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

2/2018

Primary Focus: Amount, Duration, and Scope of Medical and Remedial Care Services. Demonstration Waiver Services
Agency: Department of Medical Assistance Services
Title/Description: 12VAC30-130 Amount, Duration and Scope of Medical and Remedial Care Services (amending 12VAC30-130-5030); 12VAC30-135 Demonstration Waiver Services (adding 12VAC30-135-400 through 12VAC30-135-498)
Citation: 12 VA. ADMIN. CODE § 30-130
Summary: This action establishes the Governor’s Access Plan (GAP) Demonstration Waiver for Individuals with Serious Mental Illness to provide individuals with serious mental illness access to certain basic medical and behavioral services. The serious mental illness criteria include specific diagnoses, for example, schizophrenia; bipolar disorders; post-traumatic stress disorder; specific duration of illnesses; specific levels of impairment; and consistent need for help in accessing health care services. To qualify, the individual must also be uninsured and ineligible for any state or federal health insurance programs.
Effective Date: February 7, 2018
Notes: N/A

3/2016

The Virginia Bureau of Insurance requires plans to complete a checklist (pdf | Get Adobe® Reader®) that demonstrates how they comply with the parity sections of the state insurance law and the Federal Parity Law (the parity sections of the state insurance law is summarized at the bottom of this page under “Virginia Parity Law”). There are 4 categories relevant to parity in the checklist:

Each of these categories has detailed instructions for how plans must comply with the relevant laws. Page 3 lists 9 different NQTLs and informs plans that “an NQTL must not be designed to restrict access to MH/SUD benefits.” This checklist is the same as the 3/2015 checklist.

5/2015

The Virginia Bureau of Insurance issued an administrative letter (pdf | Get Adobe® Reader®) that provided summaries of insurance-related statutes enacted or amended during the 2015 legislative session. The letter summarizes SB 1747, which requires individual plans to provide mental health and substance use disorder benefits that are in parity with medical and surgical benefits. It also requires the Bureau of Insurance to develop reporting requirements for denied claims, complaints, and appeals.

4/2015

The Virginia Bureau of Insurance issued an administrative letter (pdf | Get Adobe® Reader®) that withdrew a previous administrative letter. This letter clarified that recently-passed legislation had removed the language in the section of the state insurance law about autism coverage that exempted only small employer plans with 50 or fewer employees. Before this language was removed there was confusion on the part of insurers about what this would mean in January of 2016 when the definition of a small employer plan changes to a plan with 100 or fewer employees.

3/2015

The Virginia Bureau of Insurance requires plans to complete a checklist (pdf | Get Adobe® Reader®) that demonstrates how they comply with the parity sections of the state insurance law and the Federal Parity Law (the parity sections of the state insurance law is summarized at the bottom of this page under “Virginia Parity Law”). There are 4 categories relevant to parity in the checklist:

Each of these categories has detailed instructions for how plans must comply with the relevant laws. Page 3 lists 9 different NQTLs and informs plans that “an NQTL must not be designed to restrict access to MH/SUD benefits.” This checklist is the same as the 3/2016 checklist.

1/2015

Primary Focus: Parity-General
Agency: State Corporation Commission, Bureau of Insurance
Title/Description: Basic Health Care Services
Citation: 14 VAC 5-211-160
Summary:  A health maintenance organization that offers coverage in the large group market shall provide, or arrange for the provision of, as a minimum, basic health care services. Mental health and substance use disorder services shall be provided on parity with the medical and surgical benefits contained in the plan in accordance with the Mental Health Parity and Addiction Equity Act of 2008.
Effective Date:  January 1, 2015
Notes: VA.R. Doc. No. R14-3888 (VA Regulations VOL. 31 ISS. 3 – OCTOBER 06, 2014)

4/2013

The Virginia Bureau of Insurance released Essential Health Benefits Guidance (pdf | Get Adobe® Reader®) – a document that helps insurers design plans in compliance with essential health benefit requirements. Section V on page 11 addresses mental health and substance use disorder services, including behavioral health treatment. In the comments section, the document specifies that insurers can not apply a quantitative treatment limitation, like day or visit limits, for behavioral health treatment if it is not also applied to medical/surgical benefits. The document goes on to comment on covered outpatient, inpatient, and residential treatment services for mental health and substance use disorders.

9/2012

The Bureau of insurance released two separate market conduct examination reports. One was in regards to HealthKeepers, Inc. and the other was in regards to Priority Health Care Inc. Among many other things, the Bureau investigated both plans for its compliance with the parity sections of the state insurance law. The investigation revealed that both plans were using different copayments for some mental health services than for other medical services, thus making the plans technically non-compliant with the law. However, both plans strongly disagreed with this interpretation of the the state insurance law because the copayments they were using for mental health services were lower than those used for other medical services (emphasis added by ParityTrack). The Bureau conceded that this was true and did not take any punitive action (found on pages 26, 27, and 28 of the Priority report (pdf | Get Adobe® Reader®) and pages 27 and 28 of the HealthKeepers (pdf | Get Adobe® Reader®) report).

12/2010

On page 7 of this report (pdf | Get Adobe® Reader®) from the Office of the Managed Care Ombudsman to the Virginia General Assembly there is a brief summary of the Parity The report also notes that retrospective market conduct examinations could reveal noncompliance with the Federal Parity Law by managed care organizations and “if that occurs, the Bureau will take appropriate action.”

