2006 Utah Code - 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 insurance policy or health maintenance organization contract that does not impose any lifetime limit, annual payment limit, episodic limit, inpatient or outpatient service limit, or maximum out-of-pocket limit that places a greater financial burden on an insured for the evaluation and treatment of a mental health condition than for the evaluation and treatment of a physical health condition.
     (ii) "Catastrophic mental health coverage" may include a restriction on cost sharing factors, such as deductibles, copayments, or coinsurance, prior to reaching any maximum out-of-pocket limit.
     (iii) "Catastrophic mental health coverage" may include one maximum out-of-pocket limit for physical health conditions and another maximum out-of-pocket limit for mental health conditions, provided that, if separate out-of-pocket limits are established, the out-of-pocket limit for mental 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 insurance policy or health maintenance organization contract that pays for 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 episodic limits, inpatient or outpatient service limits, or maximum out-of-pocket limits.
     (c) "Large employer" is as defined in Section 31A-1-301.
     (d) (i) "Mental health condition" means any condition or disorder involving mental illness that falls under any of the diagnostic categories listed in the Diagnostic and Statistical Manual, as periodically revised.
     (ii) "Mental health condition" does not include the following when diagnosed as the primary or substantial reason or need for treatment:
     (A) marital or family problem;
     (B) social, occupational, religious, or other social maladjustment;
     (C) conduct disorder;
     (D) chronic adjustment disorder;
     (E) psychosexual disorder;
     (F) chronic organic brain syndrome;
     (G) personality disorder;
     (H) specific developmental disorder or learning disability; or
     (I) mental retardation.
     (e) "Small employer" is as defined in Section 31A-1-301.
     (2) (a) At the time of purchase and renewal, an insurer shall offer to each small employer that it insures or seeks to insure a choice between catastrophic mental health coverage and 50/50 mental health coverage.
     (b) In addition to Subsection (2)(a), an insurer may offer to provide:
     (i) catastrophic mental health coverage, 50/50 mental health coverage, or both at levels that 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 health coverage, 50/50 mental health coverage, or coverage offered under Subsection (2)(b), regardless of the employer's previous coverage for mental health conditions.

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     (d) An insurer is exempt from the 30% index rating restriction in Subsection 31A-30-106(1)(b) and, for the first year only that catastrophic mental health coverage is chosen, the 15% annual adjustment restriction in Subsection 31A-30-106(1)(c)(ii), for any small employer with 20 or less enrolled employees who chooses coverage that meets or exceeds catastrophic mental health coverage.
     (3) (a) At the time of purchase and renewal, an insurer shall offer catastrophic mental health coverage to each large employer that it insures or seeks to insure.
     (b) In addition to Subsection (3)(a), an insurer may offer to provide catastrophic mental health coverage at levels that exceed the minimum requirements of this section.
     (c) A large employer may, at its option, choose either catastrophic mental health coverage, coverage that excludes benefits for mental health conditions, or coverage offered under Subsection (3)(b).
     (4) (a) An insurer may provide catastrophic mental health coverage through a managed care organization or system in a manner consistent with the provisions in Chapter 8, Health Maintenance Organizations and Limited Health Plans, regardless of whether the policy or contract uses 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 any benefit to be paid for services rendered by a nonpanel provider unless:
     (I) the insured is referred to a nonpanel provider with the prior authorization of the insurer; and
     (II) the nonpanel provider agrees to follow the insurer's protocols and treatment guidelines.
     (ii) If an insured receives services from a nonpanel provider in the manner permitted by Subsection (4)(b)(i)(B), the insurer shall reimburse the insured for not less than 75% of the average amount paid by the insurer for comparable services of panel providers under a noncapitated arrangement who are members of the same class of health care providers.
     (iii) Nothing in this Subsection (4)(b) may be construed as requiring an insurer to authorize a referral to a nonpanel provider.
     (c) To be eligible for catastrophic mental health coverage, a diagnosis or treatment of a mental 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 licensed or otherwise authorized to provide mental health services pursuant to Title 26, Chapter 21, Health Care Facility Licensing and Inspection Act, or Title 62A, Chapter 2, Licensure of Programs and Facilities, that provides a program for the treatment of a mental health condition pursuant to a written plan.
     (5) The commissioner may disapprove any policy or contract that provides mental health coverage in a manner that is inconsistent with the provisions of this section.
     (6) The commissioner shall:
     (a) adopt rules as necessary to ensure compliance with this section; and
     (b) provide general figures on the percentage of contracts and policies that include no mental health coverage, 50/50 mental health coverage, catastrophic mental health coverage, and coverage that exceeds the minimum requirements of this section.

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     (7) The Health and Human Services Interim Committee shall review:
     (a) the impact of this section on insurers, employers, providers, and consumers of mental health services before January 1, 2004; and
     (b) make a recommendation as to whether the provisions of this section should be modified and whether the cost-sharing requirements for mental health conditions should be the same as for physical health conditions.
     (8) (a) An insurer shall offer catastrophic mental health coverage as part of a health maintenance organization contract that is governed by Chapter 8, Health Maintenance Organizations and Limited Health Plans, that is in effect on or after January 1, 2001.
     (b) An insurer shall offer catastrophic mental health coverage as a part of a health insurance policy that is not governed by Chapter 8, Health Maintenance Organizations and Limited Health Plans, that is in effect on or after July 1, 2001.
     (c) This section does not apply to the purchase or renewal of an individual insurance policy or contract.
     (d) Notwithstanding Subsection (8)(c), nothing in this section may be construed as discouraging or otherwise preventing insurers from continuing to provide mental health coverage in connection with an individual policy or contract.
     (9) This section shall be repealed in accordance with Section 63-55-231.

Amended by Chapter 308, 2002 General Session