The purpose of this regulation is to set forth the format and submission requirements for the mental health parity report that is required to be submitted to the Delaware Health Information Network and the Department in accordance with 18 Del.C. §§3343 and 3571U.
The authority for this regulation is 18 Del.C. §§311, 3343 and 3571U and Del. S.B. 230/Del. S.A. 1, 149th Gen. Assem. §4 (2018), and promulgated in accordance with the Delaware Administrative Procedures Act, 29 Del.C. Chapter 101.
"Carrier" means any entity that provides health insurance in this State. For the purposes of this section, "carrier" includes an insurance company, health service corporation, health maintenance organization, managed care organization, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation. "Carrier" also includes any third-party administrator or other entity that adjusts, administers, or settles claims in connection with a health benefit plan. “Carrier” also includes any carrier who administers a health benefit plan under 31 Del.C. §505(3).
“Commissioner” means the Insurance Commissioner of the State of Delaware.
“Department” means the Delaware Department of Insurance.
“FR” means financial requirements, and includes but is not limited to deductibles, copayments, coinsurance, and out-of-pocket maximums.
“Health benefit plan" means any hospital or medical policy or certificate, major medical expense insurance, health service corporation subscriber contract, or health maintenance organization subscriber contract, as defined and qualified under 18 Del.C. §§3343 and 3578, and any assistance provided to an individual under 31 Del.C. §505(3).
“Mental health parity report” means the report that is to be submitted to the Department and to the Delaware Health Information Network pursuant to Section 5.0 of this regulation.
“MHPAEA” means the Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a) as amended and supplemented.
“MH/SUD benefits” means mental health and substance use disorder benefits.
“M/S benefits” means medical and surgical benefits.
“NQTL” means non-quantitative treatment limitation, and includes but is not limited to preauthorization requirements and first-fail requirements.
“QTL” means quantitative treatment limitation, and includes but is not limited to lifetime limits, episode limits, and day and visit limits.
5.0 Reporting Content and Format
5.1.1 Whether the health insurance coverage is or is not exempt from MHPAEA. If the carrier reports that the health insurance coverage is exempt from MHPAEA, the carrier shall indicate the reason for the exemption, which may include, by way of example only, retiree-only plan, excepted benefits (45 CFR § 146.145(b)), short term limited duration insurance, small employer exemption (45 CFR § 146.136(f)), or increased cost exemption (45 CFR § 146.136(g));
5.1.2.2.1 Inpatient, in-network;
5.1.2.2.2 Inpatient, out-of-network;
5.1.2.2.3 Outpatient, in-network;
5.1.2.2.4 Outpatient, out-of-network;
5.1.9 Whether the carrier complies with MHPAEA disclosure requirements including:
5.1.9.1 Criteria for medical necessity determinations for MH/SUD benefits; and
5.1.9.2 The reasons for any denial of benefits of any kind.
6.0 Report submission deadlines and deadline extension request requirements
6.4.1 No reporting deadline shall be extended for a period longer than 60 days.
7.1 To ensure compliance with the provisions of this regulation and to protect Delaware health care consumers, the Commissioner may, in his or her discretion, examine the business and financial affairs of a carrier doing business in this state by utilizing the powers granted by 18 Del.C. §§320, 3343(g)(5), 3571U(a)(5), and other provisions of Title 18 as may be applicable.
7.2 Any person or entity who violates any provision of this regulation shall be subject to the penalties provided in 18 Del.C. Chapter 3, and such other provisions of Title 18 as may be applicable.
This regulation shall be effective on June 11, 2019.
DATA COLLECTION TOOL FOR MENTAL HEALTH PARITY ANALYSIS
Most parity analysis examines benefits by comparing MH/SUD to M/S within a classification. 45 CFR 146.136(c)(2)(i). The exception is aggregate lifetime or annual dollar limits (to the extent the plan is not prohibited from imposing such limits under Federal or State law), which are examined for the plan as a whole. See 45 CFR 146.136(b). The following is intended to simplify data collection for parity analysis at the classification level.
A-1 GUIDANCE FOR PLACING BENEFITS INTO CLASSIFICATIONS:
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The “inpatient” classification typically refers to services or items provided to a beneficiary when a physician has written an order for admission to a facility, while the “outpatient” classification refers to services or items provided in a setting that does not require a physician’s order for admission and does not meet the definition of emergency care.
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“Office visits” are a permissible sub-classification separate from other outpatient services.
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The term “emergency care” typically refers to services or items delivered in an emergency department setting or to stabilize an emergency or crisis, other than in an inpatient setting. See 18 Del.C. Chapters 33 and 35 concerning emergency care standards.
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Some benefits, for example lab and radiology, may fit into multiple classifications depending on whether they are provided during an inpatient stay, on an outpatient basis, or in the emergency department.
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Insurers should use the same decision-making standards to classify all benefits, so that the same standard applies to M/S and MH/SUD benefits. For example, if a plan classifies care in skilled nursing facilities and rehabilitation hospitals for M/S benefits as inpatient benefits, it must classify covered care in residential treatment facilities for MH/SUD benefits as inpatient benefits.
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A-2 FINANCIAL REQUIREMENTS AND QUANTITATIVE TREATMENT LIMITATIONS:
For each type of financial requirement that applies to MH/SUD benefits, list the expected percentage of plan payments for M/S benefits in each classification that are subject to that same type of financial requirement.
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A-3 NON-QUANTITATIVE TREATMENT LIMITATIONS:
NQTLs include but are not limited to medical management techniques such as step therapy and pre-authorization requirements. Coverage cannot impose a NQTL with respect to MH/SUD benefits in any classification unless, under the terms of the plan as written and in operation, any processes, strategies, evidentiary standards, or other factors used in applying the NQTL to MH/SUD benefits in the classification are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the limitation with respect to M/S benefits in the classification. Note that not every NQTL needs an evidentiary standard. There is flexibility under MHPAEA for plans to use NQTLs. The focus is on finding out what processes and standards the plan actually uses.
All plan standards that are not FRs or QTLs and that limit the scope or duration of benefits for services are subject to the NQTL parity requirements. This includes restrictions such as geographic limits, facility-type limits, and network adequacy.
A. Definition of Medical Necessity What is the definition of medical necessity?
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C. Concurrent Review Process, including frequency and penalties for all services. Describe any step therapy or “fail first” requirements and requirements for submission of treatment required forms or treatment plans.
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