GENERAL ASSEMBLY OF NORTH CAROLINA
SESSION 2007
H 2
HOUSE BILL 973
Committee Substitute Favorable 5/8/07
Short Title: Mental Health Equitable Coverage. |
(Public) |
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Sponsors: |
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Referred to: |
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March 22, 2007
A BILL TO BE ENTITLED
AN ACT TO REQUIRE equity IN HEALTH INSURANCE COVERAGE FOR MENTAL ILLNESS AND CHEMICAL DEPENDENCY.
The General Assembly of North Carolina enacts:
SECTION 1. G.S. 58-51-50 reads as rewritten:
"§ 58-51-50. Coverage for chemical dependency treatment.
(a) Definitions. -
As used in this section, the term "chemical term:
(1) 'Chemical dependency' means the pathological use or abuse of alcohol or other drugs in a manner or to a degree that produces an impairment in personal, social or occupational functioning and which may, but need not, include a pattern of tolerance and withdrawal.
(2) 'Health benefit plan' has the same meaning as in G.S. 58-3-167 and includes the Teachers and State Employees' Comprehensive Major Medical Plan (Plan) and the Plan's optional PPO program.
(3) 'Insurer' has the same meaning as in G.S. 58-3-167.
(b) Every insurer that
writes a policy or contract of group or blanket health insurance or group or
blanket accident and health insurance that is issued, renewed, or amended on or
after January 1, 1985, shall offer to its insureds shall provide in each
group health benefit plan benefits for the necessary care and treatment of
chemical dependency that are not less favorable than benefits for physical
illness generally. Except as provided in subsection (c) of this section,
benefits Benefits for treatment of chemical dependency shall be
subject to the same durational limits, dollar limits, deductibles, and
coinsurance factors limits as are benefits for physical illness
generally. For purposes of this subsection, 'limits' includes durational
limits, deductibles, coinsurance factors, co-payments, maximum out-of-pocket
limits, annual and lifetime dollar limits, and any other dollar limits or fees
for covered services.
(b1) Weighted Average. - If a group health benefit plan contains annual limits, lifetime limits, co-payments, deductibles, or coinsurance only on selected physical illness and injury benefits, and these benefits do not represent substantially all of the physical illness and injury benefits under the health benefit plan, then the insurer may impose limits on the chemical dependency treatment benefits based on a weighted average of the respective annual, lifetime, co-payment, deductible, or coinsurance limits on the selected physical illness and injury benefits. The weighted average shall be calculated in accordance with rules adopted by the Commissioner.
(b2) Case Management. - An insurer may use a case management program for chemical dependency treatment benefits to evaluate and determine medically necessary and medically appropriate care and treatment for each patient, provided that the program complies with rules adopted by the Commissioner. These rules shall ensure that case management programs are not designed to avoid the requirements of this section concerning equity between the benefits for chemical dependency treatment and those for physical illness generally.
(b3) Medical Necessity. - Nothing in this section prohibits a group health benefit plan from managing the provision of benefits through common methods, including, but not limited to, preadmission screening, prior authorization of services, or other mechanisms designed to limit coverage to services for chemical dependency treatment only to those that are deemed medically necessary.
(c) Every group
policy or group contract of insurance that provides benefits for chemical
dependency treatment and that provides total annual benefits for all illnesses
in excess of eight thousand dollars ($8,000) is subject to the following
conditions:
(1) The policy
or contract shall provide, for each 12-month period, a minimum benefit of eight
thousand dollars ($8,000) for the necessary care and treatment of chemical
dependency.
(2) The policy
or contract shall provide a minimum benefit of sixteen thousand dollars
($16,000) for the necessary care and treatment of chemical dependency for the
life of the policy or contract.