9/2010

The Virginia State Corporation Commission, Bureau of Insurance issued a regulation requiring large employer fully-insured plans issued by health maintenance organizations to cover behavioral health services “in accordance” with the Federal Parity Law (found on page 348-350 (pdf | Get Adobe® Reader®) or can be found under A.6 here).

6/2010

The Bureau of insurance released a market conduct examination report investigating Peninsula Health Care Inc.. Among many other things, the Bureau investigated compliance with the parity sections of the state insurance law. The investigation revealed that Peninsula Health Care Inc., was using different copayments for some mental health services than for other medical services, thus making the plan technically non-compliant with the law. However, Peninsula Health Care Inc. strongly disagreed with this interpretation of the the state insurance law because the copayments they were using for mental health services were lower than those used for other medical services (emphasis added by ParityTrack). The Bureau conceded that this was true and did not take any punitive action (found on pages 26, 27, and 28 of the Peninsula Health Care Inc. report (pdf | Get Adobe® Reader®)).

5/2010

The Virginia Bureau of Insurance issued an administrative letter (pdf | Get Adobe® Reader®) to insurance plans notifying them of the then recently-passed state bill SB 706 that amended the parity sections of the state insurance law and required large employer fully-insured plans to cover behavioral health services “in accordance” with the Federal Parity Law. It then informed them that while not required, plans were “strongly encouraged” to complete the Bureau’s parity checklist, which instructs plans to demonstrate how they comply with requirements of state and federal law relevant to parity (the most recent version of this checklist is summarized above on this page in the entry “3/2015” and is linked in that entry). In this letter you might notice a reference to a section of Virginia State Law, 38.2-3412.1:01. This law was about coverage requirements for “biologically-based mental illness” and was repealed in 2015 because amendments to the another section of the state insurance law made 38.2-3412.1:01 obsolete and irrelevant (that section is 38.2-3412.1 and is summarized at the bottom of this page under “Virginia Parity Law”). If you would like to know what was in 38.2-3412.1:01 please contact us at info@paritytrack.org.

Virginia Parity Law

There are several sections of state law relevant to parity. They are summarized below in three parts: Behavioral health coverage, state employee behavioral health coverage, and autism coverage.

There was a section (38.2-3412.1:01) about coverage requirements for “biologically-based mental illness” that was repealed in 2015 because amendments to another section of the state insurance law made 38.2-3412.1:01 obsolete and irrelevant. That section is not summarized here because it is no longer in the state insurance law. If you would like to know what was in that section, contact us at info@paritytrack.org.

Behavioral Health Coverage

This section requires large employer fully-insured plans, individual plans, and non-grandfathered small employer fully-insured plans to cover behavioral health services and provide those services in a way that meets the standards of the Federal Parity Law, even if the Federal Parity Law does not directly apply to a particular plan.

This section requires the following for grandfathered small employer fully-insured plans:

  • 20 days of inpatient care for adults (inpatient care is defined to include residential – treatment)
  • 25 days of inpatient care for children
  • Up to 10 days of inpatient care can be turned into 15 days of partial hospitalization (1 for 1.5 ratio; 4 inpatient days could be come 6 days of partial hospitalization, for example)
  • 20 visits for outpatient care
  • Medication management visits do not count towards outpatient visit limit
  • For any coinsurance, a plan must cover at least 50% for the first 5 outpatient visits
  • Any outpatient visit that is not covered because the person has not yet met the plan –deductible does not count towards the 20 visit limit

State Employee Plan Behavioral Health Coverage

This section requires state employee plans must cover “biologically based mental illness” and have the same coinsurance, copayments, annual maximums, lifetime maximums, annual limits, and lifetime limits as what are in place for other medical treatment. There must be just one combined deductible for “biologically-based mental illness” and other medical treatment. Medical necessity reviews for “biologically-based mental illness” must be conducted “in the same manner” as those for other medical treatment. “Biologically-based mental illness” is defined as:

  • Schizophrenia
  • Schizoaffective disorder
  • Bipolar disorder
  • Major depressive disorder
  • Panic disorder
  • Obsessive-compulsive disorder
  • Attention deficit hyperactivity disorder
  • Autism
  • Drug and alcoholism addiction

Autism Coverage

This section requires large employer fully-insured plans, state employee plans, local government plans, and public school employee plans to cover autism services for children age 2 through age 10.

Autism spectrum disorder is defined as “any pervasive developmental disorder, including autistic disorder, Asperger’s Syndrome, Rett syndrome, childhood disintegrative disorder, or Pervasive Developmental Disorder – Not Otherwise Specified, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders.”

Autism treatment is defined as:

(All of these are defined in detail in the law)

There is a $35,000 annual maximum for applied behavior analysis.

Plans cannot have any visit limits for outpatient care, and financial requirements have to be the same as what are in place for other medical services.

Plans are allowed to review a child’s treatment plan once every 12 months.

Medical necessity reviews must conducted “in the same manner” as reviews for other medical services.

Plans are exempt from this section of the law if they can prove that complying with this section caused premiums to increase by at least 1% in a given year.

Get Support

Virginia Insurance Division

  •   Website
  • bureauofinsurance@scc.virginia.gov
  • 1-877-310-6560

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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