Bill to combat denials of physical and behavioral health coverage sent to Virginia governor

Lawmakers passed a bill aimed to provide more clarity to health insurance coverage for mental health and substance use disorders.

Del. Mark Sickles, D-Fairfax, introduced House Bill 2738. The bill defines the term “generally accepted standards of care” for physical and behavioral health conditions. Insurance providers will have to use evidence-based standards and clinical practices recognized by specialists and health care providers."

The bill also establishes that services or products which address a patient's need for screening, diagnosing, or treating these conditions will be considered “medically necessary.”

Insurers will be prohibited from applying criteria different from the generally accepted standards definition. The bill's language also requires coverage and benefits for all ages: children, adolescents and adults, according to the bill. 

Sickles cited data from the nonprofit KFF showing that in 2023, insurers using Healthcare.gov denied 19% of in-network claims and 37% of out-of-network claims. 

Advocates say the bill is necessary for proper access to essential services within mental health and substance use disorder care.

The Virginia Association of Health Plans worked with the patron and advocates to include the language that was added in the substitute, however the bill language still needs improvement, according to senior vice president Heidi Dix. 

“We feel as it's currently written, it prohibits us from using our standardized guidelines,” Dix said to the House Labor and Commerce subcommittee on Jan. 28.

“We’re trying to create a definition that's understandable by the wider public and is not dominated by the insurance industry deciding everything,” Sickles said.

There was some debate on where the bill should go after committee, with some lawmakers pushing for the legislative oversight Health Insurance Reform Commission. 

The bill is a standard of care bill, therefore not a HIRC eligible bill, Sickles told the panel. 

A Senate committee amendment added child, adolescent and adult psychiatry to the list of clinical specialties that are recognized by health care providers. It was a recommendation of the American Academy of Child and Adult Psychiatry, according to Sickles. 

The amendment also added service intensity assessment instruments as a nationally recognized clinical practice guideline, a standardized method that helps determine the needed level of care.

Mental Health Virginia is the oldest mental health advocacy organization in Virginia, according to its website. The organization favors the bill and aims to improve mental health services equally across Virginia, according to executive director Bruce Cruser. 

“It will definitely mean more people will get the care that they need when they need it," Cruser said.

The Faison Center brought attention to the issue, due to their services for young people with autism not getting funded, according to Cruser.

The center shut down one of its programs in December due to the amount of insurance denials of services, said president and CEO Brian McCann in public testimony to lawmakers. 

The program was provided to school-aged children aged six and older to receive applied behavioral analysis, or ABA, therapy, according to McCann. The insurance companies were using guidelines created in house and which had no transparency or accountability, he said.

“It applies to people who are dealing with an intellectual or developmental disability as well as mental health, a mental illness and a substance use disorder,” Cruser said about the bill. 

The bill is an important first step, according to Cruser.

“What I hope is that next year there will be a look at what really the data shows in Virginia, in terms of how people are accessing care, how much it's costing and what insurance companies are paying for,” Cruser said. 

The General Assembly and state officials have focused in recent years on efforts to improve mental health care in Virginia. Gov. Glenn Youngkin has until March 24 to make amendments, sign or veto the bill.