Highmark Commercial Medical Policy - Delaware |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Mental Health Care – Legal Description of Delaware and Federal Mandates Coverage for individuals and insured groups with less than 51 members This Delaware mandate requires that health plans delivered or issued for delivery in Delaware must provide coverage for the diagnosis and treatment of serious mental illness and drug or alcohol dependency. Serious mental illness is defined by the mandate to include:
The most recent DSM shall be used to determine whether a member meets diagnostic criteria. Parity requires that coverage may not contain terms and conditions that place a greater financial burden on an insured than terms applicable to the diagnosis and treatment of any other illness or disease covered by the health benefit plan. Examples of terms and conditions mentioned in the law include: deductibles, co-pays, dollar maximums, co-insurance limits, number of visits, limits on number and duration of in-patient stays, or limits on Rx medicines. Mental Health Care – Legal Description of Delaware and Federal Mandates Coverage for individuals and insured groups with less than 51 members This Delaware mandate requires that health plans delivered or issued for delivery in Delaware must provide coverage for the diagnosis and treatment of serious mental illness and drug or alcohol dependency. Serious mental illness is defined by the mandate to include:
The most recent DSM shall be used to determine whether a member meets diagnostic criteria. Parity requires that coverage may not contain terms and conditions that place a greater financial burden on an insured than terms applicable to the diagnosis and treatment of any other illness or disease covered by the health benefit plan. Examples of terms and conditions mentioned in the law include: deductibles, co-pays, dollar maximums, co-insurance limits, number of visits, limits on number and duration of in-patient stays, or limits on Rx medicines. Eligibility for coverage may be conditioned or limited by:
Network Services MHPAEA does not apply to:
The MHPAEA requires that a carrier or group health plan that provides coverage for mental health disorders or substance use disorders cannot impose financial requirements and treatment limitations that are more restrictive/less favorable than those applied to medical benefits. Generally, parity requirements include:
In addition, Plans and group health plans must provide the internal policies, standards or criteria for medical necessity determinations to a current or potential member or contracting provider. Parity requirements are further and more specifically defined by regulation. NOTE: MHPAEA does not mandate that a Plan or group health plan provide coverage for mental health or for any specific mental illnesses or conditions; however, where a group health plan or Plan elects to cover a mental health and substance abuse disorder, the law requires parity or general equivalence.
Mental Illness Coverage is typically outpatient and is only eligible for coverage as an inpatient in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
A network provider can bill the member for the non-covered service.
This policy is intended to document those medical guidelines used by Highmark Blue Cross Blue Shield Delaware for the purpose of coverage and reimbursement determinations under Highmark Blue Cross Blue Shield Delaware health benefit plans. These guidelines are appropriate for the majority of individuals with a particular disease, illness, or condition; however, each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records. Discrimination is Against the Law The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. ![]() Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern. Medical policies do not constitute medical advice, nor the practice of medicine. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions. Highmark Blue Cross Blue Shield Delaware retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark Blue Cross Blue Shield Delaware. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use. |