(d) Provisions for benefits for necessary care and treatment of chemical dependency in group policies or group contracts of insurance shall provide benefit payments for the following providers of necessary care and treatment of chemical dependency:
(1) The following units of
a general hospital licensed under Article 5 of General Statutes Chapter 131E:131E
of the General Statutes:
a. Chemical
dependency units in licensed facilities; facilities licensed after
October 1, 1984;
b. Medical units;
c. Psychiatric units; and
(2) The following
facilities or programs licensed after July 1, 1984, under Article 2 of
General Statutes Chapter 122C: under Article 2 of Chapter 122C of the
General Statutes:
a. Chemical dependency units in psychiatric hospitals;
b. Chemical dependency hospitals;
c. Residential chemical dependency treatment facilities;
d. Social setting detoxification facilities or programs;
e. Medical detoxification or programs; and
(3) Duly licensed
physicians and duly licensed practicing psychologists and certified
professionals working under the direct supervision of such physicians or
psychologists in facilities described in (1) and (2) above and in day/night
programs or outpatient treatment facilities licensed after July 1, 1984,
under Article 2 of General Statutes Chapter 122C.under Article 2 of
Chapter 122C of the General Statutes.
(4) Licensed or certified psychologists, licensed clinical social workers, certified clinical nurse specialists in psychiatric mental health advanced practice, nurse practitioners certified as clinical nurse specialists in psychiatric mental health advanced practice, licensed psychological associates, licensed professional counselors, licensed marriage and family therapists, licensed clinical addictions specialists, and certified clinical supervisors working within the scope of practice in facilities described in subdivisions (1) and (2) of this subsection, in day/night programs licensed under Article 2 of Chapter 122C of the General Statutes, and outpatient services.
Provided, however, that nothing in this subsection shall prohibit any policy or contract of insurance from requiring the most cost effective treatment setting to be utilized by the person undergoing necessary care and treatment for chemical dependency.
(e) Coverage
for chemical dependency treatment as described in this section shall not be
applicable to any group policy holder or group contract holder who rejects the
coverage in writing. "
SECTION 2. G.S. 58-51-55 reads as rewritten:
"§ 58-51-55.
No discrimination against the mentally ill and chemically dependent.dependent
individuals.
(a) Definitions. - As used in this section, the term:
(1) 'Mental illness' has
the same meaning as defined in G.S. 122C-3(21); andG.S. 122C-3(21),
with a mental disorder defined in the Diagnostic and Statistical Manual of
Mental Disorders, DSM-IV, or a subsequent edition published by the American
Psychiatric Association, except those mental disorders coded in the DSM-IV or
subsequent editions as substance-related disorders (291.0 through 292.9 and
303.0 through 305.9) and those coded as 'V' codes.
(2) 'Chemical dependency'
has the same meaning as defined in G.S. 58-51-5058-51-50, with a
mental disorder defined in the Diagnostic and Statistical Manual of Mental
Disorders, DSM-IV, or subsequent editions of this manual.
with a diagnosis found in the Diagnostic and Statistical
Manual of Mental Disorders DSM-3-R or the International Classification of
Diseases ICD/9/CM, or a later edition of those manuals.
(b) Coverage of Physical Illness. - No insurance company licensed in this State under this Chapter shall, solely because an individual to be insured has or had a mental illness or chemical dependency:
(1) Refuse to issue or deliver to that individual any policy that affords benefits or coverages for any medical treatment or service for physical illness or injury;
(2) Have a higher premium rate or charge for physical illness or injury coverages or benefits for that individual; or
(3) Reduce physical illness or injury coverages or benefits for that individual.
(b1) Coverage of Mental
Illness. - A policy that covers both physical illness or injury and mental
illness may not impose a lesser lifetime or annual dollar limitation on the
mental health benefits than on the physical illness or injury benefits, subject
to the following:
(1) A lifetime
limit or annual limit may be made applicable to all benefits under the policy,
without distinguishing the mental health benefits.
(2) If the
policy contains lifetime limits only on selected physical illness and injury
benefits, and these benefits do not represent substantially all of the physical
illness and injury benefits under the policy, the insurer may impose a lifetime
limit on the mental health benefits that is based on a weighted average of the
respective lifetime limits on the selected physical illness and injury
benefits. The weighted average shall be calculated in accordance with rules
adopted by the Commissioner.
