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PAG LIN
1 1 Section 1. NEW SECTION. 514C.21 MANDATED COVERAGE FOR
1 2 TREATMENT OF CHILDREN – NEUROBIOLOGICAL DISORDER AND
1 3 SUBSTANCE ABUSE.
1 4 1. Notwithstanding the uniformity of treatment
1 5 requirements of section 514C.6, a group policy or contract
1 6 providing for third-party payment or prepayment of health or
1 7 medical expenses issued by a carrier, as defined in section
1 8 513B.2, or by an organized delivery system authorized under
1 9 1993 Iowa Acts, chapter 158, shall provide coverage benefits
1 10 to any child under the age of nineteen for treatment of a
1 11 neurobiological disorder and for substance abuse if either of
1 12 the following is satisfied:
1 13 a. The policy or contract that covers the child is issued
1 14 to an employer who on at least fifty percent of the employer's
1 15 working days during the preceding calendar year employed more
1 16 than fifty full-time equivalent employees. In determining the
1 17 number of full-time equivalent employees of an employer,
1 18 employers who are affiliated or who are able to file a
1 19 consolidated tax return for purposes of state taxation shall
1 20 be considered one employer.
1 21 b. The policy or contract that covers the child is issued
1 22 to a small employer as defined in section 513B.2, and such
1 23 policy or contract provides coverage benefits for the
1 24 treatment of mental illness.
1 25 2. Notwithstanding the uniformity of treatment
1 26 requirements of section 514C.6, a plan established pursuant to
1 27 chapter 509A for public employees shall provide coverage
1 28 benefits to any child under the age of nineteen for treatment
1 29 of a neurobiological disorder and for substance abuse.
1 30 3. For purposes of this section:
1 31 a. "Neurobiological disorder" means the following:
1 32 (1) Schizophrenia and other psychotic disorders.
1 33 (2) Mood disorders.
1 34 (3) Anxiety disorders.
1 35 (4) Pervasive developmental disorders and attention
2 1 deficit.
2 2 b. "Substance abuse" means a pattern of pathological use
2 3 of alcohol or a drug that causes impairment in social or
2 4 occupational functioning, or that produces physiological
2 5 dependency evidenced by physical tolerance or by physical
2 6 symptoms when the alcohol or drug is withdrawn.
2 7 4. The commissioner, by rule, shall define the
2 8 neurobiological disorders identified in subsection 3.
2 9 Definitions established by the commissioner shall be
2 10 consistent with definitions provided in the most recent
2 11 edition of the American psychiatric association's diagnostic
2 12 and statistical manual of mental disorders, as such
2 13 definitions may be amended from time to time. The
2 14 commissioner may adopt the definitions provided in such manual
2 15 by reference.
2 16 5. This section shall not apply to accident only,
2 17 specified disease, short-term hospital or medical, hospital
2 18 confinement indemnity, credit, dental, vision, Medicare
2 19 supplement, long-term care, basic hospital and medical-
2 20 surgical expense coverage as defined by the commissioner,
2 21 disability income insurance coverage, coverage issued as a
2 22 supplement to liability insurance, workers' compensation or
2 23 similar insurance, or automobile medical payment insurance, or
2 24 individual accident and sickness policies issued to
2 25 individuals or to individual members of a member association.
2 26 6. A carrier, organized delivery system, or plan
2 27 established pursuant to chapter 509A may manage the benefits
2 28 provided through common methods including, but not limited to,
2 29 providing payment of benefits or providing care and treatment
2 30 under a capitated payment system, prospective reimbursement
2 31 rate system, utilization control system, incentive system for
2 32 the use of least restrictive and least costly levels of care,
2 33 a preferred provider contract limiting choice of specific
2 34 providers, or any other system, method, or organization
2 35 designed to assure services are medically necessary and
3 1 clinically appropriate.
3 2 7. a. A group policy or contract or plan covered under
3 3 this section shall not impose an aggregate annual or lifetime
3 4 limit on neurobiological disorder or substance abuse coverage
3 5 benefits unless the policy or contract or plan imposes an
3 6 aggregate annual or lifetime limit on substantially all
3 7 medical and surgical coverage benefits.
