Subsection B of § 38.2-3412.1 of the Code of Virginia (Code), in accordance with the federal Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA),(*1) requires mental health and substance use disorder benefits provided by individual and group health insurance plans to be in parity with medical and surgical benefits coverage.

Subsection G of that same section directs the Bureau of Insurance (Bureau) to prepare an annual report that includes a summary of findings from its review of all of Non-Quantitative Treatment Limitation (NQTL)(*2) comparative analyses requested by the Bureau and prepared by health carriers pursuant to 42 U.S.C. § 300gg-26(a)(8). It also requires the Bureau to include outcomes data compiled from information received from health carriers related to denied claims, complaints, appeals, and network adequacy for mental health and substance use disorder benefits for the reporting period January 1, 2024, through December 31, 2024. Key findings in this report include the following:

• The Bureau collected 552 comparative analyses for NQTL review during the current reporting period, which are all still under review.

• As an update to the prior reporting period, the Bureau received 320 comparative analyses, all of which were deemed insufficient. The Bureau has received 180 additional comparative analyses, with 140 still in process by the health carriers.

• Information provided to the Bureau by health carriers demonstrates that health carriers denied claims more often for substance use disorder benefits than for medical/surgical benefits and less often for mental health benefits. Carriers denied claims in fewer service categories (2 of 5) for mental health benefits and more service categories (4 of 5) for substance use disorder benefits than claims for medical/surgical benefits. The substance use disorder claim denial rates for office visits, all other outpatient services, emergency care, and inpatient services were substantially higher than those for medical/surgical claims.

• Health carriers upheld denied claims involving mental health benefits in 64% of closed internal appeals and 40% of closed external reviews, compared to 57% and 50% for medical/surgical claims, and 75% and 80% for substance use disorder claims, respectively.

• The largest share of complaints differed across each benefit category. For medical/surgical benefits, claims processing accounted for 53% of complaints; for mental health, utilization management accounted for 38%; and for substance use disorders, administrative/service accounted for 77%.
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(*1) “Emergency Economic Stabilization Act of 2008," Pub. L. 110-343, 122 Stat. 3765. The Mental Health Parity and Addiction Equity Act of 2008 is included in division C.
(*2) Treatment limitations include both Quantitative Treatment Limitations (QTLs), which are expressed numerically (such as 50 outpatient visits per year), and Non-Quantitative Treatment Limitations (NQTLs), which otherwise limit the scope or duration of benefits for treatment under a plan or coverage. See 45 CFR 146.136(c)(4)(ii), which provides an illustrative list of examples of NQTLs, such as medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness or based on whether the treatment is experimental or investigative.