(3) If the
policy contains annual limits only on selected physical illness and injury
benefits, and these benefits do not represent substantially all of the physical
illness and injury benefits under the policy, the insurer may impose an annual
limit on the mental health benefits that is based on a weighted average of the
respective annual limits on the selected physical illness and injury benefits.
The weighted average shall be calculated in accordance with rules adopted by
the Commissioner.
(4) Except as
otherwise provided in this section, the policy may distinguish between mental
illness benefits and physical injury or illness benefits with respect to other
terms of the policy, including coinsurance, limits on provider visits or days
of coverage, and requirements relating to medical necessity.
(5) If the
insurer offers two or more benefit package options under a policy, each package
must comply with this subsection.
(6) This
subsection does not apply to a policy if the insurer can demonstrate to the
Commissioner that compliance will increase the cost of the policy by one
percent (1%) or more.
(7) This
subsection expires October 1, 2001, but the expiration does not affect services
rendered before that date.
(c) Mental
Illness or Chemical Dependency Coverage Not Required. - Nothing in this section
requires an insurer to offer coverage for mental illness or chemical
dependency, except as provided in G.S. 58-51-50.
(d) Applicability.
- Subsection (b1) of this section applies only to group health insurance
contracts, other than excepted benefits as defined in G.S. 58-68-25,
covering more than 50 employees. The remainder of this section applies only to
group health insurance contracts covering 20 or more employees. For purposes of
this section, "group health insurance contracts" include MEWAs, as
defined in G.S. 58-49-30(a)."
SECTION 3. Article 3 of Chapter 58 of the General Statutes is amended by adding the following new section to read:
"§ 58-3-220. Mental illness benefits coverage.
(a) Mental Health Equity Requirement. - An insurer shall provide in each group health benefit plan benefits for the necessary care and treatment of mental illness that are no less favorable than benefits for physical illness generally. Benefits for treatment of mental illness shall be subject to the same limits as benefits for physical illness generally. For purposes of this subsection, 'limits' includes durational limits, deductibles, coinsurance factors, co-payments, maximum out-of-pocket limits, annual and lifetime dollar limits, and any other dollar limits or fees for covered services.
(b) Weighted Average. - If a health benefit plan contains annual limits, lifetime limits, co-payments, deductibles, or coinsurance only on selected physical illness and injury benefits, and these benefits do not represent substantially all of the physical illness and injury benefits under the health benefit plan, then the insurer may impose limits on the mental health benefits based on a weighted average of the respective annual, lifetime, co-payment, deductible, or coinsurance limits on the selected physical illness and injury benefits. The weighted average shall be calculated in accordance with rules adopted by the Commissioner.
(c) Case Management. - An insurer may use a case management program for mental illness benefits to evaluate and determine medically necessary and medically appropriate care and treatment for each patient, provided that the program complies with rules adopted by the Commissioner. These rules may ensure only that case management programs are not designed to avoid the requirement of this section for equity between the benefits for mental illness and those for physical illness generally.
(d) Medical Necessity. - Nothing in this section prohibits a group health benefit plan from managing the provision of benefits through common methods, including, but not limited to, preadmission screening, prior authorization of services, or other mechanisms designed to limit coverage to services for mental illness only to those that are deemed medically necessary.
(e) Definitions. - As used in this section:
(1) 'Health benefit plan' has the same meaning as in G.S. 58-3-167 and includes the Teachers' and State Employees' Comprehensive Major Medical Plan (Plan) and the Plan's optional PPO program.
(2) 'Insurer' has the same meaning as in G.S. 58-3-167.
(3) 'Mental illness' has the same meaning as in G.S. 122C-3(21), with a mental disorder defined in the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV, or subsequent editions published by the American Psychiatric Association, except those mental disorders coded in the DSM-IV or subsequent editions as substance-related disorders (291.0 through 292.9 and 303.0 through 305.9) and those coded as 'V' codes."
