2005 Vermont Code - § 4089. — Mental illness

§ 4089. Mental illness

(a) Any group health insurance policy providing coverage on an expense incurred basis, and any group service contract issued by a nonprofit corporation shall provide benefits for mental health care, as an option and after the payment of a premium, at least equal to the following minimum:

(1) In the case of benefits paid for confinement as an inpatient in a licensed general hospital, or in a public or licensed mental hospital, including inpatient care at community mental health centers, the period of confinement for which benefits shall be payable shall be forty-five day equivalents of active care per policy year or calendar year, whichever is applicable;

(2) In the case of outpatient services furnished by a licensed general hospital or public or licensed mental hospital, by a qualified mental health facility qualified under subsection (d) or by a licensed or certified mental health professional, if such a facility is approved by the secretary of the agency of human services, the reasonable charges for such services shall be included as covered medical expenses and benefits shall be payable at a rate of 100 percent with respect to the first five visits by a covered person in a policy year or calendar year and at a rate of 80 percent thereafter; provided that benefits payable under this subdivision with respect to the covered person may be limited to five hundred dollars in the policy year or calendar year, whichever is applicable. For the purposes of this section, "outpatient services" means consultations, diagnosis or treatment provided by a facility or by a licensed or certified mental health professional approved by the secretary of the agency of human services.

(3) In the case of partial hospitalization the period of treatment for which benefits shall be payable shall be forty-five day equivalents of active care per policy year or calendar year, whichever is applicable. For the purpose of this section "partial hospitalization" means a service of more than two, but less than twenty-four hours which provides treatment which can reasonably be expected to lead to full or partial recovery of the patient or which promotes emotional or psychological change to alleviate the effects of mental disorders, or prevents deterioration of patient's emotional or physical functions.

(b) To be eligible for coverage, a service must be rendered:

(1) In a mental health facility qualified under subsection (d) below, or;

(2) By a licensed or certified mental health professional.

(c) In the case of a nonprofit hospital or medical service corporation, the nonprofit corporation may require a mental health facility or licensed or certified mental health professional to enter into a contract as a condition of providing benefits.

(d) The secretary of the agency of human services shall establish, by promulgating rules and regulations in accordance with the administrative procedure act, the mental health facilities that are qualified to render services as provided for by this section.

(e) Insurance carriers may require reasonable utilization review prior to payment of benefits under this section.

(f) The benefits required under subsection (a) of this section shall be available for the active treatment of any mental or nervous condition or mental disorder falling under any of the diagnostic categories listed in the mental disorders section of the international classification of disease as periodically revised. (Added 1975, No. 209 (Adj. Sess.), § 1, eff. October 1, 1976; amended 1989, No. 43.)