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COMMISSIONER'S BULLETIN # B-0003-09

January 16, 2009

 

TO: ALL CARRIERS LICENSED TO WRITE LIFE AND ACCIDENT AND HEALTH INSURANCE, HEALTH MAINTENANCE ORGANIZATIONS, AGENTS, THIRD PARTY ADMINISTRATORS, UTILIZATION REVIEW AGENTS, PREMIUM FINANCE COMPANIES; AND MEWAS LICENSED IN TEXAS

RE: PARITY REQUIRED FOR GROUP OUTPATIENT SERIOUS MENTAL ILLNESS COVERAGE

On October 28, 2008, the Texas Attorney General (AG) issued an opinion finding that group health plans in Texas are required to provide the same number of outpatient treatment visits for serious mental illness (SMI) as they do for physical illness. [1] This bulletin is issued to provide notice of the opinion and to provide information and guidance.

The AG opinion specifically concludes that §1355.004 of the Insurance Code requires that "[g]roup health plans that provide more than 60 outpatient visits for physical illnesses must . . . provide the same number of visits for serious mental illness." [2] The Department will enforce the requirements of §1355.004 consistent with the AG opinion.

The Department expects entities subject to Chapter 1355 ("carriers") to take all necessary steps to ensure that, for example, their claims adjudications, claims processing procedures, and plan documents ("forms") are consistent with §1355.004 and the AG opinion. At a minimum, and regardless of any currently non-compliant form language, the Department believes that all claims filed on or after the date of the AG opinion (under large employer plans and small employer plans that include SMI coverage) should be processed in a manner consistent with the opinion.

Additionally, carriers with non-compliant forms currently in the market are encouraged to immediately submit corrected forms or amendments to the Department. Amendment and rider forms submitted specifically in response to the AG opinion should be identified as such when filed with the Department. Such amendments and riders will be given an expedited review and staff will work closely with carriers on any issues that arise.

To confirm compliance with statute as interpreted by the AG's opinion # GA-0674, the Department will conduct data calls, as well as reviews of forms carriers have on file. The Department anticipates that all insurance policies and evidences of coverage in the market will be compliant by June 1, 2009.

The Department also notes that the federal Mental Health Parity and Addiction Equity Act of 2008, passed as part of the Emergency Economic Stabilization Act of 2008 (HR 1424), requires full parity of coverage between mental health benefits (including substance use disorders benefits) and medical and surgical benefits, though only for large employer plans that offer mental health benefits and only for plans issued or renewed after October of 2009. The Department plans to implement the requirements of the federal act through future rulemaking.

Questions regarding this bulletin may be directed to Doug Danzeiser, Deputy Commissioner for Regulatory Matters, Life, Health & Licensing Program, at (512) 475-1964 or by e-mail at: Doug.Danzeiser@tdi.state.tx.us.


[1] Opinion No. GA-0674: www.oag.state.tx.us/opinions/opinions/50abbott/op/2008/htm/ga-0674.htm.

[2] Article 3.51-14(3) was recodified in §1355.004 in 2003. Article 3.51-14(3) required coverage of 60 days of outpatient treatment for serious mental illness. See House Insurance Committee Report on HB 1173 (75 th): www.capitol.state.tx.us/tlodocs/75R/analysis/html/HB01173H.htm (noting that the committee substitute which was eventually passed "changes required coverage from full parity to maximum required inpatient stays and outpatient treatment days").



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Last updated: 09/07/2014

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