31A-22-625 - Catastrophic coverage of mental health conditions.
31A-22-625. Catastrophic coverage of mental health conditions.
(1) As used in this section:
(a) (i) "Catastrophic mental health coverage" means coverage in a health benefit plan thatdoes not impose a lifetime limit, annual payment limit, episodic limit, inpatient or outpatientservice limit, or maximum out-of-pocket limit that places a greater financial burden on aninsured for the evaluation and treatment of a mental health condition than for the evaluation andtreatment of a physical health condition.
(ii) "Catastrophic mental health coverage" may include a restriction on cost sharingfactors, such as deductibles, copayments, or coinsurance, before reaching a maximumout-of-pocket limit.
(iii) "Catastrophic mental health coverage" may include one maximum out-of-pocketlimit for physical health conditions and another maximum out-of-pocket limit for mental healthconditions, except that if separate out-of-pocket limits are established, the out-of-pocket limit formental health conditions may not exceed the out-of-pocket limit for physical health conditions.
(b) (i) "50/50 mental health coverage" means coverage in a health benefit plan that paysfor at least 50% of covered services for the diagnosis and treatment of mental health conditions.
(ii) "50/50 mental health coverage" may include a restriction on:
(A) episodic limits;
(B) inpatient or outpatient service limits; or
(C) maximum out-of-pocket limits.
(c) "Large employer" is as defined in 42 U.S.C. Sec. 300gg-91.
(d) (i) "Mental health condition" means a condition or disorder involving mental illnessthat falls under a diagnostic category listed in the Diagnostic and Statistical Manual, asperiodically revised.
(ii) "Mental health condition" does not include the following when diagnosed as theprimary or substantial reason or need for treatment:
(A) a marital or family problem;
(B) a social, occupational, religious, or other social maladjustment;
(C) a conduct disorder;
(D) a chronic adjustment disorder;
(E) a psychosexual disorder;
(F) a chronic organic brain syndrome;
(G) a personality disorder;
(H) a specific developmental disorder or learning disability; or
(I) mental retardation.
(e) "Small employer" is as defined in 42 U.S.C. Sec. 300gg-91.
(2) (a) At the time of purchase and renewal, an insurer shall offer to a small employerthat it insures or seeks to insure a choice between catastrophic mental health coverage and 50/50mental health coverage.
(b) In addition to complying with Subsection (2)(a), an insurer may offer to provide:
(i) catastrophic mental health coverage, 50/50 mental health coverage, or both at levelsthat exceed the minimum requirements of this section; or
(ii) coverage that excludes benefits for mental health conditions.
(c) A small employer may, at its option, choose either catastrophic mental healthcoverage, 50/50 mental health coverage, or coverage offered under Subsection (2)(b), regardless
of the employer's previous coverage for mental health conditions.
(d) An insurer is exempt from the 30% index rating restriction in Section 31A-30-106.1and, for the first year only that catastrophic mental health coverage is chosen, the 15% annualadjustment restriction in Section 31A-30-106.1, for any small employer with 20 or less enrolledemployees who chooses coverage that meets or exceeds catastrophic mental health coverage.
(3) An insurer shall offer a large employer mental health and substance use disorderbenefit in compliance with Section 2705 of the Public Health Service Act, 42 U.S.C. Sec.300gg-5, and federal regulations adopted pursuant to that act.
(4) (a) An insurer may provide catastrophic mental health coverage to a small employerthrough a managed care organization or system in a manner consistent with Chapter 8, HealthMaintenance Organizations and Limited Health Plans, regardless of whether the insurance policyuses a managed care organization or system for the treatment of physical health conditions.
(b) (i) Notwithstanding any other provision of this title, an insurer may:
(A) establish a closed panel of providers for catastrophic mental health coverage; and
(B) refuse to provide a benefit to be paid for services rendered by a nonpanel providerunless:
(I) the insured is referred to a nonpanel provider with the prior authorization of theinsurer; and
(II) the nonpanel provider agrees to follow the insurer's protocols and treatmentguidelines.
(ii) If an insured receives services from a nonpanel provider in the manner permitted bySubsection (4)(b)(i)(B), the insurer shall reimburse the insured for not less than 75% of theaverage amount paid by the insurer for comparable services of panel providers under anoncapitated arrangement who are members of the same class of health care providers.
(iii) This Subsection (4)(b) may not be construed as requiring an insurer to authorize areferral to a nonpanel provider.
(c) To be eligible for catastrophic mental health coverage, a diagnosis or treatment of amental health condition must be rendered:
(i) by a mental health therapist as defined in Section 58-60-102; or
(ii) in a health care facility:
(A) licensed or otherwise authorized to provide mental health services pursuant to:
(I) Title 26, Chapter 21, Health Care Facility Licensing and Inspection Act; or
(II) Title 62A, Chapter 2, Licensure of Programs and Facilities; and
(B) that provides a program for the treatment of a mental health condition pursuant to awritten plan.
(5) The commissioner may prohibit an insurance policy that provides mental healthcoverage in a manner that is inconsistent with this section.
(6) The commissioner shall:
(a) adopt rules, in accordance with Title 63G, Chapter 3, Utah AdministrativeRulemaking Act, as necessary to ensure compliance with this section; and
(b) provide general figures on the percentage of insurance policies that include:
(i) no mental health coverage;
(ii) 50/50 mental health coverage;
(iii) catastrophic mental health coverage; and
(iv) coverage that exceeds the minimum requirements of this section.
(7) This section may not be construed as discouraging or otherwise preventing an insurerfrom providing mental health coverage in connection with an individual insurance policy.
(8) This section shall be repealed in accordance with Section 63I-1-231.
Amended by Chapter 10, 2010 General Session
Amended by Chapter 68, 2010 General Session