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This page lists some of the action toward parity compliance undertaken by Pennsylvania 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

2018

Primary Focus: Outpatient Psychiatric Services and Clinics
Agency: The Department of Human Services
Title/Description: Outpatient Psychiatric Services and Psychiatric Outpatient Clinics
Citation: 47 Pa.B. 4689
Summary: The Department of Human Services proposes to amend Chapters 1153 and 5200 to be consistent with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) to reflect changes in benefit packages resulting from the implementation of Medicaid expansion under the Patient Protection and Affordable Care Act and the consolidation of adult benefit packages, as well as codify the requirements for the delivery of Mobile Mental Health Treatment (MMHT). This proposed rulemaking will allow licensed professionals to work within their scope of practice in psychiatric outpatient clinics, increase access to medically necessary services, including the provision of mobile treatment, and reduce the paperwork requirements for licensed providers.
Effective Date: Bulletin released on August 12, 2017.
Notes: 55 PA. CODE §1153, 55 PA. CODE §5200

8/2017

Primary Focus: Outpatient Psychiatric Services and Clinics
Agency: The Department of Human Services
Title/Description: Outpatient Psychiatric Services and Psychiatric Outpatient Clinics
Citation: 47 Pa.B. 4689
Summary: The Department of Human Services proposes to amend Chapters 1153 and 5200 to be consistent with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) to reflect changes in benefit packages resulting from the implementation of Medicaid expansion under the Patient Protection and Affordable Care Act and the consolidation of adult benefit packages, as well as codify the requirements for the delivery of Mobile Mental Health Treatment (MMHT). This proposed rulemaking will allow licensed professionals to work within their scope of practice in psychiatric outpatient clinics, increase access to medically necessary services, including the provision of mobile treatment, and reduce the paperwork requirements for licensed providers.
Effective Date: Bulletin released on August 12, 2017.
Notes: 55 Pa. Code §1153, 55 Pa. Code §5200

2016

Health plans in Pennsylvania must complete an ACA compliance checklist.(pdf | Get Adobe® Reader®) Within this checklist, states must assert that they comply with the Federal Parity Law and state parity law. The parity sections of this checklist are the same as the document(pdf | Get Adobe® Reader®) from 2015.

10/2016

The Pennsylvania Insurance Department released a bulletin to provide additional guidance on parity. The bulletin provides background information on and basic requirements within the Federal Parity Law,the Affordable Care Act, and relevant state law. The bulletin then defines the impact of the different laws on plans offered in the individual,small, and large group markets. The bulletin provides two examples on the interaction between these laws.

The first example is of an individual prescribed residential treatment for a substance use disorder. The bulletin details the coverage limitations for different plans. The second example is an enrollee who needs an opioid reversal agent, such as naloxone. The bulletin makes it very clear that no individual,small, or large group plan can require more stringent prior authorization review for an opioid reversal agent, than a medical/surgical prescription drug.

The bulletin also explicitly states all group policies can not use medical management techniques on any substance use disorder service until after the minimum requirements of the section of state law that defines mandated benefits for substance use disorders are met.

10/2016

The Pennsylvania Insurance Department released a comprehensive consumer guide to mental health and substance use disorder treatment. The report is divided into different types of insurance. It then specifies the rights one is entitled to under each insurance plan. The final section provides resources for individuals if they need further assistance.

09/2016

The Pennsylvania Department of Drug and Alcohol Programs held the first of six public hearings examining existing laws government drug and alcohol treatment, including the Federal Parity Law. This multi-agency initiative includes representation from the Pennsylvania Insurance Department.

07/2016

The Pennsylvania Insurance Department released a newsletter.(pdf | Get Adobe® Reader®) On page 2 of the newsletter, Insurance Commissioner Theresa Miller discusses the importance of mental health and substance use disorder parity. In the article, she highlights efforts by the insurance department to increase enforcement of the Federal Parity Law and state parity law through policy review and market conduct exams, and consumer knowledge.

02/2016

The Pennsylvania Insurance Department released a consumer alert on mental health insurance coverage. This alert provides brief descriptions of an individual’s rights to mental health and substance use disorder care under the Federal Parity Law and the Affordable Care Act. It also links to the FAQ released in 07/2016 on the Federal Parity Law.

07/2015

The Pennsylvania Insurance Department released an FAQ to help consumers understand how the Federal Parity Law impacts their insurance. The FAQ explains who the Federal Parity Law applies to, what it mandates, and how it differs from the state parity law. The FAQ also provides link to other sources for more information.

12/2013

The Pennsylvania Insurance Department issued a notice to advise insurance plans about Governor Corbett’s proposed “Healthy Pennsylvania” Medicaid expansion. The notice had a specific provision stating that the state’s Medicaid program would become two commercial-like benefit packages and would include “mental health parity .” However, this notice became irrelevant in early 2015 after newly-elected Governor Wolf announced that Pennsylvania would enact a different form of Medicaid expansion rather than the “Healthy Pennsylvania” plan.

3/2009

The Pennsylvania Insurance Department issued a notice to advise insurance plans about the autism provisions in state law (state law found below.) Specifically, the Department issued guidance to clarify ambiguity related to the “general exclusions or limitations” language within the law. The notice stated that:

  • “Pharmacy care, psychiatric care, psychological care, rehabilitative care and therapeutic care must be provided to the extent such treatments are medically necessary …irrespective of whether those types of care are otherwise excluded by the policy.”
  • Treatments or services for autism not specified in the state law may be excluded by a policy if they are also excluded for other medical care. The notice uses the example of, “if a policy generally excludes acupuncture treatment, and an autism provider believes that acupuncture may provide some benefit to his autism patient, that particular treatment may nonetheless be excluded from the mandated coverage.”
  • Plans may impose general limitations, such as scope and duration limitations, if they do so for other medical care.
  • Reinforces the language in the law prohibiting visit limitations

Pennsylvania Parity Law

Pennsylvania’s parity provisions are found within the state’s Insurance Company Law of 1921. Please scroll down to page 174 section 635.1. The relevant section ends on pg 179.

The Pennsylvania law is not a comprehensive parity law because it only applies to certain conditions and it does not require insurance plans to provide behavioral health coverage at the same terms and conditions as coverage for other medical care, without exceptions.

The law applies to people with “serious mental illnesses” (SMI), which are defined as:

  1. Schizophrenia
  2. Bipolar disorder
  3. Obsessive-compulsive disorder
  4. Major depressive disorder
  5. Panic disorder
  6. Anorexia nervosa
  7. Bulimia nervosa
  8. Schizoaffective disorder
  9. Delusional disorder

For people with SMI, plans are required to cover at least 30 days of inpatient care and 60 outpatient visits per year. Patients are allowed to convert every 1 inpatient day to 2 outpatient visits, if they so choose. The law does specify that there cannot be any annual maximum or lifetime maximum in coverage that are different than limits for other medical care.

A separate section of the state insurance law requires large employer fully-insured plans to comply with the Federal Parity Law (scroll to 601-B on page 201).

Autism Coverage

The law does have an additional subsection addressing autism spectrum disorders for people up to age 21. Plans are required to cover at least $36,000 of treatment for autism every year without any visit limitations. The law provides specific definitions for the following:

  1. Applied behavioral analysis
  2. Autism service provider
  3. Autism Spectrum disorders
  4. Behavior specialists
  5. Diagnostic assessment of autism spectrum disorders
  6. Terms and conditions for receiving licensure as a behavior specialist

The law explicitly allows insurance plans to use utilization management at least once every 6 months. The law also explicitly grants insureds the right to expedited internal and external review processes upon denial of coverage.

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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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