(1) A
plan providing mental health or substance use disorder benefits, must provide
mental health or substance use disorder benefits in every classification in
which medical/surgical benefits are provided.
(2) Parity requirements must be applied to
the following six classifications of benefits: Inpatient, in-network;
inpa-tient, out-of-network; outpatient, in-network; outpatient, out-of-network;
emergency care; and prescription drugs. These are the only classifications of
benefits that can be used.
(a)
Inpatient, in-network. Benefits furnished on an inpatient basis
and within a network of providers established or recognized under a plan or
health insurance coverage.
(b)
Inpatient, out-of-network. Benefits furnished on an inpatient
basis and outside any network of providers established or recognized under a
plan or health insurance coverage. This classification includes inpatient
benefits under a plan (or health insurance coverage) that has no network of
providers.
(c)
Outpatient,
in-network. Benefits furnished on an outpatient basis and within a
network of providers established or recognized under a plan or health insurance
coverage.
(d)
Outpatient,
out-of-network. Benefits furnished on an outpatient basis and outside
any network of providers established or recognized under a plan or health
insurance coverage. This classification includes outpatient benefits under a
plan (or health insurance coverage) that has no network of providers.
(e)
Emergency care. Benefits for
treatment of an emergency condition related to a mental health or substance use
disorder. Such benefits must comply with the requirements for emergency medical
services in
RCW
48.43.093. Medically necessary detoxification
must be covered as an emergency medical condition according to
RCW
48.43.093, and may be provided in hospitals
licensed under chapter 70.41 RCW. Medically necessary detoxification services
must not require prenotification.
(f)
Prescription drugs. Benefits
for prescription drugs.
(3) In determining the classification in
which a particular benefit belongs, a plan must apply the same standards to
medical/surgical benefits as applied to mental health or substance use disorder
benefits.
An issuer or plan must assign covered intermediate mental
health/substance use disorder benefits such as residential treatment, partial
hospitalization, and intensive outpatient treatment, to the existing six
classifications in the same way that they assign comparable intermediate
medical/surgical benefits to these classifications. For example, if a plan
classifies medical care in skilled nursing facilities as inpatient benefits,
then it must also treat covered mental health care in residential treatment
facilities as inpatient benefits. If a plan or issuer treats home health care
as an outpatient benefit, then any covered intensive outpatient mental health
or substance use disorder services and partial hospitalization must be
considered outpatient benefits as well.
(4) A plan or issuer may not apply any
financial requirement or treatment limitation to mental health or substance use
disorder benefits that is more restrictive than the predominant financial
requirement or treatment limitation applied to medical/surgical benefits. This
parity analysis must be calculated for each type of financial requirement or
treatment limitation within a coverage unit for each classification of
services.
(5) Medical/surgical
benefits and mental health or substance use disorder benefits cannot be
categorized as being offered outside of these six classifications and therefore
not subject to the parity analysis.
(a) A
plan or issuer must treat the least restrictive level of the financial
requirement or quantitative treatment limitation that applies to at least
two-thirds of medical/surgical benefits across all provider tiers in a
classification as the predominant level that it may apply to mental health or
substance use disorder benefits in the same classification.
(b) If a plan or issuer classifies providers
into tiers, and varies cost-sharing based on the different tiers, the criteria
for classification must be applied to generalists and specialists providing
mental health or substance use disorder services no more restrictively than
such criteria are applied to medical/surgical benefit providers.
(6)
Permitted
subclassifications:
(a) A plan or
issuer is permitted to divide benefits furnished on an outpatient basis into
two subclassifica-tions:
(i) Office visits;
and
(ii) All other outpatient items
and services.
(b) A plan
or issuer may divide its benefits furnished on an in-network basis into
subclassifications that reflect network tiers, if the tiering is based on
reasonable factors and without regard to whether a provider is a mental health
or substance use disorder provider or a medical/surgical provider.
(c) After network tiers are established, the
plan or issuer may not impose any financial requirement or treatment limitation
on mental health or substance use disorder benefits in any tier that is more
restrictive than the predominant financial requirement or treatment limitation
that applies to substantially all medical/surgical benefits in that
tier.
(d) If a plan applies
different levels of financial requirements to different tiers of prescription
drug benefits based on reasonable factors and without regard to whether a drug
is generally prescribed with respect to medical/surgical benefits or with
respect to mental health/substance use disorder benefits, the plan satisfies
the parity requirements with respect to prescription drug benefits. Reasonable
factors include: Cost, efficacy, generic versus brand name, and mail order
versus pharmacy pick-up.
(e) A
parity analysis applying the financial requirement and treatment rules found in
WAC
284-43-7040
and
284-43-7060
must be performed for each type of financial requirement or quantitative
treatment limitation within a coverage unit for each subclassification of
services.
(7)
Prohibited subclassifications: All subclassifica-tions other than
the permitted subclassification listed in subsection (6) of this section are
specifically prohibited. For example, a plan is prohibited from basing a
subclassification on generalists and specialists.
