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LCAR approves DFR rule identifying primary mental‑health and substance‑use billing codes
Summary
The Legislative Committee on Administrative Rules on April 24 approved a Department of Financial Regulation rule (Rule 24 P 50) that tells insurers which mental‑health and substance‑use billing codes should receive a primary‑care copayment rather than a specialty‑care copayment. The rule does not change reimbursement rates.
The Legislative Committee on Administrative Rules on April 24, 2025 approved a Department of Financial Regulation proposed rule (Rule 24 P 50) that establishes guidelines for which mental‑health and substance‑use service billing codes insurers should treat as primary care for copayment purposes.
The rule matters because it directs health insurers which codes to apply a primary‑care copayment to — a change that affects patient cost‑sharing but, the department said, does not alter how providers are reimbursed. Sebastian, a Department of Financial Regulation presenter, told the committee: “This does not affect reimbursement at all. What this does is basically to tell health insurers which codes to apply a primary care co payment for.”
Department staff said the rule is authorized under Act 71 of 2012 and grew from a 2022 federal grant to study access to care in the commercial insurance market. The department contracted with Public Consulting Group (PCG) to recommend codes to designate as primary mental‑health care and said it circulated PCG’s recommendations to stakeholders, including the Department of Mental Health and the Vermont Psychological Association. Sebastian said the department presented PCG’s findings at the 2023 Department of Mental Health annual conference and collected stakeholder feedback.
The rule organizes covered codes into two appendices. Appendix A lists codes already required to be covered as primary care; Appendix B contains codes the department is adding. The department said the additions include five consultation/telehealth‑type codes (99446–99452), one code for self‑help or peer services, and two crisis psychotherapy codes (90839 and 90840). Sebastian said the department believes the list “captures the most commonly billed codes for primary mental health care.”
Representative Odey moved to approve the rule as presented; the committee approved the motion by voice vote with no opposition recorded. The committee transcript shows a voice “aye” vote and no roll‑call tally.
Committee members and department staff emphasized that this action changes only how insurers assess copayments and does not change insurer reimbursement schedules or provider payment rates. The department also noted it had made stylistic edits to the rule text (section numbers and headings) to align with current formatting standards.
The committee did not record amendments to the substance of the code list during the meeting. The committee’s next scheduled meeting was announced as May 15, 2025.
