This page lists some of the action toward parity compliance undertaken by state regulatory agencies since 2008.

Are we missing any actions taken by state regulatory agencies? Let us know at info@paritytrack.org

Actions in the Regulatory Arena

07/2017

Primary Focus Mandated Benefit: Provider
Title/Description Vermont Insurance Notices and Bulletins
Summary

Mental Health Parity: Vermont’s mental health parity law (8 V.S.A. § 4089b) applies to all supplemental and blanket health insurance policies. For this reason, policies may not have lower benefit levels for mental health conditions than for other covered conditions and may not exclude coverage for accidents or sickness caused by mental illness or by alcohol or substance abuse. In addition, policies that provide hospital benefits may not exclude facilities that treat mental illness or alcohol or substance abuse from the definition of a hospital.
Issued Date 07/01/2017

12/2014

Each year the Department of Financial Regulation files a performance report on managed care organizations. This is the 2014 edition (pdf | Get Adobe® Reader®). There are several sections relevant to parity, including many tables that track performance in terms of percentages; a red x with a circle around it next to any percentage indicates that the Department believes there is room for improvement:

  • Availability of and access to behavioral health providers (2.3.5-8, pages 18-20)
  • Grievance appeals outcomes for behavioral health and other medical treatment (3.4.1-4, pages 36-39)
  • Timelines in making grievance appeals decisions on behavioral health (3.4.7, page 43)
  • Outcome performance for behavioral health treatment (52-54)

The reports for other years can be found at the very bottom of this link. If you click on any of the linked years, the top report on the following page is the relevant report, like the one summarized above.

11/2014

The Department of Financial Regulation fined Cigna Behavioral Health $392,500 for violations of the state insurance law, including sections relevant to parity. The fine resulted from the Department finding that Cigna had used the recommendations of “unlicensed review agents” in making coverage determinations. These agents were under contract with the plan’s Independent review organization.

10/2013

The Department of Financial Regulation issued a regulation about distinguishing behavioral health primary care services from behavioral health specialty services, as required by the state law. Primary care services were defined as follows:

  • The most common or routine behavioral health services
  • Outpatient services only
  • Services provided to all regardless of age or gender

The regulation also noted that the Department would review these definitions every two years.

Primary Focus Mandated Benefit: Provider
Agency Department of Financial Regulation
Title/Description Guidelines for Distinguishing Between Primary and Specialty Mental Health and Substance Abuse Services: Section 1: Purpose
Citation 21-020-066 Vt. Code R. § 1
Summary

Under Vermont Law, a health plan shall apply member co-pays to mental health services and to medical services consistently in its health insurance policies/certificates. The member co-pay applicable to mental health and substance abuse services designated as “primary” when rendered by a mental health care provider shall be no greater than the member co-pay applicable to medical services rendered by a primary care provider. The member co-pay for “specialty” mental health and substance abuse services shall be no greater than the member co-pay applicable to specialty medical services and shall apply only to those mental health and substance abuse services not deemed “primary.”
Effective Date 10/01/2013

4/2013

The Department of Financial Regulation issued a bulletin notifying plans that they may “not exclude coverage for medically necessary treatment including gender reassignment surgery for gender dysphoria and related health condition” It then stated that “new insurance policy forms filed by insurers will be disapproved by DFR if they exclude such coverage”

2011 (Exact Date Unclear)

The Department of Financial Regulation issued a regulation (pdf | Get Adobe® Reader®) regarding mental health review agents. Most of this regulation is about licensure requirements, but there is some information relevant to parity:

  • Clinical review criteria for utilization review and supervision of agents who perform reviews (Part 6.A.10-11, page 8)
  • Reporting requirements for renewal of licensure, which includes requirements to report the number of and outcomes of medical necessity reviews and number of and results of grievance appeals (Part 6.C.3.a-c, page 9)
  • Standards for service reviews (Part 7.A, page 10-11)

11/2012

The Department of Financial Regulation issued a bulletin (pdf | Get Adobe® Reader®) reminding health insurers of their requirement to cover less restrictive and less expensive alternatives to hospitalization for the treatment of mental health and substance use disorders.

