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| Medical Policy: | V-39-002 |
| Topic: | Mental Illness Coverage |
| Section: | Visits |
| Effective Date: | October 1, 2016 |
| Issue Date: | October 3, 2016 |
| Last Reviewed: | November 2012 |
The Delaware Mental Health Parity mandate. |
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.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
Mental Health Care – Legal Description of Delaware and Federal Mandates
Coverage for individuals and insured groups with less than 51 members
The Delaware Mental Health Parity mandate (18 Del. C. Sections 3343, 3576 and 3578) is applicable to direct pay (individual market) policies and insured small group (under 51 employees) plans who use in-network providers. Federal Mental Health Parity laws do not apply to individual and small group (under 51 employees) coverage.
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:
- schizophrenia
- bipolar disorder
- obsessive-compulsive disorder
- major depressive disorder
- panic disorder
- anorexia nervosa
- bulimia nervosa
- schizo affective disorder
- delusional disorder
- alcohol abuse and dependence
- drug abuse and dependence
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
The Delaware Mental Health Parity mandate (18 Del. C. Sections 3343, 3576 and 3578) is applicable to direct pay (individual market) policies and insured small group (under 51 employees) plans who use in-network providers. Federal Mental Health Parity laws do not apply to individual and small group (under 51 employees) coverage.
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:
- schizophrenia
- bipolar disorder
- obsessive-compulsive disorder
- major depressive disorder
- panic disorder
- anorexia nervosa
- bulimia nervosa
- schizo affective disorder
- delusional disorder
- alcohol abuse and dependence
- drug abuse and dependence
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:
- Appropriate professional provider licensure by Delaware Board of Licensing
- Medical necessity of service
- Reasonable administrative requirements of health plans including prior authorization and certification, and referral requirements if such requirements apply to the same extent to all other illnesses and diseases.
- Additional conditions of coverage may apply if applicable to the same extent as coverage for all other illnesses and diseases. For example: utilization review, pre-admission screening, case management, and the requirement of a treatment plan are specifically permitted.
- Benefit management need not be identical to methods used for the management of benefits for other medical conditions.
Network Services
This mandate is not applicable to out of network services if a Plan has a network of providers to treat mental illnesses and drug and alcohol dependencies.
Coverage for groups with 51 or more employees
The 2008 Federal Mental Health Parity and Addiction Equity Act (MHPAEA) which updated the 1996 Mental Health Parity Act is applicable to all self-insured group health plans with greater than 50 employees. In addition, per Delaware law (18 Del. C. Section 3576), large insured group health plans (over 50 employees) must also comply with MHPAEA and any subsequent changes to the law. The law includes an exception process to the MHPAEA requirements for those group health plans that can prove a significant increase in cost to provide coverage (2% in the first year and 1% in following years).
MHPAEA does not apply to:
- Medicaid managed care plans
- Medicare Advantage plans (unless sponsored by Employer)
- FEP
- Non-federal governmental plans with less than 100 employees
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:
- Lifetime or annual limits on mental health or substance use disorder benefits
- Financial requirements (e.g., co-pays, co-insurance, deductibles)
- Out of Network coverage - if plan includes coverage for out of network medical/surgical benefits, the plan must also include coverage for out of network mental health and substance use disorders
- Quantitative treatment limitations (e.g., day limits, visit limits)
- Non-quantitative treatment limitations (e.g., medical management standards/policies), except to the extent that recognized clinically appropriate standards of care may permit a difference
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.
NOTE:
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.
| Place of Service: Inpatient/Outpatient |
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.
| The policy position applies to all commercial lines of business |
| Denial Statements |
A network provider can bill the member for the non-covered service.
| Links |
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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:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
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.
