§431M-4 - Mental illness, alcohol and drug dependence benefits.

§431M-4 Mental illness, alcohol and drug
dependence benefits. (a) The covered benefit under this chapter shall not
be less than thirty days of in-hospital services per year. Each day of
in-hospital services may be exchanged for two days of nonhospital residential
services, two days of partial hospitalization services, or two days of day
treatment services. Visits to a physician, psychologist, licensed clinical
social worker, marriage and family therapist, licensed mental health counselor,
or advanced practice registered nurse shall not be less than thirty visits per
year to hospital or nonhospital facilities or to mental health outpatient
facilities for day treatment or partial hospitalization services. Each day of
in-hospital services may also be exchanged for two outpatient visits under this
chapter; provided that the patient's condition is such that the outpatient
services would reasonably preclude hospitalization. The total covered benefit
for outpatient services in subsections (b) and (c) shall not be less than
twenty-four visits per year; provided that coverage of twelve of the
twenty-four outpatient visits shall apply only to the services under subsection
(c). The other covered benefits under this chapter shall apply to any of the
services in subsection (b) or (c). In the case of alcohol and drug dependence
benefits, the insurance policy may limit the number of treatment episodes but
may not limit the number to less than two treatment episodes per lifetime.
Nothing in this section shall be construed to limit serious mental illness
benefits.

(b) Alcohol and drug dependence benefits shall
be as follows:

(1) Detoxification services as a covered benefit
under this chapter shall be provided either in a hospital or in a nonhospital
facility that has a written affiliation agreement with a hospital for
emergency, medical, and mental health support services. The following services
shall be covered under detoxification services:

(A) Room and board;

(B) Diagnostic x-rays;

(D) Drugs, equipment use, special therapies,
and supplies.

Detoxification services shall be included as part
of the covered in-hospital services, but shall not be included in the treatment
episode limitation, as specified in subsection (a);

(2) Alcohol or drug dependence treatment through
in-hospital, nonhospital residential, or day treatment substance abuse services
as a covered benefit under this chapter shall be provided in a hospital or
nonhospital facility. Before a person qualifies to receive benefits under this
subsection, a qualified physician, psychologist, licensed clinical social
worker, marriage and family therapist, licensed mental health counselor, or
advanced practice registered nurse shall determine that the person suffers from
alcohol or drug dependence, or both; provided that the substance abuse services
covered under this paragraph shall include those services that are required for
licensure and accreditation and shall be included as part of the covered
in-hospital services as specified in subsection (a). Excluded from alcohol or
drug dependence treatment under this subsection are detoxification services and
educational programs to which drinking or drugged drivers are referred by the
judicial system and services performed by mutual self-help groups;

(3) Alcohol or drug dependence outpatient services as
a covered benefit under this chapter shall be provided under an individualized
treatment plan approved by a qualified physician, psychologist, licensed
clinical social worker, marriage and family therapist, licensed mental health
counselor, or advanced practice registered nurse and shall be services
reasonably expected to produce remission of the patient's condition. An
individualized treatment plan approved by a marriage and family therapist,
licensed mental health counselor, licensed clinical social worker, or an
advanced practice registered nurse for a patient already under the care or
treatment of a physician or psychologist shall be done in consultation with the
physician or psychologist. Services covered under this paragraph shall be
included as part of the covered outpatient services as specified in subsection
(a); and

(4) Substance abuse assessments for alcohol or drug
dependence as a covered benefit under this section for a child facing
disciplinary action under section 302A-1134.6 shall be provided by a qualified
physician, psychologist, licensed clinical social worker, advanced practice
registered nurse, or certified substance abuse counselor. The certified
substance abuse counselor shall be employed by a hospital or nonhospital
facility providing substance abuse services. The substance abuse assessment
shall evaluate the suitability for substance abuse treatment and placement in
an appropriate treatment setting.

(1) Covered benefits for mental health services set
forth in this subsection shall be limited to coverage for diagnosis and
treatment of mental disorders. All mental health services shall be provided
under an individualized treatment plan approved by a physician, psychologist,
licensed clinical social worker, marriage and family therapist, licensed mental
health counselor, or advanced practice registered nurse and must be reasonably
expected to improve the patient's condition. An individualized treatment plan
approved by a licensed clinical social worker, marriage and family therapist,
licensed mental health counselor, or an advanced practice registered nurse for
a patient already under the care or treatment of a physician or psychologist
shall be done in consultation with the physician or psychologist;

(2) In-hospital and nonhospital residential mental
health services as a covered benefit under this chapter shall be provided in a
hospital or a nonhospital residential facility. The services to be covered
shall include those services required for licensure and accreditation, and
shall be included as part of the covered in-hospital services as specified in
subsection (a);

(3) Mental health partial hospitalization as a
covered benefit under this chapter shall be provided by a hospital or a mental
health outpatient facility. The services to be covered under this paragraph
shall include those services required for licensure and accreditation and shall
be included as part of the covered in-hospital services as specified in
subsection (a); and

(4) Mental health outpatient services shall be a
covered benefit under this chapter and shall be included as part of the covered
outpatient services as specified in subsection (a). [L 1988, c 202, pt of §1,
§3; am L 1994, c 111, §§2, 4; am L 1997, c 247, §3 and c 273, §3; am L 1998, c
78, §§2, 3; am L 1999, c 121, §§2, 6; am L 2000, c 243, §8(2); am L 2001, c
111, §3; am L 2002, c 167, §5 and c 239, §1; am L 2003, c 197, §3; am L 2006, c
205, §3; am L 2007, c 38, §3; am L 2008, c 206, §4]