Sec. 38a-488a. Mandatory coverage for the diagnosis and treatment of mental or nervous conditions. Exceptions. Benefits payable re type of provider or facility. State's claim against proceeds.
Sec. 38a-488a. Mandatory coverage for the diagnosis and treatment of mental
or nervous conditions. Exceptions. Benefits payable re type of provider or facility.
State's claim against proceeds. (a) Each individual health insurance policy providing
coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state on or
after January 1, 2000, shall provide benefits for the diagnosis and treatment of mental
or nervous conditions. For the purposes of this section, "mental or nervous conditions"
means mental disorders, as defined in the most recent edition of the American Psychiatric
Association's "Diagnostic and Statistical Manual of Mental Disorders". "Mental or
nervous conditions" does not include (1) mental retardation, (2) learning disorders, (3)
motor skills disorders, (4) communication disorders, (5) caffeine-related disorders, (6)
relational problems, and (7) additional conditions that may be a focus of clinical attention, that are not otherwise defined as mental disorders in the most recent edition of
the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental
Disorders".
(b) No such policy shall establish any terms, conditions or benefits that place a
greater financial burden on an insured for access to diagnosis or treatment of mental or
nervous conditions than for diagnosis or treatment of medical, surgical or other physical
health conditions.
(c) In the case of benefits payable for the services of a licensed physician, such
benefits shall be payable for the same services when such services are lawfully rendered
by a psychologist licensed under the provisions of chapter 383 or by such a licensed
psychologist in a licensed hospital or clinic.
(d) In the case of benefits payable for the services of a licensed physician or psychologist, such benefits shall be payable for the same services when such services are rendered by:
(1) A clinical social worker who is licensed under the provisions of chapter 383b
and who has passed the clinical examination of the American Association of State Social
Work Boards and has completed at least two thousand hours of post-master's social
work experience in a nonprofit agency qualifying as a tax-exempt organization under
Section 501(c) of the Internal Revenue Code of 1986 or any subsequent corresponding
internal revenue code of the United States, as from time to time amended, in a municipal,
state or federal agency or in an institution licensed by the Department of Public Health
under section 19a-490;
(2) A social worker who was certified as an independent social worker under the
provisions of chapter 383b prior to October 1, 1990;
(3) A licensed marital and family therapist who has completed at least two thousand
hours of post-master's marriage and family therapy work experience in a nonprofit
agency qualifying as a tax-exempt organization under Section 501(c) of the Internal
Revenue Code of 1986 or any subsequent corresponding internal revenue code of the
United States, as from time to time amended, in a municipal, state or federal agency or
in an institution licensed by the Department of Public Health under section 19a-490;
(4) A marital and family therapist who was certified under the provisions of chapter
383a prior to October 1, 1992;
(5) A licensed alcohol and drug counselor, as defined in section 20-74s, or a certified
alcohol and drug counselor, as defined in section 20-74s; or
(6) A licensed professional counselor.
(e) For purposes of this section, the term "covered expenses" means the usual, customary and reasonable charges for treatment deemed necessary under generally accepted
medical standards, except that in the case of a managed care plan, as defined in section
38a-478, "covered expenses" means the payments agreed upon in the contract between
a managed care organization, as defined in section 38a-478, and a provider, as defined
in section 38a-478.
(f) (1) In the case of benefits payable for the services of a licensed physician, such
benefits shall be payable for (A) services rendered in a child guidance clinic or residential
treatment facility by a person with a master's degree in social work or by a person with
a master's degree in marriage and family therapy under the supervision of a psychiatrist,
physician, licensed marital and family therapist, or licensed clinical social worker who
is eligible for reimbursement under subdivisions (1) to (4), inclusive, of subsection (d)
of this section; (B) services rendered in a residential treatment facility by a licensed or
certified alcohol and drug counselor who is eligible for reimbursement under subdivision
(5) of subsection (d) of this section; or (C) services rendered in a residential treatment
facility by a licensed professional counselor who is eligible for reimbursement under
subdivision (6) of subsection (d) of this section.
