376.1550. Mental health coverage, requirements--definitions--exclusions.
Mental health coverage, requirements--definitions--exclusions.
376.1550. 1. Notwithstanding any other provision of law to thecontrary, each health carrier that offers or issues health benefit plans whichare delivered, issued for delivery, continued, or renewed in this state on orafter January 1, 2005, shall provide coverage for a mental health condition,as defined in this section, and shall comply with the following provisions:
(1) A health benefit plan shall provide coverage for treatment of amental health condition and shall not establish any rate, term, or conditionthat places a greater financial burden on an insured for access to treatmentfor a mental health condition than for access to treatment for a physicalhealth condition. Any deductible or out-of-pocket limits required by a healthcarrier or health benefit plan shall be comprehensive for coverage of allhealth conditions, whether mental or physical;
(2) The coverages set forth is this subsection:
(a) May be administered pursuant to a managed care program establishedby the health carrier; and
(b) May deliver covered services through a system of contractualarrangements with one or more providers, hospitals, nonresidential orresidential treatment programs, or other mental health service deliveryentities certified by the department of mental health, or accredited by anationally recognized organization, or licensed by the state of Missouri;
(3) A health benefit plan that does not otherwise provide for managementof care under the plan or that does not provide for the same degree ofmanagement of care for all health conditions may provide coverage fortreatment of mental health conditions through a managed care organization;provided that the managed care organization is in compliance with rulesadopted by the department of insurance, financial institutions andprofessional registration that assure that the system for delivery oftreatment for mental health conditions does not diminish or negate the purposeof this section. The rules adopted by the director shall assure that:
(a) Timely and appropriate access to care is available;
(b) The quantity, location, and specialty distribution of health careproviders is adequate; and
(c) Administrative or clinical protocols do not serve to reduce accessto medically necessary treatment for any insured;
(4) Coverage for treatment for chemical dependency shall comply withsections 376.779, 376.810 to 376.814, and 376.825 to 376.836 and for thepurposes of this subdivision the term "health insurance policy" as used insections 376.779, 376.810 to 376.814, and 376.825 to 376.836, the term "healthinsurance policy" shall include group coverage.
2. As used in this section, the following terms mean:
(1) "Chemical dependency", the psychological or physiological dependenceupon and abuse of drugs, including alcohol, characterized by drug tolerance orwithdrawal and impairment of social or occupational role functioning or both;
(2) "Health benefit plan", the same meaning as such term is defined insection 376.1350;
(3) "Health carrier", the same meaning as such term is defined insection 376.1350;
(4) "Mental health condition", any condition or disorder defined bycategories listed in the most recent edition of the Diagnostic and StatisticalManual of Mental Disorders except for chemical dependency;
(5) "Managed care organization", any financing mechanism or system thatmanages care delivery for its members or subscribers, including healthmaintenance organizations and any other similar health care delivery system ororganization;
(6) "Rate, term, or condition", any lifetime or annual payment limits,deductibles, co-payments, coinsurance, and other cost-sharing requirements,out-of-pocket limits, visit limits, and any other financial component of ahealth benefit plan that affects the insured.
3. This section shall not apply to a health plan or policy that isindividually underwritten or provides such coverage for specific individualsand members of their families pursuant to section 376.779, sections 376.810 to376.814, and sections 376.825 to 376.836, a supplemental insurance policy,including a life care contract, accident-only policy, specified diseasepolicy, hospital policy providing a fixed daily benefit only, Medicaresupplement policy, long-term care policy, hospitalization-surgical carepolicy, short-term major medical policies of six months or less duration, orany other supplemental policy as determined by the director of the departmentof insurance, financial institutions and professional registration.
4. Notwithstanding any other provision of law to the contrary, allhealth insurance policies that cover state employees, including the Missouriconsolidated health care plan, shall include coverage for mental illness.Multiyear group policies need not comply until the expiration of their currentmultiyear term unless the policyholder elects to comply before that time.
5. The provisions of this section shall not be violated if the insurerdecides to apply different limits or exclude entirely from coverage thefollowing:
(1) Marital, family, educational, or training services unless medicallynecessary and clinically appropriate;
(2) Services rendered or billed by a school or halfway house;
(3) Care that is custodial in nature;
(4) Services and supplies that are not immediately nor clinicallyappropriate; or
(5) Treatments that are considered experimental.
6. The director shall grant a policyholder a waiver from the provisionsof this section if the policyholder demonstrates to the director by actualexperience over any consecutive twenty-four-month period that compliance withthis section has increased the cost of the health insurance policy by anamount that results in a two percent increase in premium costs to thepolicyholder. The director shall promulgate rules establishing a procedureand appropriate standards for making such a demonstration. Any rule orportion of a rule, as that term is defined in section 536.010, RSMo, that iscreated under the authority delegated in this section shall become effectiveonly if it complies with and is subject to all of the provisions of chapter536, RSMo, and, if applicable, section 536.028, RSMo. This section andchapter 536, RSMo, are nonseverable and if any of the powers vested with thegeneral assembly pursuant to chapter 536, RSMo, to review, to delay theeffective date, or to disapprove and annul a rule are subsequently heldunconstitutional, then the grant of rulemaking authority and any rule proposedor adopted after August 28, 2004, shall be invalid and void.
(L. 2004 H.B. 855)