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

(b)  Alcohol and drug dependence benefits shallbe as follows:

(1)  Detoxification services as a covered benefitunder this chapter shall be provided either in a hospital or in a nonhospitalfacility that has a written affiliation agreement with a hospital foremergency, medical, and mental health support services.  The following servicesshall be covered under detoxification services:

(A)  Room and board;

(B)  Diagnostic x-rays;

(C)  Laboratory testing; and

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

Detoxification services shall be included as partof the covered in-hospital services, but shall not be included in the treatmentepisode limitation, as specified in subsection (a);

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

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

(4)  Substance abuse assessments for alcohol or drugdependence as a covered benefit under this section for a child facingdisciplinary action under section 302A-1134.6 shall be provided by a qualifiedphysician, psychologist, licensed clinical social worker, advanced practiceregistered nurse, or certified substance abuse counselor.  The certifiedsubstance abuse counselor shall be employed by a hospital or nonhospitalfacility providing substance abuse services.  The substance abuse assessmentshall evaluate the suitability for substance abuse treatment and placement inan appropriate treatment setting.

(c)  Mental illness benefits.

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

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

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

(4)  Mental health outpatient services shall be acovered benefit under this chapter and shall be included as part of the coveredoutpatient 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, c78, §§2, 3; am L 1999, c 121, §§2, 6; am L 2000, c 243, §8(2); am L 2001, c111, §3; am L 2002, c 167, §5 and c 239, §1; am L 2003, c 197, §3; am L 2006, c205, §3; am L 2007, c 38, §3; am L 2008, c 206, §4]