SECTION 4. G.S. 58-65-75 reads as rewritten:
"§ 58-65-75. Coverage for chemical dependency treatment.
(a) Definition. - As used in this section, the term 'chemical dependency' means the pathological use or abuse of alcohol or other drugs in a manner or to a degree that produces an impairment in personal, social, or occupational functioning and which may, but need not, include a pattern of tolerance and withdrawal.
(b) Chemical
Dependency Equity Requirement. - Every group insurance certificate or group
subscriber contract under any hospital or medical plan governed by this Article
and Article 66 of this Chapter that is issued, renewed, or amended on or
after January 1, 1985, shall offer shall provide to its insureds
benefits for the necessary care and treatment of chemical dependency that are
not less favorable than benefits for physical illness generally. Except as
provided in subsection (c) of this section, benefitsBenefits for
chemical dependency shall be subject to the same durational limits, dollar
limits, deductibles, and coinsrance factors limits as are benefits
for physical illness generally. For purposes of this subsection, 'limits'
includes durational limits, deductibles, coinsurance factors, co-payments,
maximum out-of-pocket limits, annual and lifetime dollar limits, and any other
dollar limits or fees for covered services.
(b1) Weighted Average. - If a hospital or medical plan governed by this Article contains annual limits, lifetime limits, co-payments, deductibles, or coinsurance only on selected physical illness and injury benefits, and these benefits do not represent substantially all of the physical illness and injury benefits under the plan, then the group insurance certificate or group subscriber contract may impose limits on the chemical dependency treatment benefits based on a weighted average of the respective annual, lifetime, co-payment, deductible, or coinsurance limits on the selected physical illness and injury benefits. The weighted average shall be calculated in accordance with rules adopted by the Commissioner.
(b2) Case Management. - A group insurance certificate or group subscriber contract may use a case management program for chemical dependency treatment benefits to evaluate and determine medically necessary and medically appropriate care and treatment for each patient, provided that the program complies with rules adopted by the Commissioner. These rules shall ensure that case management programs are not designed to avoid the requirements of this section concerning equity between the benefits for chemical dependency treatment and those for physical illness generally.
(b3) Medical Necessity. - Nothing in this section prohibits a hospital or medical plan governed by this Article from managing the provision of benefits through common methods, including, but not limited to, preadmission screening, prior authorization of services, or other mechanisms designed to limit coverage to services for chemical dependency treatment only to those that are deemed medically necessary.
(c) Every group
insurance certificate or group subscriber contract that provides benefits for
chemical dependency treatment and that provides total annual benefits for all
illnesses in excess of eight thousand dollars ($8,000) is subject to the
following conditions:
(1) The
certificate or contract shall provide, for each 12-month period, a minimum
benefit of eight thousand dollars ($8,000) for the necessary care and treatment
of chemical dependency.
(2) The
certificate or contract shall provide a minimum benefit of sixteen thousand
dollars ($16,000) for the necessary care and treatment of chemical dependency
for the life of the certificate or contract.
(d) Provisions for benefits for necessary care and treatment of chemical dependency in group certificates or group contracts shall provide for benefit payments for the following providers of necessary care and treatment of chemical dependency:
(1) The following units of
a general hospital licensed under Article 5 of General Statutes Chapter
131E:Chapter 131E of the General Statutes:
a. Chemical
dependency units in facilities licensed after October 1, 1984;licensed
facilities;
b. Medical units;
c. Psychiatric units; and
(2) The following
facilities or programs licensed after July 1, 1984, under Article 2 of
General Statutes Chapter 122C:under Article 2 of Chapter 122C of the
General Statutes:
a. Chemical dependency units in psychiatric hospitals;
b. Chemical dependency hospitals;
c. Residential chemical dependency treatment facilities;
d. Social setting detoxification facilities or programs;
e. Medical detoxification facilities or programs; and
(3) Duly licensed
physicians and duly licensed psychologists and certified professionals working
under the direct supervision of such physicians or psychologists in facilities
described in (1) and (2) above and in day/night programs or outpatient
treatment facilities licensed after July 1, 1984, under Article 2 of General
Statutes Chapter 122C.under Article 2 of Chapter 122C of the General
Statutes. After January 1, 1995, "duly licensed psychologist"'Duly
licensed psychologist' shall be defined as means licensed
psychologists who hold permanent licensure and certification as health services
provider psychologist issued by the North Carolina Psychology Board.
