Coverage for Autism Spectrum Disorder
May 10, 2022
On April 19, 2022, Insurance Commissioner White released Administrative Letter 2022-2 related to coverage of autism spectrum disorder (ASD). After discussions with CMS and research, the Virginia Bureau of Insurance has revised its position on ASD and related insurance coverage. Policies issued on or after January 1, 2023, must classify ASD as a mental health disorder. Coverage under any group medical policy must provide for the treatment of ASD, including medically necessary behavioral health treatment, pharmacy care, psychiatric care, psychological care and therapeutic care. Coverage must specifically include applied behavioral analysis (ABA) services. The Bureau will consider any ABA exclusion to be a violation of both Virginia law and the Mental Health Parity and Addiction Equity Act. There is an exception for grandfathered small group health insurance coverage, which is not subject to MHPAEA requirements.
Further, treatment of ASD, including ABA services, will be considered an essential health benefit under Virginia’s benchmark plan. Thus, insured policies and self-insured plans that identify Virginia as their benchmark plan will be prohibited from excluding or placing dollar limits on such coverage.
Administrative Letter 2022-2 »
Disability Coverage for Childbirth
May 11, 2021
The Bureau of Insurance issued guidance which states that, effective July 1, 2021, newly issued short-term disability policies must pay benefits for a full 12 weeks immediately following childbirth. There can be no exclusion or waiting period applied. The Bureau clarified that the mandate will not apply to renewed short-term disability policies or long-term disability policies.
Employers sponsoring short-term disability plans will want to familiarize themselves with this policy and work with their carrier to implement it.
Bureau of Insurance Memo »
Coverage for Telemedicine Expanded
April 27, 2021
On March 24, 2021, Gov. Northam signed HB 1987 into law. The new law, effective July 1, 2021, states that a healthcare provider may prescribe a Schedule II through VI controlled substance via telemedicine if the provider maintains a physical location in Virginia or is able to make referral to a licensed provider in Virginia to ensure an in-person examination if required by the standard of care.
Additionally, the healthcare provider must have an established relationship with the patient as evidenced by the following criteria:
- The patient has provided a medical history that is available for review by the prescriber.
- The prescriber obtains an updated medical history at the time of prescribing.
- The prescriber makes a diagnosis at the time of prescribing.
- The prescriber conforms to the standard of care expected of in-person care as appropriate to the patient's age and presenting condition, including when the standard of care requires the use of diagnostic testing and performance of a physical examination, which may be carried out using peripheral devices appropriate to the patient's condition.
- The prescriber is actively licensed in Virginia and authorized to prescribe.
- If the patient is a member or enrollee of a health plan or carrier, the prescriber has been credentialed by the health plan or carrier as a participating provider and the diagnosing and prescribing meets the qualifications for reimbursement by the health plan or carrier.
- Upon request, the prescriber provides patient records in a timely manner in accordance with state and federal laws and regulations.
- The establishment of a bona fide practitioner-patient relationship via telemedicine is consistent with the standard of care, and the standard of care does not require an in-person examination for the purpose of diagnosis.
- The establishment of a bona fide practitioner patient relationship via telemedicine is consistent with federal law and regulations and any waiver thereof.
Employers should be aware of these developments.
HB 1987 »
March 02, 2021
No Prior Authorization for Newborn Hospital Transfer
May 27, 2020
On April 9, 2020, Gov. Northam signed SB 718 into law. The new law prohibits group health insurance policies issued on or after January 1, 2021 from requiring prior authorization for the interhospital transfer of a newborn experiencing a life-threatening emergency condition or the hospitalized mother to accompany the newborn.
SB 718 »
12-Week Short-Term Disability Benefits for Childbirth
May 27, 2020
On April 9, 2020, Gov. Northam signed SB 567 into law. The new law requires group short-term disability policies to pay benefits for at least 12 weeks for a disability related to childbirth. The requirement is effective for policies issued or renewed on or after July 1, 2021.
SB 567 »
Discriminatory Coverage Related to Transplants Prohibited
May 12, 2020
Effective for policies issued on or after January 1, 2021, HB 1273 prohibits a group health plan from denying or limiting overage related to organ, eye or tissue transplant services solely because of the insured’s physical, intellectual, developmental or other disability. Services include referral to a transplant center or specialist; inclusion on an organ, eye or tissue transplantation waiting list; evaluation, surgery and related health care services; counseling; and post-transplantation treatment and services. The law only applies to policies that include coverage for services related to such transplants.
HB 1273 »
Coverage for Hearing Aids
May 12, 2020
On April 10, 2020, Gov. Northam signed SB 423 into law. The new law requires group health insurance policies to provide coverage for hearing aids and related services for children 18 years of age or younger when recommended by an otolaryngologist. The coverage must include one hearing aid per hearing-impaired ear, up to a cost of $1,500, every 24 months. The mandate applies to policies issued or renewed on and after January 1, 2021.
SB 423 »
Coverage for Applied Behavioral Analysis
April 28, 2020
On April 22, 2020, Commissioner White issued Administrative Letter 2020-03 related to required coverage of autism spectrum disorder (ASD). The letter clarifies qualified health plans in the small group market are not required to provide coverage for applied behavioral analysis (ABA) as such coverage exceeds the state benchmark plan’s essential health benefits. However, if the plan defines ASD as a mental health condition rather than a medical/surgical condition, then the exclusion of such may need to be reviewed in light of mental health parity requirements.
For policies issued on or after January 1, 2021, large group policies are required to provide coverage for ABA to treat ASD. If the plan defines ASD as a medical/surgical condition, there can be no limit on the number of ABA visits, but may cap annual benefits to $35,000. If the plan defines ASD as a mental health condition, the plan cannot impose a limit on the number of ABA visits and can only apply the $35,000 annual cap if compliant with mental health parity requirements.
Employer plan sponsors should discuss the requirements with their insurer to understand the coverages offered under the plan in 2021.
Administrative Letter 2020-03 »
Worker Misclassification Initiative
October 15, 2019
On August 8, 2019, Gov. Northam issued Executive Order No. 38. The order reauthorizes the inter-agency taskforce on worker misclassification and payroll fraud. The governor’s office believes that the misclassification of actual employees as independent contractors deprives the state of Virginia of millions of dollars in tax revenues and prevents workers from receiving protections and benefits to which they are otherwise entitled.
The order authorizes the existing taskforce to continue reporting current enforcement practices against employers and recommending procedures for more effective enforcement. Virginia employers should review their employment practices to make sure that workers are properly classified as employees or independent contractors. Employees that are improperly classified as independent contractors could put the employer at risk for penalties under the employer mandate, as well as past liability for group health plan claims, employment taxes, and workers compensation benefits.
Executive Order No. 38 »