Action in the Regulatory Arena
|Primary Focus||Reasonable Access to Mental Health Care|
|Agency||Connecticut Insurance Department|
|Citation||CONN. AGENCIES REGS. §§38a-472f-2 through 38a-472f-5|
CONN. AGENCIES REGS. §§38a-472f-2 through 38a-472f-5 defines the term “specialist” to mean a health care provider who (i) focuses on a specific area of physical, mental or behavioral health or a specific group of patients, and (ii) has successfully completed required training and is recognized by this state to provide specialty care. The regulations further establish reasonable wait times for access mental health care. Providers under these regulations must serve individual with mental health disabilities. The regulations mandate that each health carrier shall contract with the providers to ensure that each person covered by such health carrier under such a plan or certificate has reasonable access to participating providers located near such covered person’s place of residence or employment. Reasonable access to mental health care includes maintaining a sufficient number and appropriate types of participating providers that predominately serve, without unreasonable travel or delay.
|Primary Focus||Compliance: Reporting Requirement, Certification|
|Agency||Connecticut Insurance Department|
|Title/Description||Additional Rate Filing Requirements|
|Citation||Conn. Agencies Regs. § 38a-481-9 (2016)|
This statute requires insurers to submit filings including an annual certification of compliance with mental health parity.
The Market Conduct Division of the Connecticut Insurance Department examined (pdf | Get Adobe® Reader®) the utilization review practices of United Behavioral Health. The examination reviewed 204 sample complaints and appeal certifications from January 1, 2013 through December 31, 2013. Among other things, the examination found that 2 appeal determinations were not reviewed by an “appropriate clinical peer for the service requested”.
The Connecticut Insurance Department fined United Behavioral Health $8,500 for the violations. United Behavioral Health also agreed to provide a full report of the actions taken to comply with the legislative and regulatory requirements impacting utilization review within 90 days of the release of this document.
The Connecticut Insurance Department issued a bulletin (pdf | Get Adobe® Reader®) clarifying changes in mandated coverage of autism spectrum disorders and early intervention services resulting from the ACA. The bulletin announces an amendment that extends group health insurance coverage for ASD to a yearly benefit of $50,000 for a child less than nine, $35,000 for a child between nine and 13, and $25,000 for a child between 13 and 14. The amendment requires individual and group policies to cover early intervention services in individualized family service plans to a maximum of $6,400 per child per year from birth until age 3 or an aggregate benefit of $19,200 per child over a three-year period.
The Connecticut Insurance Department issued a bulletin (pdf | Get Adobe® Reader®) announcing a new element of the market conduct examination process dealing with mental health parity compliance. The bulletin requires any entity delivering individual and group health insurance to complete an annual mental health parity compliance survey. If the entity is not in full compliance, they must attach an action plan to their survey response. Entities will pay a late filing fee of one hundred dollars per day for each day passed the survey due date.
The Connecticut Insurance Department released a report (pdf | Get Adobe® Reader®) on what it is doing to ensure that insurance plans under its jurisdiction are complying with the state parity law and the Federal Parity Law. This report had been mandated by the Connecticut General Assembly earlier in the year. Here are some of the activities the Insurance Department listed in the report:
- Issued a bulletin (pdf | Get Adobe® Reader®) to insurance plans about new requirements regarding external review appeals and grievance appeals. This informed insurance plans that state law now required new criteria for behavioral health appeals and that reviewers were now required to be of the same background as the patient’s treating provider. It also informed plans that state law now required plans to process urgent requests for behavioral health services in less than 24 hours.
- Created a short consumer guide (pdf | Get Adobe® Reader®) about how to navigate the appeals process.
- Recovered $1.3 million for consumers from insurance plans after investigating complaints about health insurance coverage. Some of these complaints were about behavioral health coverage.
- Created an awareness program about parity and behavioral health coverage.
- Created a behavioral health consumer toolkit (pdf | Get Adobe® Reader®) to help consumers better understand how to get quality behavioral healthcare through their insurance plans.
- Mentioned that the Insurance Department investigates all complaints that could be possible parity violations and checks to see if there are any violations of the state laws or the Federal Parity Law.
- Listed how many complaints that were not under Insurance Department jurisdiction that were referred to the Office of the Healthcare Advocate.
- Urged state legislators to tell their constituents to contact the Insurance Department’s Consumer Affairs Unit so the Department can spot trends of possible non-compliance with parity laws.
- Issued the Department’s annual Consumer Report Card on Health Insurance Carriers (pdf | Get Adobe® Reader®) that can help locate trends of possible non-compliance within its section on behavioral health.
- Issued a bulletin (pdf | Get Adobe® Reader®) that requires insurance plans to submit information that demonstrates their compliance with parity laws.
- Responded to complaints about a major health insurance plan’s behavioral health reimbursement practices and required the insurance plan to reprocess nearly 40,000 claims. This led to over $472,000 of additional reimbursement that had originally been denied.
- Met with members of Connecticut’s federal delegation to push for the appropriate federal agencies to release the final regulation (pdf | Get Adobe® Reader®) for the Federal Parity Law.
- “Strongly requested” that insurance plans change the tone and content of their behavioral health coverage denial letters.
- Wrote to the Sandy Hook Commission clarifying examples of non-quantitative treatment limitations.
- Launched a parity page on the Insurance Department’s website.
The Connecticut Insurance Department issued a bulletin that informed insurance plans that they are not allowed to exclude any medically necessary services for gender dysphoria. This bulletin informs plans that excluding these services would violate the state parity laws, state anti-discrimination laws, and state unfair trade practices laws. The bulletin also clearly states that gender reassignment services cannot be excluded. However, plans are still allowed to conduct medical necessity reviews for gender dysphoria services.
The Connecticut Insurance Department issued a bulletin (pdf | Get Adobe® Reader®) clarifying requirements for how insurance plans use copayments under the state parity laws and the Federal Parity Law. The final determination was that large employer plans had to follow the formulas in place for determining copayments as dictated by the interim final regulation (pdf | Get Adobe® Reader®) for the Federal Parity Law.