(4) Licensed or certified psychologists, licensed clinical social workers, certified clinical nurse specialists in psychiatric mental health advanced practice, nurse practitioners certified as clinical nurse specialists in psychiatric mental health advanced practice, licensed psychological associates, licensed professional counselors, licensed marriage and family therapists, licensed clinical addictions specialists, and certified clinical supervisors working within the scope of practice in facilities described in subdivisions (1) and (2) of this subsection, in day/night programs licensed under Article 2 of Chapter 122C of the General Statutes, and outpatient services.
Provided, however, that nothing in this subsection shall prohibit any certificate or contract from requiring the most cost effective treatment setting to be utilized by the person undergoing necessary care and treatment for chemical dependency.
(e) Coverage
for chemical dependency treatment as described in this section shall not be
applicable to any group certificate holder or group subscriber contract holder
who rejects the coverage in writing."
SECTION 5. G.S. 58-65-90 reads as rewritten:
"§ 58-65-90.
No discrimination against the mentally ill and chemically dependent.dependent
individuals.
(a) Definitions. - As used in this section, the term:
(1) 'Mental illness' has
the same meaning as defined in G.S. 122C-3(21); andG.S. 122C-3(21),
with a mental disorder defined in the Diagnostic and Statistical Manual of
Mental Disorders, DSM-IV, or subsequent editions published by the American
Psychiatric Association, except those mental disorders coded in the DSM-IV or
subsequent editions as substance-related disorders (291.0 through 292.9 and
303.0 through 305.9) and those coded as 'V' codes.
(2) 'Chemical dependency'
has the same meaning as defined in G.S. 58-65-7558-65-75, with a
mental disorder defined in the Diagnostic and Statistical Manual of Mental
Disorders, DSM-IV, or subsequent editions of this manual.
with a diagnosis found in the Diagnostic and Statistical
Manual of Mental Disorders DSM-3-R or the International Classification of
Diseases ICD/9/CM, or a later edition of those manuals.
(b) Coverage of Physical Illness. - No service corporation governed by this Chapter shall, solely because an individual to be insured has or had a mental illness or chemical dependency:
(1) Refuse to issue or deliver to that individual any individual or group subscriber contract in this State that affords benefits or coverage for medical treatment or service for physical illness or injury;
(2) Have a higher premium rate or charge for physical illness or injury coverages or benefits for that individual; or
(3) Reduce physical illness or injury coverages or benefits for that individual.
(b1) Coverage of Mental
Illness. - A subscriber contract that covers both physical illness or injury
and mental illness may not impose a lesser lifetime or annual dollar limitation
on the mental health benefits than on the physical illness or injury benefits,
subject to the following:
(1) A lifetime
limit or annual limit may be made applicable to all benefits under the
subscriber contract, without distinguishing the mental health benefits.
(2) If the
subscriber contract contains lifetime limits only on selected physical illness
or injury benefits, and these benefits do not represent substantially all of
the physical illness and injury benefits under the subscriber contract, the
service corporation may impose a lifetime limit on the mental health benefits
that is based on a weighted average of the respective lifetime limits on the
selected physical illness and injury benefits. The weighted average shall be
calculated in accordance with rules adopted by the Commissioner.
(3) If the
subscriber contract contains annual limits only on selected physical illness
and injury benefits, and these benefits do not represent substantially all of
the physical illness and injury benefits under the subscriber contract, the
service corporation may impose an annual limit on the mental health benefits
that is based on a weighted average of the respective annual limits on the
selected physical illness and injury benefits. The weighted average shall be
calculated in accordance with rules adopted by the Commissioner.
