Maryland Regulations

The MIA released a memo calling for public comments to draft proposed regulations. Regulation of note concerned 31:10:18: Denials of Coverage Based on Medical Necessity. Changes include the addition of an individual using “intoxicating substance” or experiencing “withdrawal symptoms” to the list of compelling reasons to file complaints.

The MIA released the form filing checklists for insurers issuing individual plans, HMOs, and Small Employer plans to verify plan compliance with the Federal Parity Law. The form specifically covers financial requirements, non-quantitative treatment limitations, network adequacy, licensed professionals, and the processes, strategies, evidentiary standards, and other factors applied during utilization review for both behavioral health and other medical reviews to ensure full compliance. The form makes note of regulations prohibiting prior authorization for methadone, buprenorphine, or naltrexone if being used for the treatment of an opioid use disorder, and prohibits prior authorization for other purposes unless one formulation is covered without such a restriction. Additionally, abuse-deterrent opioid analgesics are required to be on the the lowest cost of the drug tier if the contract lists specific covered drugs. This list should  include at least two brand and two generic drugs.

The MIA released the form filing checklists specific for individual short term plans to verify plan compliance with the Federal Parity Law. The form specifically covers financial requirements, non-quantitative treatment limitations, network adequacy, licensed professionals, processes, strategies, evidentiary standards, and other factors applied during utilization review for both behavioral health and other medical reviews  to ensure full compliance. The form makes note of regulations prohibiting prior authorization or any fail first protocols for abuse deterrent opioid analgesic drugs. Additionally, abuse-deterrent opioid analgesics are required to be on the lowest cost of the drug tier if the contract lists specific covered drugs. This list should include at least two brand and two generic drugs.

The MIA released a Notice of Final Action which, among other things, clarified Title 31.10.44.08 network adequacy regulations concerning requirements that plans provide certain information regarding non-quantitative treatment limitations to prove compliance with the Federal Parity Law. Meetings were held throughout 2016 to gather testimony.

The MIA released a bulletin regarding changes to requirements for minimum coverage of treatment of mental health and substance use disorders per HB 1127. This bill requires coverage of residential treatment centers, and intensive outpatient benefits, such as diagnostic evaluation, opioid treatment services, and medication evaluation and management.

MIA released an Overview of Changes to network adequacy regulations, which, among other things, clarified the requirement of plans to provide certain information related to non-quantitative treatment limitations to prove compliance with the Federal Parity Law.

MIA hosted a Mental Health Parity and Addiction Equity Act Survey Stakeholder Meeting to discuss the third market conduct survey regarding the consistency and uniformity of  the application of processes and policies to mental health and substance use disorder benefits and medical/surgical benefits and network adequacy regulations. Input was received from the Health Education and Advocacy Unit of the Office of the Maryland Attorney General’s Consumer Protection Division, the Maryland Psychiatric Society, Legal Action Center, the American Psychiatric Association, Cigna, and  United Healthcare.

The MIA released the form filing checklists for nonprofit health insurance plans to verify plan compliance with the Federal Parity Law. The form specifically covers mental health and substance use disorder benefits, financial requirements, and non-quantitative treatment limitations and specifies that the 60-day limit on partial hospitalization is only allowed if it complies with the quantitative treatment limitation rules of the Federal Parity Law.

The MIA released a letter describing the 2017 Benchmark Plan used to determine the essential health benefits required in every non-grandfathered health benefit plan issued or renewed in the individual and small employer markets on and after January 1, 2017. The letter included a description of the process used to make the selection. The plan chosen had received concerns about particular text regarding limitations on provider types eligible for reimbursement for substance use disorder services that was not compliant with the Federal Parity law. The MIA included in its release MIA’s expectation that all plans comply with all federal requirements and allowed for more flexibility in reimbursement.

The Maryland Insurance Administration (MIA) released a Consumer Guide to Understanding Your Health Insurance Coverage for Mental Health and Substance Use Disorders. While the guide does not specifically mention parity, it provides useful information to individuals accessing behavioral health care through their health insurer. The guide provides the following information

• Tips for selecting a health plan
• Key insurance terms
• Information on how to obtain pre-authorization for private health insurance coverage for behavioral health disorders
• Information on how your health plan works
• Information on your rights when your health insurer does not pay for your health care services
• A list of federal and state agency health resources and other resources

The MIA also released a pamphlet on Navigating Private Health Insurance Coverage for mental Health and Substance Use Disorder Emergencies. The pamphlet provides information on treatment authorization and provides additional resources for further assistance.

The MIA released a Powerpoint detailing the role the MIA plays in combating the opioid crisis by regulating insurance and information about how to file complaints and response to a variety of claim denials.

A letter was written to MIA by  Ellen Weber on behalf of the Drug Policy Clinic at the University of Maryland Carey School of Law Clinical Law Program, notifying MIA of an updated version of the Fifty-State Survey: Network Adequacy Quantitative Standards. The letter also included a  summary of survey results regarding Opioid Treatment Program participation in the CareFirst/Magellan network. Concerns were described regarding the lack of OTP providers in network but clear willingness of OTP providers to become network providers.

