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2 1 symptoms when the alcohol or drug is withdrawn.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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