(4) Except as
otherwise provided in this section, the subscriber contract may distinguish
between mental illness benefits and physical injury or illness benefits with
respect to other terms of the subscriber contract, including coinsurance,
limits on provider visits or days of coverage, and requirements relating to medical
necessity.
(5) If the
service corporation offers two or more benefit package options under a
subscriber contract, each package must comply with this subsection.
(6) This
subsection does not apply to a subscriber contract if the service corporation
can demonstrate to the Commissioner that compliance will increase the cost of
the subscriber contract by one percent (1%) or more.
(7) This
subsection expires October 1, 2001, but the expiration does not affect services
rendered before that date.
(c) Mental
Illness or Chemical Dependency Coverage Not Required. - Nothing in this section
requires a service corporation to offer coverage for mental illness or chemical
dependency, except as provided in G.S. 58-65-75.
(d) Applicability.
- Subsection (b1) of this section applies only to subscriber contracts, other
than excepted benefits as defined in G.S. 58-68-25, covering more than 50
employees. The remainder of this section applies only to group contracts
covering 20 or more employees."
SECTION 6. G.S. 58-67-70 reads as rewritten:
"§ 58-67-70. Coverage for chemical dependency treatment.
(a) Definition. - As used in this section, the term 'chemical dependency' means the pathological use or abuse of alcohol or other drugs in a manner or to a degree that produces an impairment in personal, social or occupational functioning and which may, but need not, include a pattern of tolerance and withdrawal.
(b) Chemical
Dependency Requirement. - On and after January 1, 1985, everyEvery
health maintenance organization that writes a health care plan on a group basis
and that is subject to this Article shall offer provide benefits
for the necessary care and treatment of chemical dependency that are not less
favorable than benefits under the health care plan generally. Except as
provided in subsection (c) of this section, benefits Benefits for
chemical dependency shall be subject to the same durational limits, dollar
limits, deductibles, and coinsurance factors limits as are benefits
under the health care plan generally. For purposes of this subsection,
'limits' includes durational limits, deductibles, coinsurance factors, co-payments,
maximum out-of-pocket limits, annual and lifetime dollar limits, and any other
dollar limits or fees for covered services.
(b1) Weighted Average. - If a group health plan contains annual limits, lifetime limits, co-payments, deductibles, or coinsurance only on selected physical illness and injury benefits, and these benefits do not represent substantially all of the physical illness and injury benefits under the plan, then the health maintenance organization may impose limits on the chemical dependency treatment benefits based on a weighted average of the respective annual, lifetime, co-payment, deductible, or coinsurance limits on the selected physical illness and injury benefits. The weighted average shall be calculated in accordance with rules adopted by the Commissioner.
(b2) Case Management. - A health maintenance organization may use a case management program for chemical dependency treatment benefits to evaluate and determine medically necessary and medically appropriate care and treatment for each patient, provided that the program complies with rules adopted by the Commissioner. These rules shall only ensure that case management programs are not designed to avoid the requirements of this section concerning equity between the benefits for chemical dependency treatment and those for physical illness generally.
(b3) Medical Necessity. - Nothing in this section prohibits a health maintenance organization from managing the provision of benefits through common methods, including, but not limited to, preadmission screening, prior authorization of services, or other mechanisms designed to limit coverage to services for chemical dependency treatment only to those that are deemed medically necessary.
(c) Every group
health care plan that provides benefits for chemical dependency treatment and
that provides total annual benefits for all illnesses in excess of eight
thousand dollars ($8,000) is subject to the following conditions:
(1) The plan
shall provide, for each 12-month period, a minimum benefit of eight thousand
dollars ($8,000) for the necessary care and treatment of chemical dependency.
(2) The plan
shall provide a lifetime minimum benefit of sixteen thousand dollars ($16,000)
for the necessary care and treatment of chemical dependency for each enrollee.
