Code of Vermont Rules › Agency 21 - DEPARTMENT OF FINANCIAL REGULATION › Sub-Agency 020 - INSURANCE DIVISION › Chapter 066 - REGULATION I - 2013 - 01 GUIDELINES FOR DISTINGUISHING BETWEEN PRIMARY AND SPECIALTY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES › Section 21 020 066 - REGULATION I - 2013 - 01 GUIDELINES FOR DISTINGUISHING BETWEEN PRIMARY AND SPECIALTY MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES

Current through June,
				2024
Section 1 Purpose
Under Vermont Law, a health plan shall apply member co-pays
				  to mental health services and to medical services consistently in its health
				  insurance policies/certificates. The member co-pay applicable to mental health
				  and substance abuse services designated as "primary" when rendered by a mental
				  health care provider shall be no greater than the member co-pay applicable to
				  medical services rendered by a primary care provider. The member co-pay for
				  "specialty" mental health and substance abuse services shall be no greater than
				  the member co-pay applicable to specialty medical services and shall apply only
				  to those mental health and substance abuse services not deemed "primary." The
				  purpose of this regulation is to prescribe guidelines for distinguishing
				  between "primary" and "specialty" mental health and substance abuse
				  services.
Section 2
				Authority
This rule is issued pursuant to the authority vested in the
				  Commissioner of Financial Regulation ("Commissioner"), including but not
				  limited to
				  8 V.S.A. §
											15, 3 V.S.A. chapter 25, and Act 171 of 2012,
				  Section 11e, which states: "No later than October 1, 2013, the commissioner of
				  financial regulation shall adopt rules pursuant to 3 V.S.A. chapter 25
				  establishing the guidelines for distinguishing between primary and specialty
				  mental health services developed pursuant to Section 11c of this act, taking
				  into account any recommendations received from the committees of
				  jurisdiction."
Section 3
				Legislative Mandate
"A health insurance plan shall provide coverage for the
				  treatment of a mental health condition and shall not establish any rate, term,
				  or condition that places a greater burden on an insured for access to treatment
				  for a mental health condition [n1] [] than for access to treatment for other
				  health conditions, including no greater co-payment for primary mental health
				  care or services than the co-payment applicable to care or services provided by
				  a primary care provider under an insured's policy and no greater co-payment for
				  specialty mental health care or services than the co-payment applicable to care
				  or services provided by a specialist provider under an insured's policy[.]"
				  8
				  V.S.A. §
											4089b(c)(1)
				  (effective January 1, 2014).
[n1 The definition of "mental health condition" includes
				  conditions or disorders involving alcohol or substance abuse.
				  8
				  V.S.A. §
											4089b.]
Pursuant to Act 171 of 2012, Section 11c, the Department of
				  Financial Regulation ("Department"), in collaboration with a group of
				  stakeholders, compiled a list of mental health and substance abuse services,
				  identified by procedure codes, and recommended to the Commissioner that these
				  services be deemed "primary" mental health and substance abuse services for
				  purposes of implementing
				  8
				  V.S.A.§
											4089b(c)(1) on
				  January 1, 2014. The list of mental health and substance abuse services with
				  associated procedure codes compiled by the stakeholder group titled "Primary
				  Care Mental Health and Substance Abuse Procedure Codes" shall be published on
				  the Department's website.
Section
				4 Mental Health and Substance Abuse Services Deemed to Be
				"Primary" and Therefore Subject to a CoPay No Greater Than the Co-Pay
				Applicable to Medical Services Offered by Primary Care Providers
The list of services and related procedure codes (CPT/HCPCS)
				  in "Primary Care Mental Health and Substance Abuse Procedure Codes" shall be
				  deemed "primary" mental health and substance abuse services. The common
				  elements underlying the selection of these "primary" mental health and
				  substance abuse services include:
(1)
				the most common or routine mental health and substance abuse services;
(2) outpatient/office mental
				health and substance abuse services only; and
(3) services provided to all persons
				regardless of age or gender.
On and after October 1, 2013, each health insurance plan
				  shall establish, maintain, administer, and update as required, a list of mental
				  health and substance abuse services consistent with those identified in
				  "Primary Care Mental Health and Substance Abuse Procedure Codes" that shall be
				  "primary" when rendered by a mental health care provider and for which the
				  member co-pay shall be no greater than the co-pay applicable to medical
				  services rendered by a primary care provider.