Senate File 58
SENATE FILE
BY TINSMAN, LUNDBY, and HOLVECK
Passed Senate, Date Passed House, Date
Vote: Ayes Nays Vote: Ayes Nays
Approved
A BILL FOR
1 An Act relating to third=party payment of health care coverage
2 costs for biologically based mental illness treatment
3 services.
4 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
5 TLSB 1595SS 80
6 jj/pj/5
PAG LIN
1 1 Section 1. NEW SECTION. 514C.21 BIOLOGICALLY BASED
1 2 MENTAL ILLNESS.
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 issued by a carrier, as defined in section
1 7 513B.2, or by an organized delivery system authorized under
1 8 1993 Iowa Acts, chapter 158, shall provide coverage benefits
1 9 for treatment of a biologically based mental illness if either
1 10 of the following is satisfied:
1 11 a. The policy or contract is issued to an employer who on
1 12 at least fifty percent of the employer's working days during
1 13 the preceding calendar year employed more than fifty full=time
1 14 equivalent employees. In determining the number of full=time
1 15 equivalent employees of an employer, employers who are
1 16 affiliated or who are able to file a consolidated tax return
1 17 for purposes of state taxation shall be considered one
1 18 employer.
1 19 b. The policy or contract is issued to a small employer as
1 20 defined in section 513B.2, and such policy or contract
1 21 provides coverage benefits for the treatment of mental
1 22 illness.
1 23 2. Notwithstanding the uniformity of treatment
1 24 requirements of section 514C.6, a plan established pursuant to
1 25 chapter 509A for public employees shall provide coverage
1 26 benefits for treatment of a biologically based mental illness.
1 27 3. For purposes of this section, "biologically based
1 28 mental illness" means the following psychiatric illnesses:
1 29 a. Schizophrenia.
1 30 b. Bipolar disorders.
1 31 c. Major depressive disorders.
1 32 d. Schizo=affective disorders.
1 33 e. Obsessive=compulsive disorders.
1 34 f. Pervasive developmental disorders.
1 35 g. Autistic disorders.
2 1 4. The commissioner, by rule, shall define the
2 2 biologically based mental illnesses identified in subsection
2 3 3. Definitions established by the commissioner shall be
2 4 consistent with definitions provided in the most recent
2 5 edition of the American psychiatric association's diagnostic
2 6 and statistical manual of mental disorders, as such
2 7 definitions may be amended from time to time. The
2 8 commissioner may adopt the definitions provided in such manual
2 9 by reference.
2 10 5. This section shall not apply to accident only,
2 11 specified disease, short=term hospital or medical, hospital
2 12 confinement indemnity, credit, dental, vision, Medicare
2 13 supplement, long=term care, basic hospital and medical=
2 14 surgical expense coverage as defined by the commissioner,
2 15 disability income insurance coverage, coverage issued as a
2 16 supplement to liability insurance, workers' compensation or
2 17 similar insurance, automobile medical payment insurance, or
2 18 individual accident and sickness policies issued to
2 19 individuals or to individual members of a member association.
2 20 6. A carrier, organized delivery system, or plan
2 21 established pursuant to chapter 509A may manage the benefits
2 22 provided through common methods including, but not limited to,
2 23 providing payment of benefits or providing care and treatment
2 24 under a capitated payment system, prospective reimbursement
2 25 rate system, utilization control system, incentive system for
2 26 the use of least restrictive and least costly levels of care,
2 27 a preferred provider contract limiting choice of specific
2 28 providers, or any other system, method, or organization
2 29 designed to ensure that services provided are medically
2 30 necessary and clinically appropriate.
2 31 7. a. A group policy, contract, or plan covered under
2 32 this section shall not impose an aggregate annual or lifetime
2 33 limit on biologically based mental illness coverage benefits
2 34 unless the policy, contract, or plan imposes an aggregate
2 35 annual or lifetime limit on substantially all medical and
3 1 surgical coverage benefits.
3 2 b. A group policy, contract, or plan covered under this
3 3 section that imposes an aggregate annual or lifetime limit on
3 4 substantially all medical and surgical coverage benefits shall
3 5 not impose an aggregate annual or lifetime limit on
3 6 biologically based mental illness coverage benefits which is
3 7 less than the aggregate annual or lifetime limit imposed on
3 8 substantially all medical and surgical coverage benefits.