(d) Provisions for benefits for necessary care and treatment of chemical dependency in group health care plans shall provide for benefit payments for the following providers of necessary care and treatment of chemical dependency:
(1) The following units of
a general hospital licensed under Article 5 of General Statutes Chapter
131E:Chapter 131E of the General Statutes:
a. Chemical
dependency units in facilities licensed after October 1, 1984;licensed
facilities;
b. Medical units;
c. Psychiatric units; and
(2) The following
facilities or programs licensed after July 1, 1984, under Article 2 of
General Statutes Chapter 122C:under Article 2 of Chapter 122C of the
General Statutes:
a. Chemical dependency units in psychiatric hospitals;
b. Chemical dependency hospitals;
c. Residential chemical dependency treatment facilities;
d. Social setting detoxification facilities or programs;
e. Medical detoxification facilities or programs; and
(3) Duly licensed
physicians and duly licensed practicing psychologists and certified
professionals working under the direct supervision of such physicians or
psychologists in facilities described in (1) and (2) above and in day/night
programs or outpatient treatment facilities licensed after July 1, 1984,
under Article 2 of General Statutes Chapter 122C.under Article 2 of
Chapter 122C of the General Statutes.
(4) Licensed or certified psychologists, licensed clinical social workers, certified clinical nurse specialists in psychiatric mental health advanced practice, nurse practitioners certified as clinical nurse specialists in psychiatric mental health advanced practice, licensed psychological associates, licensed professional counselors, licensed marriage and family therapists, licensed clinical addictions specialists, and certified clinical supervisors working within the scope of practice in facilities described in subdivisions (1) and (2) of this subsection, in day/night programs licensed under Article 2 of Chapter 122C of the General Statutes, and outpatient services.
Provided, however, that nothing in this subsection shall prohibit any plan from requiring the most cost effective treatment setting to be utilized by the person undergoing necessary care and treatment for chemical dependency.
(e) Coverage
for chemical dependency treatment as described in this section shall not be
applicable to any group that rejects the coverage in writing.
(f) Notwithstanding any other provision of this section or Article, any health maintenance organization subject to this Article that becomes a qualified health maintenance organization under Title XIII of the United States Public Health Service Act shall provide the benefits required under that federal Act, which shall be deemed to constitute compliance with the provisions of this section; and any health maintenance organization may provide that the benefits provided under this section must be obtained through providers affiliated with the health maintenance organization."
SECTION 7. G.S. 58-67-75 reads as rewritten:
"§ 58-67-75.
No discrimination against the mentally ill and chemically dependent.dependent
individuals.
(a) Definitions. - As used in this section, the term:
(1) 'Mental illness' has
the same meaning as defined in G.S. 122C-3(21); andG.S. 122C-3(21),
with a mental disorder defined in the Diagnostic and Statistical Manual of
Mental Disorders, DSM-IV, or subsequent editions published by the American
Psychiatric Association, except those mental disorders coded in the DSM-IV or
subsequent editions as substance-related disorders (291.0 through 292.9 and
303.0 through 305.9) and those coded as 'V' codes.
(2) 'Chemical dependency'
has the same meaning as defined in G.S. 58-67-70G.S. 58-67-70,
with a mental disorder defined in the Diagnostic and Statistical Manual of
Disorders, DSM-IV, or subsequent editions of this manual.
with a diagnosis found in the Diagnostic and Statistical
Manual of Mental Disorders DSM-3-R or the International Classification of
Diseases ICD/9/CM, or a later edition of those manuals.
(b) Coverage of Physical Illness. - No health maintenance organization governed by this Chapter shall, solely because an individual has or had a mental illness or chemical dependency:
(1) Refuse to enroll that individual in any health care plan covering physical illness or injury;
(2) Have a higher premium rate or charge for physical illness or injury coverages or benefits for that individual; or
(3) Reduce physical illness or injury coverages or benefits for that individual.
(b1) Coverage of Mental
Illness. - A health care plan that covers both physical illness or injury and
mental illness may not impose a lesser lifetime or annual dollar limitation on
the mental health benefits than on the physical illness or injury benefits,
subject to the following:
(1) A lifetime
limit or annual limit may be made applicable to all benefits under the plan,
without distinguishing the mental health benefits.
