Text: HF00490 Text: HF00492 Text: HF00400 - HF00499 Text: HF Index Bills and Amendments: General Index Bill History: General Index
PAG LIN 1 1 Section 1. NEW SECTION. 514C.21 MENTAL HEALTH AND 1 2 SUBSTANCE ABUSE COVERAGE. 1 3 1. Notwithstanding the uniformity of treatment 1 4 requirements of section 514C.6, a group policy or contract 1 5 providing for third-party payment or prepayment of health or 1 6 medical expenses shall provide mental health and substance 1 7 abuse treatment coverage benefits and shall not impose 1 8 limitations on financial terms for coverage of services for 1 9 serious mental illnesses or substance abuse if similar 1 10 limitations are not imposed on the coverage benefits for 1 11 services for medical or surgical conditions. 1 12 2. For purposes of this section, unless the context 1 13 otherwise requires: 1 14 a. "Medically necessary or clinically appropriate" means, 1 15 with respect to a service or benefit, a service or benefit 1 16 which is consistent with generally accepted principles of 1 17 professional medical practice. 1 18 b. "Serious mental illness" means the following disorders, 1 19 as defined by the American psychiatric association's 1 20 diagnostic and statistical manual of mental disorders: 1 21 (1) Schizophrenia. 1 22 (2) Schizo-affective disorder. 1 23 (3) Bipolar disorder. 1 24 (4) Major depressive disorder. 1 25 (5) Obsessive-compulsive disorder. 1 26 (6) Autism. 1 27 (7) Pervasive developmental disorders. 1 28 (8) Panic disorder. 1 29 (9) Paranoia and other psychotic disorders. 1 30 (10) Eating disorders, including but not limited to 1 31 bulimia nervosa and anorexia nervosa. 1 32 c. "Substance abuse" means a pattern of pathological use 1 33 of alcohol or a drug that causes impairment in social or 1 34 occupational functioning, or that produces physiological 1 35 dependency evidenced by physical tolerance or by physical 2 1 symptoms when the alcohol or drug is withdrawn. 2 2 2. This section shall not apply to accident-only, specific 2 3 disease, short-term hospital or medical, hospital confinement 2 4 indemnity, credit, dental, vision, Medicare supplement, long- 2 5 term care, basic hospital and medical-surgical expense 2 6 coverage as defined by the commissioner, disability income 2 7 insurance coverage, coverage issued as a supplement to 2 8 liability insurance, workers' compensation or similar 2 9 insurance, automobile medical payment insurance, or individual 2 10 accident or sickness policies issued pursuant to chapter 513C. 2 11 3. A third-party payor may manage the benefits provided 2 12 through common methods including, but not limited to, 2 13 providing payment of benefits or providing care and treatment 2 14 under a capitated payment system, prospective reimbursement 2 15 rate system, utilization control system, incentive system for 2 16 the use of least restrictive and least costly levels of care, 2 17 a preferred provider contract limiting choice of specific 2 18 provider, or any other system, method, or organization 2 19 designed to ensure services are medically necessary and 2 20 clinically appropriate. 2 21 4. A group policy or contract covered under this section, 2 22 at a minimum, shall provide for thirty inpatient and sixty 2 23 outpatient days annually. The policy or contract may also 2 24 include deductibles, coinsurance, or copayments if such 2 25 deductibles, coinsurance, or copayments are applicable to 2 26 other medical or surgical services coverage under the policy 2 27 or contract. It is not a violation of this section if the 2 28 policy or contract excludes entirely from coverage benefits 2 29 the cost of providing the following: 2 30 a. Marital, family, educational, developmental, or 2 31 training services. 2 32 b. Care that is substantially custodial in nature. 2 33 c. Services and supplies that are not medically necessary 2 34 or clinically appropriate. 2 35 d. Experimental treatments. 3 1 5. The commissioner, by rule, shall increase the mental 3 2 health and substance abuse lifetime limit in the individual 3 3 market guaranteed standard product to one hundred thousand 3 4 dollars. 3 5 6. A group policy is exempt from this section upon 3 6 submitting to the commissioner evidence demonstrating a 3 7 premium increase for the policy term in excess of three 3 8 percent as a result of the requirements of this section. 3 9 7. This section applies to third-party payment provider 3 10 contracts or policies delivered, issued for delivery, 3 11 continued, or renewed in this state on or after January 1, 3 12 2002. 3 13 8. This section is repealed effective July 1, 2004. 3 14 EXPLANATION 3 15 This bill creates new Code section 514C.21 and provides 3 16 that a group policy or contract providing for third-party 3 17 payment or prepayment of health or medical expenses shall 3 18 provide coverage benefits for treatment of a serious mental 3 19 illness and substance abuse. The bill prohibits a group 3 20 policy or contract from imposing limitations on the financial 3 21 terms for coverage of services for serious mental illnesses or 3 22 substance abuse if similar limitations are not imposed on the 3 23 coverage benefits for services for medical or surgical 3 24 conditions. 3 25 The bill defines "serious mental illness" as psychiatric 3 26 illnesses including schizophrenia, schizo-affective disorder, 3 27 bipolar disorders, major depressive disorders, obsessive- 3 28 compulsive disorders, autism, pervasive developmental 3 29 disorders, panic disorders, paranoia and other psychotic 3 30 disorders, and eating disorders, including, but not limited 3 31 to, bulimia nervosa and anorexia nervosa. 3 32 The bill defines "substance abuse" as a pattern of 3 33 pathological use of alcohol or a drug that causes impairment 3 34 in social or occupational functioning, or that produces 3 35 physiological dependency evidenced by physical tolerance or by 4 1 physical symptoms when the alcohol or drug is withdrawn. 4 2 The bill provides that a third-party payor may manage the 4 3 benefits provided through common methods including, but not 4 4 limited to, providing payment of benefits or providing care 4 5 and treatment under a capitated payment system, prospective 4 6 reimbursement rate system, utilization control system, 4 7 incentive system for the use of least restrictive and least 4 8 costly levels of care, a preferred provider contract limiting 4 9 choice of specific provider, or any other system, method, or 4 10 organization designed to ensure services are medically 4 11 necessary and clinically appropriate. The bill defines 4 12 "medically necessary or clinically appropriate" services 4 13 according to generally accepted principles of professional 4 14 medical practice. 4 15 The bill provides that the commissioner, by rule, is to 4 16 increase the mental health and substance abuse lifetime limit 4 17 in the individual market guaranteed standard product to 4 18 $100,000. 4 19 The bill provides that a group policy is exempt from the 4 20 requirements of the new Code section upon submitting to the 4 21 commissioner evidence demonstrating a premium increase for the 4 22 policy term in excess of 3 percent as a result of the 4 23 requirements of this section. 4 24 The bill provides that the new Code section applies to 4 25 third-party payment provider contracts or policies delivered, 4 26 issued for delivery, continued, or renewed in this state on or 4 27 after January 1, 2002. 4 28 The new Code section is repealed effective July 1, 2004. 4 29 LSB 2243HH 79 4 30 jj/cf/24
Text: HF00490 Text: HF00492 Text: HF00400 - HF00499 Text: HF Index Bills and Amendments: General Index Bill History: General Index
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