December 17, 2014
OLYMPIA, Wash. - New enhanced standards and tools for measuring parity between mental health and medical and surgical benefits takes effect Dec. 18, 2014.
“Washington state has been a leader in ensuring mental health coverage for consumers,” said Insurance Commissioner Mike Kreidler. “This new rule gives us one more set of tools to make sure insurers are living up to their promises and that people are getting fair access to the mental health services they need.”
The rule aligns state and federal mental health parity laws and creates clear standards or formulas for health insurers to show the Office of the Insurance Commissioner (OIC) how they are delivering mental health services and substance use disorder treatments compared to medical and surgical benefits.
It also gives the OIC better tools to measure if health insurers are delivering these services fairly and correctly.
Now, health insurers must demonstrate the parity of their coverage between mental health and substance use disorders and medical and surgical benefits for each of six categories of services:
- Inpatient, in-network
- Inpatient, out-of-network
- Outpatient, in-network
- Outpatient, out-of-network
- Emergency care
- Prescription drugs
For example, if a health plan classifies a residential skilled nursing facility as inpatient medical care, it also must classify a mental health residential treatment facility as inpatient care.
The regulation addresses how insurers must evaluate differences in co-pays/deductibles and treatment limitations between mental health services and medical and surgical benefits. It also requires insurers to give consumers the actual reason for denying a benefit, as well as access to their claim documents and records upon request and free of charge.
“If you believe you’ve been unfairly denied insurance coverage for mental health services, contact my insurance consumer hotline at 800-562-6900 or file a complaint,” added Kreidler.