§ 135-45.9. Special provisions for chemical dependency and mental health benefits.
§ 135‑45.9. Specialprovisions for chemical dependency and mental health benefits.
(a) Except as otherwiseprovided in this section, benefits for the treatment of mental illness andchemical dependency are covered by the Plan and shall be subject to the samedeductibles, durational limits, and coinsurance factors as are benefits forphysical illness generally.
(b) Notwithstanding anyother provision of this Part, the following necessary services for the care andtreatment of chemical dependency and mental illness shall be covered asprovided in this section: allowable institutional and professional charges forinpatient care, outpatient care, intensive outpatient program services, partialhospitalization treatment, and residential care and treatment:
(1) For mental illnesstreatment:
a. Licensed psychiatrichospitals or State psychiatric hospitals accredited by the Joint Commission onthe Accreditation of Healthcare Organizations;
b. Licensed psychiatricbeds in licensed general hospitals;
c. Licensed residentialtreatment facilities that have 24‑hour on‑site care provided by aregistered nurse who is physically located at the facility at all times andthat hold current accreditation by a national accrediting body approved by thePlan's mental health case manager;
d. Area Mental Health,Developmental Disabilities, and Substance Abuse Authorities or County Programsin accordance with G.S. 122C‑141;
e. Licensed intensiveoutpatient treatment programs; and
f. Licensed partialhospitalization programs.
(2) For chemicaldependency treatment:
a. Licensed chemicaldependency units in licensed psychiatric hospitals or in State psychiatrichospitals accredited by the Joint Commission on the Accreditation of HealthcareOrganizations;
b. Licensed chemicaldependency hospitals;
c. Licensed chemicaldependency treatment facilities;
d. Area Mental Health,Developmental Disabilities, and Substance Abuse Authorities or County Programsin accordance with G.S. 122C‑141;
e. Licensed intensiveoutpatient treatment programs;
f. Licensed partialhospitalization programs; and
g. Medicaldetoxification facilities or units.
(c) Notwithstanding anyother provisions of this Part, the following providers and no others mayprovide necessary care and treatment for mental health under this section:
(1) Psychiatrists whohave completed a residency in psychiatry approved by the American Council forGraduate Medical Education and who are licensed as medical doctors or doctorsof osteopathy in the state in which they perform and services covered by thePlan;
(2) Licensed doctors ofpsychology;
(3) Clinical socialworkers licensed or certified by the North Carolina Social Work Certificationand Licensure Board under Chapter 90B of the General Statutes.
(4) Licensedprofessional counselors;
(5) Certified clinicalspecialists in psychiatric and mental health nursing in accordance with Article9A of Chapter 90 of the General Statutes;
(6) Nurses working underthe employment and direct supervision of such physicians, psychologists, orpsychiatrists;
(7) Licensedpsychological associates;
(8) Certified fee‑basedpracticing pastoral counselors in accordance with Article 26 of Chapter 90 ofthe General Statutes;
(9) Licensed physicianassistants under the supervision of a licensed psychiatrist and acting pursuantto G.S. 90‑18.1 or the applicable laws and rules of the area in which thephysician assistant is licensed or certified; and
(10) Licensed marriage andfamily therapists; [and]
(11) Physicians licensedunder Chapter 90 of the General Statutes and certified professionals withtraining and experience in the care and treatment for mental health and workingunder the direct supervision of such physicians.
(d) Notwithstanding anyother provisions of this Part, the following providers and no others may providenecessary care and treatment for chemical dependency under this section:
(1) The followingproviders with appropriate substance abuse training and experience in the fieldof alcohol and other drug abuse as determined by the mental health casemanager, in facilities described in subdivision (b)(2) of this section, in day/nightprograms or outpatient treatment facilities licensed after July 1, 1984, underArticle 2 of Chapter 122C of the General Statutes or in North Carolina areaprograms in substance abuse services are authorized to provide treatment forchemical dependency under this section:
a. Licensed physiciansincluding, but not limited to, physicians who are certified in substance abuseby the American Society of Addiction Medicine (ASAM);
b. Licensedpsychologists;
c. Psychiatrists;
d. Certified substanceabuse counselors working under the direct supervision of such physicians,psychologists, or psychiatrists;
e. Licensedpsychological associates;
f. Nurses workingunder the direct supervision of such physicians, psychologists, orpsychiatrists;
g. Clinical socialworkers licensed or certified by the North Carolina Social Work Certificationand Licensure Board under Chapter 90B of the General Statutes;
h. Certified clinicalspecialists in psychiatric and mental health nursing in accordance with Article9A of Chapter 90 of the General Statutes;
i. Licensedprofessional counselors;
j. Certified fee‑basedpracticing pastoral counselors in accordance with Article 26 of Chapter 90 ofthe General Statutes;
k. Substance abuseprofessionals certified under Article 5C of Chapter 90 of the General Statutes;and
l. Licensed marriageand family and therapists.
