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

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

Actions in the Regulatory Arena

7/2017

Primary Focus: Mandated Benefit: Provider
Title/Description: Vermont Insurance Notices and Bulletins
Summary: Mental Health Parity: Vermont’s mental health parity law (8 V.S.A. § 4089b) applies to all supplemental and blanket health insurance policies. For this reason, policies may not have lower benefit levels for mental health conditions than for other covered conditions and may not exclude coverage for accidents or sickness caused by mental illness or by alcohol or substance abuse. In addition, policies that provide hospital benefits may not exclude facilities that treat mental illness or alcohol or substance abuse from the definition of a hospital.
Issued Date: July 1, 2017

12/2014

Each year the Department of Financial Regulation files a performance report on managed care organizations. This is the 2014 edition (pdf | Get Adobe® Reader®). There are several sections relevant to parity, including many tables that track performance in terms of percentages; a red x with a circle around it next to any percentage indicates that the Department believes there is room for improvement:

  • Availability of and access to behavioral health providers (2.3.5-8, pages 18-20)
  • Grievance appeals outcomes for behavioral health and other medical treatment (3.4.1-4, pages 36-39)
  • Timelines in making grievance appeals decisions on behavioral health (3.4.7, page 43)
  • Outcome performance for behavioral health treatment (52-54)

The reports for other years can be found at the very bottom of this link. If you click on any of the linked years, the top report on the following page is the relevant report, like the one summarized above.

11/2014

The Department of Financial Regulation fined Cigna Behavioral Health $392,500 for violations of the state insurance law, including sections relevant to parity. The fine resulted from the Department finding that Cigna had used the recommendations of “unlicensed review agents” in making coverage determinations. These agents were under contract with the plan’s Independent review organization.

10/2013

The Department of Financial Regulation issued a regulation about distinguishing behavioral health primary care services from behavioral health specialty services, as required by the state law. Primary care services were defined as follows:

  • The most common or routine behavioral health services
  • Outpatient services only
  • Services provided to all regardless of age or gender

The regulation also noted that the Department would review these definitions every two years.

Primary Focus: Mandated Benefit: Provider
Agency: Department of Financial Regulation
Title/Description: Guidelines for Distinguishing Between Primary and Specialty Mental Health and Substance Abuse Services: Section 1: Purpose
Citation: 21-020-066 Vt. Code R. § 1
Summary: Under Vermont Law, a health plan shall apply member co-pays to mental health services and to medical services consistently in its health insurance policies/certificates. The member co-pay applicable to mental health and substance abuse services designated as “primary” when rendered by a mental health care provider shall be no greater than the member co-pay applicable to medical services rendered by a primary care provider. The member co-pay for “specialty” mental health and substance abuse services shall be no greater than the member co-pay applicable to specialty medical services and shall apply only to those mental health and substance abuse services not deemed “primary.”
Effective Date: October 1, 2013
Notes: N/A

4/2013

The Department of Financial Regulation issued a bulletin notifying plans that they may “not exclude coverage for medically necessary treatment including gender reassignment surgery for gender dysphoria and related health condition” It then stated that “new insurance policy forms filed by insurers will be disapproved by DFR if they exclude such coverage”

2011 (Exact Date Unclear)

The Department of Financial Regulation issued a regulation (pdf | Get Adobe® Reader®) regarding mental health review agents. Most of this regulation is about licensure requirements, but there is some information relevant to parity:

  • Clinical review criteria for utilization review and supervision of agents who perform reviews (Part 6.A.10-11, page 8)
  • Reporting requirements for renewal of licensure, which includes requirements to report the number of and outcomes of medical necessity reviews and number of and results of grievance appeals (Part 6.C.3.a-c, page 9)
  • Standards for service reviews (Part 7.A, page 10-11)

11/2012

The Department of Financial Regulation issued a bulletin (pdf | Get Adobe® Reader®) reminding health insurers of their requirement to cover less restrictive and less expensive alternatives to hospitalization for the treatment of mental health and substance use disorders.

4/2011

The Department of Financial Regulation (then called the Department of Banking, Insurance, Securities, and Health Care Administration) issued a bulletin notifying plans that they must comply with the section of the insurance law about autism coverage.