The MIA and CareFirst BlueChoice agreed upon a consent order following the October 2015 Federal Parity Law compliance investigation detailed below. The consent order demonstrates that BlueChoice is now in compliance by accomplishing the following two requirements of the 2015 order:

1. Maintaining an adequate network of methadone treatment providers
2. Not applying geofactors to reimbursement rates for mental health/substance use disorders providers

To view the market conduct exam discussed above, email info@paritytrack.org

The MIA and CareFirst BlueChoice agreed upon a consent order following the October 2015 Federal Parity Law compliance investigation detailed below. The consent order demonstrates that BlueChoice is now in compliance by accomplishing the following two requirements of the 2015 order –

• Maintaining an adequate network of methadone treatment providers
• Not applying geofactors to reimbursement rates for mental health/substance use disorder providers

To view the order discussed above, email info@paritytrack.org

The MIA conducted a market conduct examination of Coventry Health & Life Insurance following responses to a survey about compliance with the Federal Parity Law. The market conduct exam revealed the following violations in the health insurer’s plans –

• No in-network methadone treatment clinics
• No in-network psychologists in all of Western Maryland
• No in-network psychiatrists in Garrett or Allegheny Counter
• Only one in-network psychiatrists in Washington County
• No in-network licensed professional counselors or licensed clinical social workers in Garrett County

To come into compliance, Coventry Health & Life Insurance was required to complete the following actions –

• Documentation demonstrating in-network access to methadone treatment clinics to serve their members within 90 days
• Written documentation showing network adequacy of psychiatrists, psychologists, licensed professional counselors, and licensed social workers in Western Maryland within 90 days
• A written update to the Administration on steps taken to accomplish network adequacy at six months

To view the order discussed above, email info@paritytrack.org

The MIA conducted a market conduct examination of Cigna Health and Life Insurance Company following responses to a survey about compliance with the Federal Parity Law. The market conduct exam revealed the following violations in the health insurer’s plans –

• Requirement of a screening interview for credentialing for both medical and mental health providers
• Requirement that any mental health provider who has been treated for a substance use disorder is not eligible for network participation until they have been sober for two years. This is not a requirement for medical/surgical providers
• Requirement that mental health providers are allotted 20 days to respond to inquiries relating to credentialing, while medical/surgical providers are allotted 30 days

To come into compliance, Cigna Health and Life Insurance Company was required to complete the following actions –

• Remove the practice of requiring a screening interview for credentialing within 10 days
• Change the allotted time for mental health providers to respond to inquiries relating to credentialing to 30 days
• Pay a penalty of $9,000 within 30 days

To view the order discussed above, email info@paritytrack.org

The MIA conducted a market conduct examination of CareFirst Blue Choice, Inc. following responses to a survey about compliance with the Federal Parity Law. The market conduct exam revealed the following violations in the health insurer’s plans –

• No in-network methadone treatment clinics
• Geofactors are applied to the base reimbursement rate for providers of medical/surgical benefits but not of mental health/substance use disorder benefits

To come into compliance, CareFire Blue Choice, Inc. was required to complete the following actions –

• Documentation demonstrating in-network access to methadone treatment clinics to serve their members within 90 days
• Documentation showing changes to the factors used to calculate reimbursement rates within 90 days
• Pay a penalty of $30,000 within 30 days

To view the order discussed above, email info@paritytrack.org

The MIA ordered Freedom Life Insurance Company to pay a fine of $500 following their failure to respond to a survey about compliance with the Federal Parity Law. In the order, Freedom Life Insurance Commission is also required to complete the original survey.

To view the order discussed above, email info@paritytrack.org

The MIA has agreed to undertake market conduct surveys of insurance issuers for the next five years, which could reveal patterns of non-compliance with state and federal parity laws. However, this information will not be public and is a compromise on a legislative attempt, to require insurance plans to submit annual reports demonstrating parity compliance.

The MIA issued regulations regarding utilization review and autism care. The regulations apply to how insurance plans or review agents acting on their behalf use utilization review for children receiving treatment for autism. A plan or its review agent cannot deny coverage for:

1. Up to or less than 25 hours per week for a child aged 18 months to 5.
2. Up to or less than 10 hours per week for a child aged 6 to 18.
3. Treatment that takes place in a child’s educational setting
4. Applied behavioral analysis on the basis that it is experimental

The MIA also issued a bulletin (pdf | Get Adobe® Reader®) that notified plans about these regulations and asked them to submit documentation of the specific criteria they were going to use for utilization review of autism services within 30 days of the release of this bulletin (by 4/17/104).

The MIA posted a consumer advisory on its website that briefly explained to consumers the Federal Parity Law and its requirements. The advisory stated that financial requirements, quantitative and non-quantitative treatment limitations for behavioral health services cannot be “more restrictive” than those used for other medical services.

The advisory then notified consumers that they can file a complaint with the MIA if they think their plan has violated their parity rights and that consumers can contact The Health Education and Advocacy Unit of the Attorney General’s Office for assistance.

The MIA issued a bulletin (pdf | Get Adobe® Reader®) that notified plans that they could contract “with State-certified outpatient and intensive outpatient treatment programs” in order to deliver a “full continuum” of medically necessary care for substance use disorder services.

The MIA issued a bulletin (pdf | Get Adobe® Reader®) regarding essential health benefits for individual plans and small employer fully-insured plans. On pages 3 and 4 it details the requirements for behavioral health coverage. It specified the types of providers whose services plans must cover, specific services that must be covered, requirements for inpatient care and residential treatment, clarified that intensive outpatient treatment and partial hospitalization are covered, and it listed several forms of treatment that are not required, such as services that are not medically necessary.

This MIA also requires plans to fill out annual checklists that demonstrate plan compliance with essential health benefits, including all of the requirements mentioned in this bulletin. Here is an example (pdf | Get Adobe® Reader®) of one of these checklists. The compliance boxes relevant to parity can be found on pages 2, 8-9, 11, 12, 13, and 24.