Vermont

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

• Behavioral Health Coverage
• Utilization Review
• Autism Coverage (referred to as “Early Childhood Developmental Disorders” in the law)

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

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

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.