Virginia

There are several sections of state law relevant to parity. They are summarized below in three parts: Behavioral health coverage, state employee behavioral health coverage, and autism coverage.

There was a section (38.2-3412.1:01) about coverage requirements for “biologically-based mental illness” that was repealed in 2015 because amendments to another section of the state insurance law made 38.2-3412.1:01 obsolete and irrelevant. That section is not summarized here because it is no longer in the state insurance law. If you would like to know what was in that section, contact us at info@paritytrack.org.

This section requires large employer fully-insured plans, individual plans, and non-grandfathered small employer fully-insured plans to cover behavioral health services and provide those services in a way that meets the standards of the Federal Parity Law, even if the Federal Parity Law does not directly apply to a particular plan.

This section requires the following for grandfathered small employer fully-insured plans:

• 20 days of inpatient care for adults (inpatient care is defined to include residential – treatment)
• 25 days of inpatient care for children
• Up to 10 days of inpatient care can be turned into 15 days of partial hospitalization (1 for 1.5 ratio; 4 inpatient days could be come 6 days of partial hospitalization, for example)
• 20 visits for outpatient care
• Medication management visits do not count towards outpatient visit limit
• For any coinsurance, a plan must cover at least 50% for the first 5 outpatient visits
• Any outpatient visit that is not covered because the person has not yet met the plan –deductible does not count towards the 20 visit limit

This section requires state employee plans must cover “biologically based mental illness” and have the same coinsurance, copayments, annual maximums, lifetime maximums, annual limits, and lifetime limits as what are in place for other medical treatment. There must be just one combined deductible for “biologically-based mental illness” and other medical treatment. Medical necessity reviews for “biologically-based mental illness” must be conducted “in the same manner” as those for other medical treatment. “Biologically-based mental illness” is defined as:

• Schizophrenia
• Schizoaffective disorder
• Bipolar disorder
• Major depressive disorder
• Panic disorder
• Obsessive-compulsive disorder
• Attention deficit hyperactivity disorder
• Autism
• Drug and alcoholism addiction

This section requires large employer fully-insured plans, state employee plans, local government plans, and public school employee plans to cover autism services for children age 2 through age 10.

Autism spectrum disorder is defined as “any pervasive developmental disorder, including autistic disorder, Asperger’s Syndrome, Rett syndrome, childhood disintegrative disorder, or Pervasive Developmental Disorder – Not Otherwise Specified, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders.”

Autism treatment is defined as:

• Behavioral health treatment
• Pharmacy care
• Psychiatric care
• Psychological care
• Therapeutic care
• Applied behavior analysis

(All of these are defined in detail in the law)

There is a $35,000 annual maximum for applied behavior analysis.

Plans cannot have any visit limits for outpatient care, and financial requirements have to be the same as what are in place for other medical services.

Plans are allowed to review a child’s treatment plan once every 12 months.

Medical necessity reviews must conducted “in the same manner” as reviews for other medical services.

Plans are exempt from this section of the law if they can prove that complying with this section caused premiums to increase by at least 1% in a given year.