(2) In the case of benefits payable for the services of a licensed psychologist under
subsection (d) of this section, such benefits shall be payable for (A) services rendered
in a child guidance clinic or residential treatment facility by a person with a master's
degree in social work or by a person with a master's degree in marriage and family
therapy under the supervision of such licensed psychologist, licensed marital and family
therapist, or licensed clinical social worker who is eligible for reimbursement under
subdivisions (1) to (4), inclusive, of subsection (d) of this section; (B) services rendered
in a residential treatment facility by a licensed or certified alcohol and drug counselor
who is eligible for reimbursement under subdivision (5) of subsection (d) of this section;
or (C) services rendered in a residential treatment facility by a licensed professional
counselor who is eligible for reimbursement under subdivision (6) of subsection (d) of
this section.
(g) In the case of benefits payable for the service of a licensed physician practicing
as a psychiatrist or a licensed psychologist, under subsection (d) of this section, such
benefits shall be payable for outpatient services rendered (1) in a nonprofit community
mental health center, as defined by the Department of Mental Health and Addiction
Services, in a nonprofit licensed adult psychiatric clinic operated by an accredited hospital or in a residential treatment facility; (2) under the supervision of a licensed physician
practicing as a psychiatrist, a licensed psychologist, a licensed marital and family therapist, a licensed clinical social worker, a licensed or certified alcohol and drug counselor
or a licensed professional counselor who is eligible for reimbursement under subdivisions (1) to (6), inclusive, of subsection (d) of this section; and (3) within the scope of
the license issued to the center or clinic by the Department of Public Health or to the
residential treatment facility by the Department of Children and Families.
(h) Except in the case of emergency services or in the case of services for which
an individual has been referred by a physician affiliated with a health care center, nothing
in this section shall be construed to require a health care center to provide benefits under
this section through facilities that are not affiliated with the health care center.
(i) In the case of any person admitted to a state institution or facility administered
by the Department of Mental Health and Addiction Services, Department of Public
Health, Department of Children and Families or the Department of Developmental Services, the state shall have a lien upon the proceeds of any coverage available to such
person or a legally liable relative of such person under the terms of this section, to the
extent of the per capita cost of such person's care. Except in the case of emergency
services, the provisions of this subsection shall not apply to coverage provided under a
managed care plan, as defined in section 38a-478.
(June 18 Sp. Sess. P.A. 97-8, S. 63, 88; P.A. 99-284, S. 27, 60; P.A. 00-135, S. 10, 21; P.A. 02-24, S. 6; P.A. 07-73, S. 2(a).)
History: June 18 Sp. Sess. P.A. 97-8 effective July 1, 1997; P.A. 99-284 rewrote Subsec. (a) and referenced Subdivs.
(1), (2), (4), (11) and (12) of Sec. 38a-469, deleted reference to biologically-based mental or nervous conditions and
definition thereof and replaced with provision for coverage of the diagnosis and treatment of mental or nervous conditions,
and defined "mental or nervous conditions", added new Subsec. (b) re prohibition on terms, conditions or benefits that
place a greater financial burden on insured re mental or nervous conditions than for other conditions, added new Subsec.
(c) re benefits payable when rendered by a psychologist, added new Subsec. (d) re benefits payable for enumerated providers,
added new Subsec. (e) to define "covered expenses", added new Subsec. (f) re benefits payable for services rendered in
certain facilities, added new Subsec. (g) re certain outpatient benefits, added new Subsec. (h) re benefits provided by a
health care center, and added new Subsec. (i) re state liens against certain coverage proceeds, effective January 1, 2000;
P.A. 00-135 reorganized section and added provisions re licensed professional counselors, effective May 26, 2000; P.A.
02-24 deleted "the" re "post-master's social work experience" in Subsec. (d)(1) and (3); pursuant to P.A. 07-73 "Department
of Mental Retardation" was changed editorially by the Revisors to "Department of Developmental Services", effective
October 1, 2007.
See Sec. 38a-514 for similar provisions re group policies.