violations

Definition

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