Approximately one in five adults report experiencing a mental health condition. At the same time, many individuals continue to face delays or barriers when trying to access care, even when they have insurance coverage. Delays, denials, or truncation of treatment leave families and their doctors battling for coverage instead of focusing on treatment and recovery. Families must pay out of pocket for care, on top of premiums for coverage they are not receiving. Further, Delawareans are five times more likely to go out-of-network for mental health care than for primary care, resulting in higher costs.
This Act, known as the Fair Standards in Mental Health Care Act, builds on previous work to advance mental health parity and aims to ensure patients with private insurance can access timely, evidence-based mental health and substance use disorder care in Delaware. This Act supports improved access to mental health disorder and substance use disorder treatment by:
1. Adding and refining key terms, including definitions of mental health disorders and substance use disorders, level of care criteria, medically necessary treatment, utilization review and utilization review criteria to ensure consistency with widely accepted clinical standards of treatment and service intensity determination. This bill forges gold-standard clinical guidelines through requiring insurers to use transparent, evidence-based standards from independent experts, including the American Academy of Child and Adolescent Psychiatry.
2. Requiring coverage for all medically necessary treatment, including emergency services and all clinically appropriate levels of care. This bill ends prior authorization delays for mental health and guarantees emergency mental health coverage, just as Delaware already does for addiction treatment.
3. Requiring at least one formulation of certain FDA-approved medications to treat substance use disorders to be placed on the lowest-cost tier of drug formularies.
4. Prohibiting discrimination against individuals with current or predicted mental health disorders or substance use disorders.
5. Requiring carriers to arrange coverage of medically necessary out-of-network services without additional cost to the enrollee if in-network options are unavailable within applicable network access standards, thus ensuring real network access.
6. Removing language currently in the code barring a private right of action for violations of 18 Del. Code § 3343. In addition, the Act clarifies that carriers must provide nonquantitative treatment limitation parity analysis (NQTL parity analysis) that they are required to have completed under federal law to health care providers and current and prospective covered persons, free of charge, upon request.
This Act applies to individual health insurance policies under Chapter 33 of Title 18 and group and blanket health insurance policies under Chapter 35 of Title 18. This Act applies to all policies, contracts, or certificates issued, renewed, modified, altered, amended, or reissued after December 31, 2027.
This Act also makes technical corrections to conform existing law to the standards of the Delaware Legislative Drafting Manual.