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

2016

The Insurance Division of the Tennessee Department of Commerce and Insurance issued an interpretive opinion, (pdf | Get Adobe® Reader®) as a letter, in response to a request to clarify standards for utilization review for outpatient mental health and chemical dependency care under Tennessee Code § 56-6-705. The interpretive opinion clarifies that generally a patient is entitled to 12 visits to a provider for outpatient mental health and chemical dependency care followed by twelve additional visits, pending utilization review. This standard is permissible if it is no more restrictive than the standard applied for medical benefits.

The opinion goes on to apply this standard to three scenarios:

  • Intensive outpatient care for chemical dependency treatment from an out of network provider
  • Neuropsychological testing for Alzheimer’s disease diagnosis and follow up
  • Autism spectrum disorder services on a “per hour” basis rather than a “per visit” basis.

2013

The Insurance Division of the Tennessee Department of Commerce and Insurance issued an interpretive opinion (pdf | Get Adobe® Reader®), as a letter, in response to a request to clarify the term “at risk population” used in a section of the Tennessee Code § 56-6-705(a)(10)©. Under this law, follow-up utilization review for outpatient mental health and chemical dependency services can only make up 18% of the total number of outpatient mental health and chemical dependency services. There is an exception to this for at risk populations, making it so the 18% utilization review limit does not apply. Under this law, at risk populations can be subject to more follow-up review.

The Insurance Division stated that at risk populations are patients that are being seen for more than two visits a week or patients with reported or suspected substance abuse .

The opinion specifically states that this is the opinion of the Insurance Division, and not of the Department of Commerce and Insurance as a whole.

Please be aware that it is not possible to provide a direct link to Section 56-6-705(a)(10)© of the law. To find this section, go to this link and click on the plus sign next to Title 56. Then click on the plus sign next to Chapter 6.

2011

The Tennessee Attorney General’s Office released an opinion (pdf | Get Adobe® Reader®) on the Federal Parity Law , and three Tennessee statutes that address insurance coverage of behavioral health conditions: Sections 56-7-2360, 56-7-2601, and 56-7-2602. The opinion was requested by State Senator Douglas Henry.

The opinion states that the Commissioner of the Tennessee Department of Commerce and Insurance is responsible for enforcing Tenn. Code Ann. § 56-7-2602.

The opinion also states that there is not a private cause of action under Tenn. Code Ann. § 56-7-2602. However, the opinion also states that Tenn. Code Ann. § 56-7-2602 allows administrative enforcement by the Commissioner and criminal penalties for violations of the law.

The opinion goes on to state that there is no statutory authority for a state agency to enforce the Internal Revenue Code or ERISA , therefore, no state agency can enforce the parts of the Federal Parity Law that amend those statutes. However, the Commissioner may enforce the Federal Parity Law and regulations that apply to group health insurance policies offered and sold in Tennessee.

The opinion also states that Tenn. Code Ann. § 56-7-2602 requires insurers selling group health insurance plans to offer coverage for substance use disorders on the same terms as physical health services. However, the entity purchasing the insurance (generally the employer), can reject this coverage. Under Tennessee law, the purchaser may reject behavioral health coverage or purchase less extensive coverage for behavioral health benefits.

The opinion states that the Federal Parity Law applies to group health plans with more than fifty employees, and for nonfederal governmental plans, the Federal Parity Law applies to group health plans with more than one hundred employees.

Tennessee Parity Law

The sections of Tennessee law relevant to parity can be found in the state’s Insurance Law:

Please be aware that it is not possible to provide direct links to any of these sections of the law. To find these sections, go to this link and click on the plus sign next to Title 56. Then click on the plus sign next to the appropriate chapter. Then click on the plus sign next to the appropriate part (2360 and 2367 are part 23. 2601 and 2602 are part 26.)

Large Employer Fully-Insured Plans

This section of the law states that for large employer fully-insured plans , annual maximums and lifetime maximums for mental health services must be determined similarly to how they are for other medical services. Small employer plans and individual plans are specifically exempted from this.

This section of the law requires 20 days of inpatient mental healthcare and 25 outpatient visits. The law also allows the days of inpatient days to be used instead for residential care or partial hospitalization with the day limit doubled so that a person could have up to 40 days of coverage.

This section of the law makes it clear that office visits for medication management do not count as outpatient visits.

This section of the law specifically says that it does not apply to treatment of substance use disorders .

Small Employer Fully-Insured Plans and Individual Plans

Insurance companies must offer small employer fully-insured plans and individuals plans that meet the requirements listed here for behavioral health coverage. However, the small employers or individual can choose different plans that do not meet these requirements:

Substance Use Disorders

For substance use disorder services, insurance companies must offer large employer fully-insured and small employer fully-insured plans that have annual maximums , lifetime maximums , deductibles , coinsurance , inpatient day limits, and outpatient visit limits that are the same as those for other medical services. However the employer can decide not to accept it and choose a plan with less coverage or no coverage for substance use disorder services.

Autism

All insurance plans are required to cover autism services for children through age 11 that are “at least as comprehensive as those provided for other neurological disorders” (like epilepsy or cerebral palsy).

Insurance plans must cover autism services with the same financial requirements and treatment limitations used for services of other neurological disorders.

There is nothing in this section about annual maximums or lifetime maximums, unlike most other state laws about autism.

Utilization Review Agents

Within the sections of state law about utilization review agents there are several things that are relevant to parity :

  • Utilization review methods for behavioral health services must follow national criteria from either URAC or NCQA
  • Utilization review programs for behavioral health must give patient’s provider written copy of the criteria used
  • Medical necessity reviews must be made by a behavioral health professional in the same discipline as the patient’s provider
  • Patients must always be approved for at least 12 outpatient behavioral health visits
  • Agents are required to limit their review reports to 1 page and must send it to the patient using the internet
  • Agents are only allowed to have follow-up utilization reviews make up 18% of how many total reviews they conducted the previous year

Get Support

Tennessee 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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