4/2011

The Department of Financial Regulation (then called the Department of Banking, Insurance, Securities, and Health Care Administration) issued a bulletin notifying plans that they must comply with the section of the insurance law about autism coverage.

8/2010

The Department of Financial Regulation (then called the Department of Banking, Insurance, Securities, and Health Care Administration) issued a bulletin notifying plans that a section of the state insurance law relevant to parity had been changed and that plans could no longer deny coverage for behavioral health services just because they were provided out-of-network.

Primary Focus Mandated Benefit: Provider
Agency Department of Financial Regulation
Title/Description Long Term Care Insurance Regulation: Section 6: Policy Practices and Provisions
Citation 21-040-025 Vt. Code R. § 1
Summary

The regulates long term care insurance and mandates that no long-term care insurance policy may Deny benefits or coverage on the basis that the need for long-term care services arises from a mental health condition, including Alzheimer’s disease, dementia and other related disorders.
Effective Date 08/01/1992
Notes Amended 04/01/2010

12/2019

The Department of Financial Regulation issued a regulation (pdf | Get Adobe® Reader®) (see the bottom of this entry for an important note regarding page numbers) regarding managed care organizations (MCOs) that included a number of provisions related to parity. We will list the relevant sections of the regulation, where they can be found (including PDF page numbers), and how they are relevant:

  • Information regarding availability of behavioral health providers and how MCOs must disclose and orally communicate that information to patients (Part 2.2.C.2, pages 20-22 in PDF*)
  • Access to and continuity of behavioral health care and coordination with other medical care (Part 2.3.B.1-3, pages 22-23*)
  • Requirements for medical necessity criteria for behavioral health services (Part 3.1.C, page 26*)
  • Utilization management standards for behavioral health services (Part 3.1.E, pages 26-27*)
  • Grievance appeals standards for behavioral health services (Part 3.3.B.1, pages 34-35*)
  • Impact of quality improvement measures on behavioral health outcomes for patients (Part 6.3.B.5-7, page 63*)
  • Quality improvement goals regarding behavioral health for insurance plans, their contracted MCOs, and contracted mental health review agents, along with those entities reporting requirements to the Department of Financial Regulation (Part 6.4.C, page 68*)

*The page numbers listed are the visible page numbers within the document, NOT the page numbers given by your PDF viewer

04/2001

Primary Focus Compliance: Reporting Requirement
Agency Department of Financial Regulation
Title/Description Health Insurance Coverage of Mental Health and Substance Abuse Services: Section 1: General Provisions
Citation 21-040-016 Vt. Code R. § 1
Summary

The five largest health insurance companies doing business in Vermont, as measured by covered lives, are required to file with the Commissioner (1) an annual report card on the health insurance plan’s performance in relation to quality measures for the care, treatment, and treatment options of mental health and substance abuse conditions covered under the plan, and (2) the health insurance plan’s revenue loss and expense ratio relating to the care and treatment of mental health conditions covered under the health insurance plan. This regulation sets out the minimum reporting requirements.
Effective Date 04/03/2001

11/1992

Primary Focus Mandated Benefit: Provider
Agency Department of Financial Regulation
Title/Description Minimum Requirements for Compliance With 8 V.S.A. Section 4080(a) (Small Group Carriers): Section 5: Common Health Care Plans
Citation 21-020-029 Vt. Code R. § 1
Summary

Except as stated in the model plan, no policy can be issued or delivered or advertised unless mental health care benefits, with the minimums stated in 8 V.S.A., Section 4089 are offered as an option, among other minimum benefit options.
Effective Date 11/01/1992

07/1986

Primary Focus Medicaid
Agency Agency of Human Services
Title/Description Department of Mental Health Medicaid Regulations
Citation 13-150-004 Vt. Code R. § 1
Summary

Medicaid payment for covered services is limited to Community Mental Health Centers that are facilities established for the purpose of providing outpatient mental health care. Mental health clinic services cannot be reimbursed when provided in skilled nursing (Level I) or intermediate care (Level II) facilities. However, if a client is a resident of either type of facility and is seen at a mental health facility, the services provided may be billed.
Effective Date 07/01/1986

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Common Violations

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Common Violations