(2) If the plan
contains lifetime limits only on selected physical illness and injury benefits,
and these benefits do not represent substantially all of the physical illness
and injury benefits under the plan, the HMO may impose a lifetime limit on the
mental health benefits that is based on a weighted average of the respective
lifetime limits on the selected physical illness and injury benefits. The
weighted average shall be calculated in accordance with rules adopted by the
Commissioner.
(3) If the plan
contains annual limits only on selected physical illness and injury benefits,
and these benefits do not represent substantially all of the physical illness
and injury benefits under the plan, the HMO may impose an annual limit on the
mental health benefits that is based on a weighted average of the respective
annual limits on the selected physical illness and injury benefits. The
weighted average shall be calculated in accordance with rules adopted by the
Commissioner.
(4) Except as
otherwise provided in this section, the plan may distinguish between mental
illness benefits and physical injury or illness benefits with respect to other
terms of the plan, including coinsurance, limits on provider visits or days of
coverage, and requirements relating to medical necessity.
(5) If the HMO
offers two or more benefit package options under a plan, each package must
comply with this subsection.
(6) This
subsection does not apply to a health benefit plan if the HMO can demonstrate
to the Commissioner that compliance will increase the cost of the plan by one
percent (1%) or more.
(7) This
subsection expires October 1, 2001, but the expiration does not affect services
rendered before that date.
(c) Mental
Illness or Chemical Dependency Coverage Not Required. - Nothing in this section
requires an HMO to offer coverage for mental illness or chemical dependency,
except as provided in G.S. 58-67-70.
(d) Applicability.
- Subsection (b1) of this section applies only to group contracts, other than
excepted benefits as defined in G.S. 58-68-25, covering more than 50
employees. The remainder of this section applies only to group contracts
covering 20 or more employees."
SECTION 8. G.S. 58-50-155 reads as rewritten:
"§ 58-50-155. Standard and basic health care plan coverages.
(a) Notwithstanding G.S. 58-50-125(c), the standard health plan developed and approved under G.S. 58-50-125 shall provide coverage for all of the following:
(1) Mammograms and pap smears at least equal to the coverage required by G.S. 58-51-57.
(2) Prostate-specific antigen (PSA) tests or equivalent tests for the presence of prostate cancer at least equal to the coverage required by G.S. 58-51-58.
(3) Reconstructive breast surgery resulting from a mastectomy at least equal to the coverage required by G.S. 58-51-62.
(4) For a qualified individual, scientifically proven bone mass measurement for the diagnosis and evaluation of osteoporosis or low bone mass at least equal to the coverage required by G.S. 58-3-174.
(5) Prescribed contraceptive drugs or devices that prevent pregnancy and that are approved by the United States Food and Drug Administration for use as contraceptives, or outpatient contraceptive services at least equal to the coverage required by G.S. 58-3-178, if the plan covers prescription drugs or devices, or outpatient services, as applicable. The same exceptions and exclusions as are provided under G.S. 58-3-178 apply to standard plans developed and approved under G.S. 58-50-125.
(6) Colorectal cancer examinations and laboratory tests at least equal to the coverage required by G.S. 58-3-179.
(7) Treatment of chemical dependency and mental illness that is at least equal to the coverage required by G.S. 58-51-50 and G.S. 58-3-220, respectively. The Plan may use a case management program in accordance with G.S. 58-51-50 and G.S. 58-3-220, respectively.
(a1), (a2) Repealed by Session Laws 1999-197, s. 2.
(b) Notwithstanding G.S. 58-50-125(c), in developing and approving the plans under G.S. 58-50-125, the Committee and Commissioner shall give due consideration to cost-effective and life-saving health care services and to cost-effective health care providers."
SECTION 9. This act becomes effective January 1, 2008, and applies to health benefit plans that are delivered, issued for delivery, or renewed on and after that date. For purposes of this act, renewal of a health benefit policy, contract, or plan is presumed to occur on each anniversary of the date on which coverage was first effective on the person or persons covered by the health benefit plan.