3 8 b. A group policy or contract or plan covered under this
3 9 section that imposes an aggregate annual or lifetime limit on
3 10 substantially all medical and surgical coverage benefits shall
3 11 not impose an aggregate annual or lifetime limit on
3 12 neurobiological disorder or substance abuse coverage benefits
3 13 which is less than the aggregate annual or lifetime limit
3 14 imposed on substantially all medical and surgical coverage
3 15 benefits.
3 16 8. A group policy or contract or plan covered under this
3 17 section shall at a minimum allow for thirty inpatient days and
3 18 fifty-two outpatient visits annually. The policy or contract
3 19 or plan may also include deductibles, coinsurance, or
3 20 copayments, provided the amounts and extent of such
3 21 deductibles, coinsurance, or copayments applicable to other
3 22 medical or surgical services coverage under the policy or
3 23 contract or plan are the same. It is not a violation of this
3 24 section if the policy or contract or plan excludes entirely
3 25 from coverage benefits for the cost of providing the
3 26 following:
3 27 a. Marital, family, educational, developmental, or
3 28 training services.
3 29 b. Care that is substantially custodial in nature.
3 30 c. Services and supplies that are not medically necessary
3 31 or clinically appropriate.
3 32 d. Experimental treatments.
3 33 9. This section applies to third-party payment provider
3 34 policies or contracts and plans established pursuant to
3 35 chapter 509A delivered, issued for delivery, continued, or
4 1 renewed in this state on or after January 1, 2002.
4 2 EXPLANATION
4 3 This bill creates a new Code section 514C.21 and provides
4 4 that a group policy or contract providing for third-party
4 5 payment or prepayment of health or medical expenses issued by
4 6 a carrier, as defined in Code section 513B.2, or by an
4 7 organized delivery system authorized under 1993 Iowa Acts,
4 8 chapter 158, shall provide coverage benefits for children
4 9 under the age of 19 for treatment of a neurobiological
4 10 disorder and for substance abuse if the policy or contract is
4 11 issued to an employer who on at least 50 percent of the
4 12 employer's working days during the preceding calendar year
4 13 employed more than 50 full-time equivalent employees; if the
4 14 policy or contract is issued to a small employer as defined in
4 15 Code section 513B.2, and such policy or contract provides
4 16 coverage benefits for the treatment of mental illness; or if
4 17 the plan is established pursuant to Code chapter 509A for
4 18 public employees.
4 19 The bill defines "neurobiological disorder" as
4 20 schizophrenia and other psychotic disorders, mood disorders,
4 21 anxiety disorders, pervasive developmental disorders, and
4 22 attention deficit. The commissioner is directed to establish
4 23 by rule the definition of the neurobiological disorders
4 24 identified. The definitions established by the commissioner
4 25 are to be consistent with definitions provided in the most
4 26 recent edition of the American psychiatric association's
4 27 diagnostic and statistical manual of mental disorders, as the
4 28 definitions may be amended from time to time. The
4 29 commissioner may adopt the definitions provided in such manual
4 30 by reference.
4 31 "Substance abuse" is defined as a pattern of pathological
4 32 use of alcohol or a drug that causes impairment in social or
4 33 occupational functioning, or that produces physiological
4 34 dependency evidenced by physical tolerance or by physical
4 35 symptoms when the alcohol or drug is withdrawn.
5 1 The bill provides that a carrier, organized delivery
5 2 system, or plan established pursuant to Code chapter 509A may
5 3 manage the benefits provided through common methods including,
5 4 but not limited to, providing payment of benefits or providing
5 5 care and treatment under a capitated payment system,
5 6 prospective reimbursement rate system, utilization control
5 7 system, incentive system for the use of least restrictive and
5 8 least costly levels of care, a preferred provider contract
5 9 limiting choice of specific providers, or any other system,
5 10 method, or organization designed to assure services are
5 11 medically necessary and clinically appropriate.
5 12 The bill provides that the new Code section created applies
5 13 to third-party payment provider contracts or policies and
5 14 public employer plans delivered, issued for delivery,
5 15 continued, or renewed in this state on or after January 1,
5 16 2002.
5 17 LSB 1276SS 79
5 18 jj/pj/5
Text: SF00131 Text: SF00133 Text: SF00100 - SF00199 Text: SF Index Bills and Amendments: General Index Bill History: General Index
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