RD615 - 2022 Report: Claims - Complaints – Appeals – Mental Health, Substance Use Disorder Benefits and Network Adequacy for the Period January 1, 2021 - December 31, 2021
As required by § 38.2-3412.1 G of the Code of Virginia (Code) and in accordance with the federal Mental Health Parity and Addiction Equity Act of 2008, P.L. 110-343, mental health and substance use disorder benefits provided by group and individual health insurance coverage must be in parity with medical and surgical benefits coverage. Further, § 38.2-3412.1 G of the Code requires the State Corporation Commission, Bureau of Insurance (Bureau), to:
• develop reporting requirements for health carriers regarding denied claims, complaints, appeals, and network adequacy involving coverage of mental health and substance use disorder benefits;
• provide a report of the information gathered by November 1 of each year;
• post the report on the Bureau’s website; and
• submit the report to the House Committee on Commerce and Energy and the Senate Committee on Commerce and Labor.
In order to gather the necessary information to fulfill the reporting requirements under § 38.2-3412.1 G of the Code, the Bureau developed a survey in collaboration with the Virginia Department of Behavioral Health and Developmental Services, the Virginia Association of Health Plans (“VAHP") and health carriers that are not members of VAHP. Through this survey, the Bureau receives information(*1) to help it analyze: (a) whether health carriers ensure that claims, complaints and appeals related to mental health and substance use disorder benefits are being treated in parity with claims, complaints and appeals related to medical/surgical benefits; and (b) whether health carriers provide reasonable access to network providers of mental health and substance use disorder services in parity with access to network providers of medical/surgical services.
The Bureau surveyed 16 health carriers, each identified as insuring more than 5,000 lives in Virginia in the individual, small group, and large group health insurance markets during the 2021 calendar year. In total, these carriers reported more than 1.68 million covered lives. Carriers were requested to report information specific to three benefit categories: medical/surgical benefits, mental health benefits, and substance use disorder benefits. Further, for these three benefit categories, carriers were required to report data for the 2021 calendar year for:
• Claims paid, denied and the reason for the denial;
• Complaints received and processed;
• Internal appeals processed; and
• External reviews processed.
This report provides an overview of the information obtained through the survey, broken down into four sections. Key takeaways include the following:
• Claims were generally denied more frequently for mental health and substance use disorder benefits than for medical/surgical benefits.
• Complaints concerning access to care was the reason provided most often regarding mental health benefits and substance use disorder benefits.
• Denied claims for mental health or substance use disorder benefits handled internally by a health carrier were upheld in the majority of internal appeals. Closed external reviews were upheld in a larger majority for these benefits than for medical/surgical benefits.
• Network adequacy parity or comparison of access to network providers for mental health, substance use disorder or medical/surgical services cannot be reasonably determined based on information submitted by the health insurance carriers.
Finally, the 2022 General Assembly amended the reporting requirements under § 38.2-3412.1 G of the Code to include a summary of all comparative analyses prepared by health insurance carriers pursuant to 42 U.S.C. § 300gg-26(a)(8). Since this amendment was not effective until July 1, 2022, this summary will be included in next year’s report due November 1, 2023.