8/2010

The Department of Financial Regulation (then called the Department of Banking, Insurance, Securities, and Health Care Administration) issued a bulletin notifying plans that a section of the state insurance law relevant to parity had been changed and that plans could no longer deny coverage for behavioral health services just because they were provided out-of-network.

Primary Focus: Mandated Benefit: Provider
Agency: Department of Financial Regulation
Title/Description: Long Term Care Insurance Regulation: Section 6: Policy Practices and Provisions
Citation: 21-040-025 Vt. Code R. § 1
Summary: The regulates long term care insurance and mandates that no long-term care insurance policy may Deny benefits or coverage on the basis that the need for long-term care services arises from a mental health condition, including Alzheimer’s disease, dementia and other related disorders.
Effective Date: August 1, 1992
Notes: Amended April 1, 2010

12/2009

The Department of Financial Regulation issued a regulation (pdf | Get Adobe® Reader®) (see the bottom of this entry for an important note regarding page numbers) regarding managed care organizations (MCOs) that included a number of provisions related to parity. We will list the relevant sections of the regulation, where they can be found (including PDF page numbers), and how they are relevant:

  • Information regarding availability of behavioral health providers and how MCOs must disclose and orally communicate that information to patients (Part 2.2.C.2, pages 20-22 in PDF*)
  • Access to and continuity of behavioral health care and coordination with other medical care (Part 2.3.B.1-3, pages 22-23*)
  • Requirements for medical necessity criteria for behavioral health services (Part 3.1.C, page 26*)
  • Utilization management standards for behavioral health services (Part 3.1.E, pages 26-27*)
  • Grievance appeals standards for behavioral health services (Part 3.3.B.1, pages 34-35*)
  • Impact of quality improvement measures on behavioral health outcomes for patients (Part 6.3.B.5-7, page 63*)
  • Quality improvement goals regarding behavioral health for insurance plans, their contracted MCOs, and contracted mental health review agents, along with those entities reporting requirements to the Department of Financial Regulation (Part 6.4.C, page 68*)

*The page numbers listed are the visible page numbers within the document, NOT the page numbers given by your PDF viewer

4/2001

Primary Focus: Compliance: Reporting Requirement
Agency: Department of Financial Regulation
Title/Description: Health Insurance Coverage of Mental Health and Substance Abuse Services: Section 1: General Provisions
Citation: 21-040-016 Vt. Code R. § 1
Summary: The five largest health insurance companies doing business in Vermont, as measured by covered lives, are required to file with the Commissioner (1) an annual report card on the health insurance plan’s performance in relation to quality measures for the care, treatment, and treatment options of mental health and substance abuse conditions covered under the plan, and (2) the health insurance plan’s revenue loss and expense ratio relating to the care and treatment of mental health conditions covered under the health insurance plan. This regulation sets out the minimum reporting requirements.
Effective Date: April 3, 2001
Notes: N/A

11/1992

Primary Focus: Mandated Benefit: Provider
Agency: Department of Financial Regulation
Title/Description: Minimum Requirements for Compliance With 8 V.S.A. Section 4080(a) (Small Group Carriers): Section 5: Common Health Care Plans
Citation: 21-020-029 Vt. Code R. § 1
Summary: Except as stated in the model plan, no policy can be issued or delivered or advertised unless mental health care benefits, with the minimums stated in 8 V.S.A., Section 4089 are offered as an option, among other minimum benefit options.
Effective Date: November 1, 1992
Notes: N/A

7/1986

Primary Focus: Medicaid
Agency: Agency of Human Services
Title/Description: Department of Mental Health Medicaid Regulations
Citation: 13-150-004 Vt. Code R. § 1
Summary: Medicaid payment for covered services is limited to Community Mental Health Centers that are facilities established for the purpose of providing outpatient mental health care. Mental health clinic services cannot be reimbursed when provided in skilled nursing (Level I) or intermediate care (Level II) facilities. However, if a client is a resident of either type of facility and is seen at a mental health facility, the services provided may be billed.
Effective Date: July 1, 1986
Notes: N/A

Vermont Parity Law

There are three sections in the state insurance law relevant to parity. They will be summarized below in three parts:

Behavioral Health Coverage

This section requires individual plans, small employer fully-insured plans, large employer fully-insured plans, and any state-administered insurance plans to cover all behavioral health conditions listed in the ICD.

