376.811. Coverage required for chemical dependency by all insurance and health service corporations--minimum standards--offer of coverage may be accepted or rejected by policyholders, companies may of
Coverage required for chemical dependency by all insurance and healthservice corporations--minimum standards--offer of coverage may beaccepted or rejected by policyholders, companies may offer asstandard coverage--mental health benefits provided,when--exclusions.
376.811. 1. Every insurance company and health services corporationdoing business in this state shall offer in all health insurance policiesbenefits or coverage for chemical dependency meeting the following minimumstandards:
(1) Coverage for outpatient treatment through a nonresidentialtreatment program, or through partial- or full-day program services, of notless than twenty-six days per policy benefit period;
(2) Coverage for residential treatment program of not less thantwenty-one days per policy benefit period;
(3) Coverage for medical or social setting detoxification of not lessthan six days per policy benefit period;
(4) The coverages set forth in this subsection may be subject to aseparate lifetime frequency cap of not less than ten episodes of treatment,except that such separate lifetime frequency cap shall not apply to medicaldetoxification in a life-threatening situation as determined by thetreating physician and subsequently documented within forty-eight hours oftreatment to the reasonable satisfaction of the insurance company or healthservices corporation; and
(5) The coverages set forth in this subsection:
(a) Shall be subject to the same coinsurance, co-payment anddeductible factors as apply to physical illness;
(b) May be administered pursuant to a managed care programestablished by the insurance company or health services corporation; and
(c) 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.
2. In addition to the coverages set forth in subsection 1 of thissection, every insurance company, health services corporation and healthmaintenance organization doing business in this state shall offer in allhealth insurance policies, benefits or coverages for recognized mentalillness, excluding chemical dependency, meeting the following minimumstandards:
(1) Coverage for outpatient treatment, including treatment throughpartial- or full-day program services, for mental health services for arecognized mental illness rendered by a licensed professional to the sameextent as any other illness;
(2) Coverage for residential treatment programs for the therapeuticcare and treatment of a recognized mental illness when prescribed by alicensed professional and rendered in a psychiatric residential treatmentcenter licensed by the department of mental health or accredited by theJoint Commission on Accreditation of Hospitals to the same extent as anyother illness;
(3) Coverage for inpatient hospital treatment for a recognized mentalillness to the same extent as for any other illness, not to exceed ninetydays per year;
(4) The coverages set forth in this subsection shall be subject tothe same coinsurance, co-payment, deductible, annual maximum and lifetimemaximum factors as apply to physical illness; and
(5) The coverages set forth in this subsection may be administeredpursuant to a managed care program established by the insurance company,health services corporation or health maintenance organization, and coveredservices may be delivered through a system of contractual arrangements withone or more providers, community mental health centers, hospitals,nonresidential or residential treatment programs, or other mental healthservice delivery entities certified by the department of mental health, oraccredited by a nationally recognized organization, or licensed by thestate of Missouri.
3. The offer required by sections 376.810 to 376.814 may be acceptedor rejected by the group or individual policyholder or contract holder and,if accepted, shall fully and completely satisfy and substitute for thecoverage under section 376.779. Nothing in sections 376.810 to 376.814shall prohibit an insurance company, health services corporation or healthmaintenance organization from including all or part of the coverages setforth in sections 376.810 to 376.814 as standard coverage in their policiesor contracts issued in this state.
4. Every insurance company, health services corporation and healthmaintenance organization doing business in this state shall offer in allhealth insurance policies mental health benefits or coverage as part of thepolicy or as a supplement to the policy. Such mental health benefits orcoverage shall include at least two sessions per year to a licensedpsychiatrist, licensed psychologist, licensed professional counselor,licensed clinical social worker, or, subject to contractual provisions, alicensed marital and family therapist, acting within the scope of suchlicense and under the following minimum standards:
(1) Coverage and benefits in this subsection shall be for the purposeof diagnosis or assessment, but not dependent upon findings; and
(2) Coverage and benefits in this subsection shall not be subject toany conditions of preapproval, and shall be deemed reimbursable as long asthe provisions of this subsection are satisfied; and
(3) Coverage and benefits in this subsection shall be subject to thesame coinsurance, co-payment and deductible factors as apply to regularoffice visits under coverages and benefits for physical illness.
5. If the group or individual policyholder or contract holder rejectsthe offer required by this section, then the coverage shall be governed bythe mental health and chemical dependency insurance act as provided insections 376.825 to 376.836.
6. This section shall not apply to 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 policy of six months or less duration, orany other supplemental policy as determined by the director of thedepartment of insurance, financial institutions and professionalregistration.
(L. 1991 S.B. 352 § 7 subsecs. 2, 3, 4, A.L. 1997 H.B. 335, A.L. 1999 H.B. 191, A.L. 2004 H.B. 855, A.L. 2009 H.B. 326 merged with S.B. 296)