(2) The followingproviders with appropriate substance abuse training and experience in the fieldof alcohol and other drug abuse as determined by the mental health case managerare authorized to provide treatment for chemical dependency in outpatientpractice settings:
a. Licensed physiciansincluding, but not limited to, physicians who are certified in substance abuseby the American Society of Addiction Medicine (ASAM);
b. Licensedpsychologists;
c. Psychiatrists;
d. Certified substanceabuse counselors working under the direct supervision of such physicians,psychologists, or psychiatrists;
e. Licensed psychologicalassociates;
f. Nurses workingunder the direct supervision of such physicians, psychologists, orpsychiatrists;
g. Clinical socialworkers licensed or certified by the North Carolina Social Work Certificationand Licensure Board under Chapter 90B of the General Statutes.
h. Certified clinicalspecialists in psychiatric and mental health nursing in accordance with Article9A of Chapter 90 of the General Statutes;
i. Licensedprofessional counselors;
j. Certified fee‑basedpracticing pastoral counselors in accordance with Article 26 of Chapter 90 ofthe General Statutes;
k. Licensed marriageand family and therapists;
l. Substance abuseprofessionals certified under Article 5C of Chapter 90 of the General Statutes;and
m. In the absence ofmeeting one of the criteria above, the Mental Health Case Manager couldconsider, on a case‑by‑case basis, a provider who supplies:
1. Evidence of graduateeducation in the diagnosis and treatment of chemical dependency, and
2. Supervised workexperience in the diagnosis and treatment of chemical dependency (withsupervision by an appropriately credentialed provider), and
3. Substantive past andcurrent continuing education in the diagnosis and treatment of chemicaldependency commensurate with one's profession.
(3) Physicians licensedunder Chapter 90 of the General Statutes and certified professionals withtraining and experience in the care and treatment for chemical dependency andworking under the direct supervision of such physicians.
Provided, however, that nothingin this subsection shall prohibit the Plan from requiring the most cost‑effectivetreatment setting to be utilized by the person undergoing necessary care andtreatment for chemical dependency.
(e) Benefits providedunder this section shall be subject to a case management program for medicalnecessity and medical appropriateness consisting of (i) precertification ofoutpatient visits beyond 26 visits each Plan year, (ii) all electroconvulsivetreatment, (iii) inpatient utilization review through preadmission and length‑of‑staycertification for nonemergency admissions to the following levels of care:inpatient units, partial hospitalization programs, residential treatmentcenters, chemical dependency detoxification and treatment programs, andintensive outpatient programs, (iv) length‑of‑stay certification ofemergency inpatient admissions, and (v) a network of qualified, availableproviders of inpatient and outpatient psychiatric and chemical dependencytreatment. Care which is not both medically necessary and medically appropriatewill be noncertified, and benefits will be denied.
(f) For the purpose ofthis section, "emergency" is the sudden and unexpected onset of acondition manifesting itself by acute symptoms of sufficient severity that, inthe absence of an immediate psychiatric or chemical dependency inpatientadmission, could imminently result in injury or danger to self or others.
(g) As used in thissection, the word "Plan" includes all optional and alternative plans,and programs available under the optional or alternative plans, in effect underthe State Health Plan for Teachers and State Employees and its successor Plans. (1991, c. 427,s. 32; 1993, c. 464, ss. 3(a), 4; 1995, c. 157, s. 2; c. 406, s. 2; 1997‑512,s. 14; 1999‑186, s. 1; 1999‑199, s. 3; 1999‑210, s. 8; 1999‑351,s. 7; 2001‑258, s. 1; 2001‑487, s. 40(n); 2003‑368, ss. 2, 3;2004‑124, s. 31.28; 2007‑323, ss. 28.22(f), (o); 2008‑168,ss. 1(a), 3(a), (n); 2009‑16, s. 5(d).)