Plans cannot use any financial requirement or quantitative treatment limitation for behavioral health services that “places a greater burden on an insured” for access to care than what is in place for other medical services.

Plans cannot exclude any provider from in-network status if the provider is willing to meet the terms and conditions of being in the network.

There must be only one deductible for all medical care; not one for behavioral health care and another for other medical care.

Plans can use managed care (and separate managed care organizations) for behavioral health services, even if they do not for other medical services, but the managed care practices must follow regulations issued by the Commissioner of the Department of Financial Regulation. Those regulations must ensure that:

  • Timely access to care and an adequate amount of providers are available
  • Plan protocols and utilization review procedures do not reduce access to medically necessary care
  • The amount of plan premiums that are attributed to behavioral health services should be reviewed to determine if it is “excessive, inadequate, unfairly discriminatory, unjust, unfair, inequitable, misleading or contrary to the laws of” Vermont
  • Plans must complete an annual “quality improvement plan” with their managed care organizations to make sure they are using “best practices and evidence-based guidelines” concerning behavioral health services
  • Plans and their managed care organizations will have a list of “active” providers who have in-network status

Before issuing these rules, the Commissioner is required to consult the Commissioner of Mental Health to help design provider incentives for increasing access to care and incorporate “incorporating nationally recognized best practices and evidence-based guidelines into the utilization review” of behavioral health services.

The section specifies that plans are responsible for any actions of their separate managed care organizations and lists some penalties the Commissioner of the Department of Financial Regulation can use in case of a violation of this section or regulations regarding this section:

  • Fines
  • Cease and desist orders
  • Order a plan to correct any violations and end its contract with its managed care organization
  • Revoke or suspend the license of a plan or a managed care organization, or make their continued licensure contingent on conditions put in place by the Commissioner

This section also requires some insurance plans to file an annual report that includes the following information:

  • Behavioral health patient discharge rates from inpatient care, the average length of stay, and the percentage of those patients who were readmitted
  • Percentage of enrollees receiving behavioral health treatment and number of people denied behavioral health services
  • Number of denials appealed by patients and number of denials appealed by providers
  • Level of patient satisfaction with their behavioral health coverage

Utilization Review

This section is mostly about utilization review and requires the Commissioner of the Department of Financial Regulation to issue regulations. Some of the significant requirements are:

  • Plans’ utilization review agents must disclose to patients the criteria used when performing reviews and their credentials
  • Any utilization review or prior authorization that results in a denial of services must include the “evaluation, findings, and concurrence of a mental health professional whose training and expertise is at least comparable to that of the treating clinician”
  • The number of people involved in making utilization review decisions must be specified by the regulations
  • Utilization review decisions cannot be made without talking to the patient’s provider first
  • Review agents are forbidden from having agreements with insurance plans that financially incentivize the agent to deny or reduce benefits

Autism Coverage (Early Childhood Developmental Disorders)

This section requires individual plans, small employer fully-insured plans, large employer fully-insured plans, and Medicaid plans to cover autism services from birth through age 20.

There is no annual maximum for coverage, and the “amount, duration, and frequency” of treatment must be based on whether the treatment is medically necessary.

Financial requirements cannot be any different than those in place for other medical services.

Plans must cover services that take place in a child’s home, as long as they are provided by the appropriate professional for those services.

Plans can review a child’s treatment plan once every 6 months.

Autism spectrum disorder is defined as “one or more pervasive developmental disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, including autistic disorder, pervasive developmental disorder not otherwise specified, and Asperger’s disorder”

“Early childhood developmental disorder” is defined as “childhood mental or physical impairment or combination of mental and physical impairments that results in functional limitations in major life activities, accompanied by a diagnosis defined by the DSM or the ICD. The term includes autism spectrum disorders, but does not include a learning disability”

Treatment of autism is listed as the following (these are all defined in detail within the law):

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

It states that the Department of Financial Regulation should “facilitate and encourage” plans to bundle copayments for various autism services.

Get Support

Vermont 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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