Maryland Health - General Section 19-703.1

      (a)      (1)      In this section the following terms have the meanings indicated.

            (2)      "Alcohol abuse" has the meaning stated in § 8-101 of this article.

            (3)      "Drug abuse" has the meaning stated in § 8-101 of this article.

            (4)      "Managed care system" means a method that a carrier uses to review and preauthorize a treatment plan that a health care practitioner develops for a covered person using a variety of cost containment methods to control utilization, quality, and claims.

            (5)      "Partial hospitalization" means the provision of medically directed intensive or intermediate short-term treatment for mental illness, emotional disorders, drug abuse or alcohol abuse for a period of less than 24 hours but more than 4 hours in a day for a member or subscriber in a licensed or certified facility or program.

      (b)      (1)      Subject to the provisions of this section, each contract or certificate issued to a member or subscriber by a health maintenance organization that provides health benefits and services for diseases may not discriminate against any person with a mental illness, emotional disorder or a drug abuse or alcohol abuse disorder by failing to provide benefits for treatment and diagnosis of these illnesses under the same terms and conditions as provided for covered benefits offered under the contract or certificate for the treatment of physical illness.

            (2)      It shall not be considered to be discriminatory under paragraph (1) of this subsection if at least the following benefits are provided:

                  (i)      With respect to inpatient benefits provided in a licensed or certified facility, which shall include hospital inpatient benefits, the total number of days for which benefits are payable shall be:

                        1.      Except as provided in subsection (d) of this section, from July 1, 1994 through June 30, 1995, at least 60 days in any calendar year or benefit period of not more than 12 months under the same terms and conditions that apply to benefits available under the contract or certificate for physical illness; and

                        2.      On or after July 1, 1995, at least equal to the same terms and conditions that apply to the benefits available under the contract or certificate for physical illness;

                  (ii)      Subject to subsection (f) of this section, with respect to benefits for partial hospitalization, at least 60 days of partial hospitalization shall be covered under the same terms and conditions that apply to the benefit available under the contract or certificate for physical illness; and

                  (iii)      With respect to outpatient coverage, other than for inpatient or partial hospitalization services, benefits for covered expenses arising from services, including psychological and neuropsychological testing for diagnostic purposes, which are rendered to treat mental illness, emotional disorders, drug abuse and alcohol abuse shall be at a rate which is, after the applicable deductible, not less than:

                        1.      80 percent for the first 5 visits in any calendar year or benefit period of not more than 12 months;

                        2.      65 percent for the 6th through 30th visit in any calendar year or benefit period of not more than 12 months; and

                        3.      50 percent for the 31st visit and any visit after the 31st visit in any calendar year or benefit period of not more than 12 months.

      (c)      (1)      The benefits under this section shall be required only for expenses arising for treatment of mental illnesses, emotional disorders, drug abuse and alcohol abuse which in the professional judgment of practitioners is medically necessary and treatable.

            (2)      The benefits required under this section shall be provided as one set of benefits covering mental illnesses, emotional disorders, drug abuse and alcohol abuse.

            (3)      The benefits required under this section may be delivered under a managed care system.

            (4)      Except as specifically provided in this section, benefits for illnesses covered by this section and the benefits for physical illnesses covered under a contract or certificate shall have the same terms and conditions.

            (5)      Except for the coinsurance provisions in subsection (b)(2)(iii) of this section, a contract or certificate that is subject to this section may not have:

                  (i)      Separate lifetime maximums for physical illnesses and illnesses covered under this section;

                  (ii)      Separate deductibles and coinsurance amounts for physical illnesses and illnesses covered under this section; or

                  (iii)      Separate out-of-pocket limits in a benefit period of not more than 12 months for physical illnesses and illnesses covered under this section.

            (6)      (i)      Subject to subparagraph (ii) of this paragraph, any copayments required under a contract or certificate for benefits for illnesses covered under this section shall be:

                        1.      Actuarially equivalent to any coinsurance requirements under this section; or

                        2.      Where there are no coinsurance requirements, not greater than a copayment required for a benefit under the contract or a certificate for a physical illness.

                  (ii)      A health maintenance organization may not charge a copayment that is greater than 50% of the daily cost for methadone maintenance treatment.

      (d)      Notwithstanding the provisions of subsection (b)(2)(i)1 of this section, until July 1, 1995, a contract or certificate that is subject to this section that offers less than 60 days coverage for inpatient care for health care for physical illness must only include coverage for mental illness, emotional disorders, drug abuse and alcohol abuse that is at least equal to the benefit offered for those other types of health care. On and after July 1, 1995, the provisions of subsection (b)(2)(i)2 of this section shall apply.

      (e)      An office visit to a physician or other health care provider for the purpose of medication management may not be counted against the number of visits required to be covered as a part of the benefits required under subsection (b)(2)(iii) of this section and shall be reimbursed under the same terms and conditions as an office visit for physical illnesses covered under the contract or certificate.

      (f)      Nothing in this section shall be construed to prohibit exceeding the minimum benefits required under subsection (b)(2)(ii) of this section for any partial hospitalization day that is medically necessary and would serve to prevent inpatient hospitalization.