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
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.

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.

• Link to Diagnosis Codes