Text: SF02219 Text: SF02221 Text: SF02200 - SF02299 Text: SF 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 TREATMENT 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. "Serious mental illness" means the following disorders,
1 15 as defined by the American psychiatric association's
1 16 diagnostic and statistical manual of mental disorders:
1 17 (1) Schizophrenia.
1 18 (2) Schizo-affective disorder.
1 19 (3) Bipolar disorder.
1 20 (4) Major depressive disorder.
1 21 (5) Obsessive-compulsive disorder.
1 22 (6) Autism.
1 23 (7) Pervasive developmental disorders.
1 24 (8) Anxiety disorders.
1 25 (9) Paranoia and other psychotic disorders.
1 26 (10) Eating disorders, including but not limited to
1 27 bulimia nervosa and anorexia nervosa.
1 28 b. "Substance abuse" means a pattern of pathological use
1 29 of alcohol or a drug that causes impairment in social or
1 30 occupational functioning, or that produces physiological
1 31 dependency evidenced by physical tolerance or by physical
1 32 symptoms when the alcohol or drug is withdrawn.
1 33 3. This section shall not apply to accident-only, specific
1 34 disease, short-term hospital or medical, hospital confinement
1 35 indemnity, credit, dental, vision, Medicare supplement, long-
2 1 term care, basic hospital and medical-surgical expense
2 2 coverage as defined by the commissioner, disability income
2 3 insurance coverage, coverage issued as a supplement to
2 4 liability insurance, workers' compensation or similar
2 5 insurance, automobile medical payment insurance, or individual
2 6 accident or sickness policies issued pursuant to chapter 513C.
2 7 4. A third-party payor may manage the benefits provided
2 8 through common methods including, but not limited to,
2 9 providing payment of benefits or providing care and treatment
2 10 under a capitated payment system, prospective reimbursement
2 11 rate system, utilization control system, incentive system for
2 12 the use of least restrictive and least costly levels of care,
2 13 a preferred provider contract limiting choice of specific
2 14 provider, or any other system, method, or organization
2 15 designed to ensure services are medically necessary and
2 16 clinically appropriate.
2 17 5. A group policy or contract covered under this section,
2 18 at a minimum, shall provide for thirty inpatient and sixty
2 19 outpatient days annually. The policy or contract may also
2 20 include deductibles, coinsurance, or copayments if such
2 21 deductibles, coinsurance, or copayments are applicable to
2 22 other medical or surgical services coverage under the policy
2 23 or contract. It is not a violation of this section if the
2 24 policy or contract excludes entirely from coverage benefits
2 25 the cost of providing the following:
2 26 a. Marital, family, educational, developmental, or
2 27 training services.
2 28 b. Care that is substantially custodial in nature.
2 29 c. Services and supplies that are not medically necessary
2 30 or clinically appropriate.
2 31 d. Experimental treatments.
2 32 6. The commissioner, by rule, shall increase the mental
2 33 health and substance abuse treatment lifetime limit in the
2 34 individual market guaranteed standard product to one hundred
2 35 thousand dollars.
3 1 7. A group policy is exempt from this section upon
3 2 submitting to the commissioner evidence demonstrating a
3 3 premium increase for the policy term in excess of three
3 4 percent as a result of the requirements of this section.
3 5 8. This section applies to third-party payment provider
3 6 contracts or policies delivered, issued for delivery,
3 7 continued, or renewed in this state on or after January 1,
3 8 2003.
3 9 9. This section is repealed effective July 1, 2005.
3 10 EXPLANATION
3 11 This bill creates new Code section 514C.21 and provides
3 12 that a group policy or contract providing for third-party
3 13 payment or prepayment of health or medical expenses shall
3 14 provide coverage benefits for treatment of a serious mental
3 15 illness and substance abuse. The bill prohibits a group
3 16 policy or contract from imposing limitations on the financial
3 17 terms for coverage of services for serious mental illnesses or
3 18 substance abuse if similar limitations are not imposed on the
3 19 coverage benefits for services for medical or surgical
3 20 conditions.
3 21 The bill defines "serious mental illness" as schizophrenia,
3 22 schizo-affective disorder, bipolar disorders, major depressive
3 23 disorders, obsessive-compulsive disorders, autism, pervasive
3 24 developmental disorders, anxiety disorders, paranoia and other
3 25 psychotic disorders, and eating disorders, including, but not
3 26 limited to, bulimia nervosa and anorexia nervosa. The bill
3 27 defines "substance abuse" as a pattern of pathological use of
3 28 alcohol or a drug that causes impairment in social or
3 29 occupational functioning, or that produces physiological
3 30 dependency evidenced by physical tolerance or by physical
3 31 symptoms when the alcohol or drug is withdrawn.
3 32 The bill requires that a third-party payor may manage the
3 33 benefits provided through common methods including, but not
3 34 limited to, providing payment of benefits or providing care
3 35 and treatment under a capitated payment system, prospective
4 1 reimbursement rate system, utilization control system,
4 2 incentive system for the use of least restrictive and least
4 3 costly levels of care, a preferred provider contract limiting
4 4 choice of specific provider, or any other system, method, or
4 5 organization designed to ensure services are medically
4 6 necessary and clinically appropriate.
4 7 The bill requires the insurance commissioner, by rule, to
4 8 increase the mental health and substance abuse lifetime limit
4 9 in the individual market guaranteed standard product to
4 10 $100,000.
4 11 The bill provides that a group policy is exempt from the
4 12 requirements of the new Code section upon submitting to the
4 13 commissioner evidence demonstrating a premium increase for the
4 14 policy term in excess of 3 percent as a result of the
4 15 requirements of the new Code section.
4 16 The bill provides that the new Code section applies to
4 17 third-party payment provider contracts or policies delivered,
4 18 issued for delivery, continued, or renewed in this state on or
4 19 after January 1, 2003. The new Code section is repealed
4 20 effective July 1, 2005.
4 21 LSB 5553ST 79
4 22 jj/cf/24
Text: SF02219 Text: SF02221 Text: SF02200 - SF02299 Text: SF Index Bills and Amendments: General Index Bill History: General Index
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