RD582 - Coverage for Mental Health and Substance Use Disorders: Summary of 2022 Insurance Carrier Data – November 1, 2023

Executive Summary:

As required by § 38.2-3412.1 B 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.

The Bureau of Insurance (Bureau) has developed health carrier reporting requirements for mental health and substance use disorder benefits that includes denied claims, complaints, appeals, and network adequacy, and compiled the information into a report pursuant to § 38.2-3412.1 G of the Code. In addition, this report also includes a summary of all comparative analyses of Non-Quantitative Treatment Limitations (NQTL) prepared by health insurance carriers pursuant to 42 U.S.C. § 300gg-26(a)(8) and requested by the Bureau during the reporting period.

To gather the necessary information, the Bureau conducted a data call of 17 health carriers insuring more than 2.51 million lives in the individual, small group, and large group health insurance markets in Virginia during 2022. The Bureau also conducted a supplemental data call to assess network adequacy. Key takeaways include:

• In total, while the difference was small, carriers denied claims more often for mental health and substance use disorder benefits than for medical/surgical benefits. Carriers generally denied claims in fewer service categories (2 of 5) for mental health benefits and in more service categories (5 of 5) for substance use disorder benefits than claims for medical/surgical benefits.

• The largest share of complaints for both mental health and medical/surgical benefits concerned administrative/service (36.7 percent and 33.3 percent, respectively), while the largest share of complaints for substance use disorder benefits concerned utilization management (37.5 percent).

• Denied claims involving mental health benefits were upheld by carriers in 62 percent of closed internal appeals and upheld in 25 percent of closed external reviews.

• Based on information submitted by the health carriers and the differing standards for network adequacy, the Bureau could not reasonably determine parity in network adequacy or compare access to network providers for mental health, substance use disorder or medical/surgical benefits.

• The Bureau deemed all reported comparative analyses of NQTLs insufficient.