Washington Regulations

The Washington State Office of the Insurance Commissioner has a webpage on mental health parity. The page defines mental health parity, how this law impacts consumers, and how to resolve benefit concerns.

The Washington State Office of the Insurance Commissioner requires plans to fill out checklists demonstrating how they comply with certain sections of the state insurance law and with relevant federal laws. These checklists include boxes for addressing the sections of the state insurance law relevant to parity and the Federal Parity Law. There are many of these checklists that are identical or very similar. For simplicity’s sake, here is an example of one (pdf | Get Adobe® Reader®) that is for small employer fully-insured plans that are required to offer essential health benefits by the Affordable Care Act.

The Washington State Office of the Insurance Commissioner released a report to explain the recent rule issued in September, 2014. The report provides background information on the Federal Parity Law and state parity law. It also details the rule development process, differences between the proposed and final rule, and a summary of comments received on the proposed rule.

The Washington State Office of the Insurance Commissioner issued this letter to plans, which clarified their obligations due to the then recently-decided Washington State Supreme Court Case, O.S.T. v. Regence Blueshield. The court decided that the sections of the state insurance law relevant to parity (summarized at the bottom of this page) do not allow insurance plans to use blanket exclusions for mental health services that could be medically necessary.

The Commissioner informed plans that the Office was going to examine all plans for 2015 and make sure they complied with the sections of the law as interpreted by the Court. He also instructed plans that their current practices must comply with the court’s interpretation, no matter what language is currently in any given plan.

The commissioner then ordered plans to identify any claims denied since 1/1/2006 that may have violated the law, as currently interpreted by the court, and inform those consumers that their claims can be reevaluated. He then ordered plans to submit the following to the Office:

• Number of notices sent to consumers
• Number of consumers who request to have their denial reevaluated
• Outcome of each claim reevaluated

The Washington State Office of the Insurance Commissioner issued an updated regulation regarding parity. The purpose of this regulation was to consolidate into one regulation all parity regulations regarding the Federal Parity Law and relevant sections of the state insurance law. This regulation defined all of the following:

• Aggregate lifetime limits (lifetime maximums)
• Annual dollar limits (annual maximums)
• Approved treatment program
• Chemical dependency professional
• Classification of benefits
• Coverage unit
• Cumulative financial requirement
• Cumulative quantitative treatment limitations (lifetime limits)
• Emergency condition
• Essential health benefits
• Financial requirements
• Health carrier or issuer
• Medical/surgical benefits
• Medically necessary or medical necessity
• Mental health benefits
• Non-quantitative treatment limitations (NQTLs)
• Predominant level
• Quantitative parity analysis
• Quantitative treatment limitations (QTLs)
• Substance use disorder and substance use disorder benefits
• Substantially all
• limitations

It specified that parity requirements must be applied to the 6 different classifications of benefits. It also made clear that all services must fall into one of these 6 classifications of benefits. In other words, something like residential treatment or partial hospitalization cannot be an excluded service on the grounds that it is not in one of the 6 classifications. It then listed permitted subclassifications within each classification and stated that no other subclassifications are allowed.

The regulation then went into great detail about the parity requirements for quantitative treatment limitations, financial requirements, and non-quantitative treatment limitations. These parts are worded similarly to corresponding sections of the final regulation for the Federal Parity Law.

The regulation also listed forbidden exclusions of care:

• Denials because a treatment plan was not completed
• Denials of medically necessary treatment because it is part of category of services specifically excluded by the plan
• Services cannot be denied only because of a person’s age or the type of condition the service is for; for example, no exclusions for all services for anorexia (example added by ParityTrack, not the regulation itself)
• Denials for court-ordered treatment

The regulation also lists information plans must disclose and release to patients regarding denials and NQTLs.

And finally, the regulation requires plans to submit filings that demonstrate plans’ parity analysis of quantitative treatment limitations and financial requirements.

The Washington State Office of the Insurance Commissioner issued this letter to insurance plans informing them that denying coverage for medically necessary services on the basis of gender identity or a diagnosis of gender dysphoria is against state and federal law. The Commissioner clarifies that the section of state law about discrimination explicitly supersedes any section of the state insurance law that might seem to allow these kinds of denials.

The Washington State Office of the Insurance Commissioner released an explanatory statement on a recent regulation that addressed network adequacy. A response to a comment on the final rule explains why the regulation does not directly address adequate networks for substance use disorder treatment. The response states that other rules already address adequacy in substance use disorder treatment and that, therefore, an emphasis on this area would be redundant.