Sec. 38a-514. (Formerly Sec. 38-174d). Mandatory coverage for the diagnosis and treatment of mental or nervous conditions. Exceptions. Benefits payable re type of provider or facility. State's cla
Sec. 38a-514. (Formerly Sec. 38-174d). 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) Except as provided
in subsection (j) of this section, each group 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 group 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.
(j) A group health insurance policy may exclude the benefits required by this section
if such benefits are included in a separate policy issued to the same group by an insurance
company, health care center, hospital service corporation, medical service corporation
or fraternal benefit society. Such separate policy, which shall include the benefits required by this section and the benefits required by section 38a-533, shall not be required
to include any other benefits mandated by this title.
(k) In the case of benefits based upon confinement in a residential treatment facility,
such benefits shall be payable in situations in which the insured has a serious mental or
nervous condition that substantially impairs the insured's thoughts, perception of reality,
emotional process or judgment or grossly impairs the behavior of the insured, and, upon
an assessment of the insured by a physician, psychiatrist, psychologist or clinical social
worker, cannot appropriately, safely or effectively be treated in an acute care, partial
hospitalization, intensive outpatient or outpatient setting.
(l) The services rendered for which benefits are to be paid for confinement in a
residential treatment facility must be based on an individual treatment plan. For purposes
of this section, the term "individual treatment plan" means a treatment plan prescribed
by a physician with specific attainable goals and objectives appropriate to both the
patient and the treatment modality of the program.
(1971, P.A. 238, S. 1; P.A. 74-34, S. 1, 2; P.A. 75-215, S. 1, 2; 75-286; P.A. 77-604, S. 24, 84; P.A. 79-614; P.A. 82-110; P.A. 83-157; P.A. 84-193, 84-455, S. 2; P.A. 87-275, S. 1; P.A. 89-86, S. 1; P.A. 90-108; 90-193; 90-243, S. 98; P.A.
92-117; P.A. 93-91, S. 1, 2; 93-381, S. 9, 39; P.A. 95-75; 95-116, S. 6; 95-257, S. 11, 12, 21, 58; 95-289, S. 10, 11; P.A.
96-180, S. 122, 166; P.A. 99-284, S. 28, 60; P.A. 00-135, S. 11, 21; P.A. 02-24, S. 7; P.A. 07-73, S. 2(a); P.A. 08-125, S. 1.)
History: P.A. 74-34 clarified prohibition by rephrasing statement of applicability and defined "covered expenses"; P.A.
75-215 included renewals in applicability provision and deleted obsolete date reference, raised minimum confinement
period from 30 to 60 days in Subsec. (a) and maximum dollar amount of major medical coverage from $500 to $1,000 in
Subsec. (b) and redefined "covered expenses" to include reference to usual and customary charges; P.A. 75-286 added
Subsec. (c) re services of psychologists; P.A. 77-604 designated definition of "covered expenses" as Subsec. (d); P.A. 79-614 added Subsec. (e) re services of child guidance clinics; P.A. 82-110 inserted new Subsec. (b) re benefits for partial
hospitalization sessions, relettering as necessary and added provisions re additional benefits in Subsec. (c), formerly (b);
P.A. 83-157 added Subsec. (g) which outlines when benefits shall be payable for the outpatient services of a psychiatrist
or psychologist; P.A. 84-193 required that medical benefits contracts issued by health care centers comply with the mental
health coverage requirements of this section, except as limited in new Subsec. (h); P.A. 84-455 added Subsec. (i) creating
state's lien upon insurance coverage available to persons receiving care or legally liable relatives; P.A. 87-275 amended
Subsec. (c) to increase the maximum for outpatient benefits from $1,000 to $2,000; P.A. 89-86 added Subsec. (j) providing
for exclusion of the benefits required by this section in a group contract if such benefits are included in a separate contract
issued to the same group which also includes the benefits required by Sec. 38-262b; P.A. 90-108 amended Subsec. (a) to
define "residential treatment facility", added references to "residential treatment facility" to require that mental health
benefits must be offered in a setting other than a hospital, added new Subsecs. (l) and (m) specifying that for benefits in a
residential treatment center to be payable, the insured must have a serious mental illness, must be hospitalized within a
specific time period after confinement in the residential treatment facility and would have been hospitalized if not for the
existence of a residential treatment center and that treatment must be based on an individual plan tailored to the patient;
P.A. 90-193 inserted new Subsec. (e) re services of certified independent social workers, relettering the remaining Subsecs.
and adding references to certified independent social workers in Subsecs. (g) and (h); P.A. 90-243 added a reference to
"group health insurance policy" and substituted "policy" for "contract" where occurring; Sec. 38-174d transferred to Sec.
38a-514 in 1991; P.A. 92-117 amended Subsec. (e) to make its provisions apply to the services of a Connecticut certified
marriage and family therapist certified prior to October 1, 1992, amended Subsec. (g) to make provisions applicable to the
services rendered by a Connecticut certified marriage and family therapist and made technical corrections for statutory
consistency throughout section; P.A. 93-91 substituted commissioner and department of children and families for commissioner and department of children and youth services, effective July 1, 1993; P.A. 93-381 replaced department of health
services with department of public health and addiction services, effective July 1, 1993; P.A. 95-75 amended Subsec. (g)
to authorize payment of benefits for services rendered by a person with a master's degree in marriage and family therapy
under the supervision of a psychiatrist, physician, Connecticut certified marriage and family therapist or a certified independent social worker; P.A. 95-116 replaced references to certified independent social workers with references to licensed
clinical social workers; P.A. 95-257 replaced Commissioner and Department of Public Health and Addiction Services
with Commissioner and Department of Public Health and replaced Commissioner and Department of Mental Health with
Commissioner and Department of Mental Health and Addiction Services, effective July 1, 1995; P.A. 95-289 made technical
changes to Subsecs. (e), (g) and (h) concerning changing marital and family therapists from "certified" to "licensed"; P.A.
96-180 amended Subsec. (e)(4) to substitute "marital" for "marriage" in reference to "marital and family therapist", effective
June 3, 1996; P.A. 99-284 rewrote introductory language and designated it as Subsec. (a), added reference to Subdivs. (1),
(2), (4), (11) and (12) of Sec. 38a-469, and added coverage for "mental or nervous conditions" and defined term, deleted
provisions of Subsecs. (a), (b) and (c), inserted new Subsec. (b) re requirement that no policy place a greater financial
burden on an insured for access to diagnosis or treatment of mental or nervous conditions than for other conditions,
redesignated former Subsecs. (d) and (e) as (c) and (d), respectively, and added Subdiv. (d)(5) re alcohol and drug counselors,
redesignated former Subsec. (f) as (e) and added exception for managed care plans, redesignated former Subsecs. (g) and
(h) as (f) and (g), respectively, and added Subdiv. (f)(3) and amended Subdiv. (h)(2) re alcohol and drug counselors,
redesignated Subsecs. (i) and (j) as (h) and (i), respectively, and amended Subsec. (i) to add exception re coverage provided
under a managed care plan, redesignated former Subsecs. (k), (l) and (m) as (j), (k) and (l), respectively, and made technical
changes, 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; P.A. 08-125 amended Subsec. (k) by deleting former provision re
hospitalization requirement and limitation to children and adolescents and making conforming and technical changes,
effective January 1, 2009.
See Sec. 38a-538 re conversion and extension rights of group members and re liability of group employers.
See Sec. 38a-488a for similar provisions re individual policies.