3 9 8. A group policy, contract, or plan covered under this
3 10 section shall at a minimum allow for thirty inpatient days and
3 11 fifty=two outpatient visits annually for each person covered
3 12 under the policy, contract, or plan. The policy, contract, or
3 13 plan may also include deductibles, coinsurance, or copayments,
3 14 provided the amounts and extent of such deductibles,
3 15 coinsurance, or copayments applicable to other medical or
3 16 surgical services coverage under the policy, contract, or plan
3 17 are the same. It is not a violation of this section if the
3 18 policy, contract, or plan excludes entirely from coverage
3 19 benefits for the cost of providing the following:
3 20 a. Marital, family, educational, developmental, or
3 21 training services.
3 22 b. Care that is substantially custodial in nature.
3 23 c. Services and supplies that are not medically necessary
3 24 or clinically appropriate.
3 25 d. Experimental treatments.
3 26 9. This section applies to third=party payment provider
3 27 policies, contracts, and plans as described in this section
3 28 that are delivered, issued for delivery, continued, or renewed
3 29 in this state on or after January 1, 2004.
3 30 EXPLANATION
3 31 This bill creates a new Code section 514C.21, providing
3 32 that a group policy or contract for third=party payment or
3 33 prepayment of health or medical expenses issued by a carrier,
3 34 as defined in Code section 513B.2, or by an organized delivery
3 35 system authorized under 1993 Iowa Acts, chapter 158, shall
4 1 provide coverage benefits for treatment of a biologically
4 2 based mental illness if the policy or contract is issued to an
4 3 employer who on at least 50 percent of the employer's working
4 4 days during the preceding calendar year employed more than 50
4 5 full=time equivalent employees; if the policy or contract is
4 6 issued to a small employer as defined in Code section 513B.2,
4 7 and such policy or contract provides coverage benefits for the
4 8 treatment of mental illness; or if the plan is established
4 9 pursuant to Code chapter 509A for public employees.
4 10 The bill defines "biologically based mental illness" as
4 11 psychiatric illnesses including schizophrenia, bipolar
4 12 disorders, major depressive disorders, schizo=affective
4 13 disorders, obsessive=compulsive disorders, pervasive
4 14 developmental disorders, and autistic disorders. The
4 15 commissioner is directed to establish by rule the definition
4 16 of the biologically based mental illnesses identified. The
4 17 definitions established by the commissioner are to be
4 18 consistent with definitions provided in the most recent
4 19 edition of the American psychiatric association's diagnostic
4 20 and statistical manual of mental disorders, as such
4 21 definitions may be amended from time to time. The
4 22 commissioner may adopt the definitions provided in such manual
4 23 by reference.
4 24 The bill provides that a carrier, organized delivery
4 25 system, or plan established pursuant to Code chapter 509A may
4 26 manage the benefits provided through common methods including,
4 27 but not limited to, providing payment of benefits or providing
4 28 care and treatment under a capitated payment system,
4 29 prospective reimbursement rate system, utilization control
4 30 system, incentive system for the use of least restrictive and
4 31 least costly levels of care, a preferred provider contract
4 32 limiting choice of specific providers, or any other system,
4 33 method, or organization designed to assure services are
4 34 medically necessary and clinically appropriate.
4 35 The bill provides that a group policy, contract, or plan
5 1 shall not impose an aggregate annual or lifetime limit on
5 2 biologically based mental illness coverage benefits unless the
5 3 policy, contract, or plan imposes an aggregate limit on
5 4 substantially all medical and surgical coverage benefits, and
5 5 that a group policy, contract, or plan that imposes an
5 6 aggregate limit on substantially all medical and surgical
5 7 coverage benefits shall not impose an aggregate annual or
5 8 lifetime limit on biologically based mental illness coverage
5 9 benefits that is less than that imposed on the medical and
5 10 surgical coverage benefits.
5 11 The bill requires a group policy, contract, or plan covered
5 12 under this contract to allow for a minimum of 30 inpatient and
5 13 52 outpatient days annually for each person covered under the
5 14 policy, contract, or plan. Any deductibles, coinsurance, or
5 15 copayments under the policy, contract, or plan must be the
5 16 same as the deductibles, coinsurance, or copayments applicable
5 17 to other medical or surgical services covered under the
5 18 policy, contract, or plan. The policy, contract, or plan may
5 19 exclude all of the following: (1) marital, family,
5 20 educational, developmental, or training services; (2)
5 21 substantially custodial care; (3) services and supplies that
5 22 are not medically necessary or clinically appropriate; and (4)
5 23 experimental treatments.
5 24 The bill provides that the new Code section created applies
5 25 to third=party payment provider contracts or policies and
5 26 public employer plans delivered, issued for delivery,
5 27 continued, or renewed in this state on or after January 1,
5 28 2004.
5 29 LSB 1595SS 80
5 30 jj/pj/5