2005 Vermont Code - § 4098. — Coverage required

§ 4098. Coverage required

(a) Insurers shall provide benefits for the necessary care and treatment of alcohol dependency. Benefits under this subchapter shall be subject to the durational limits, dollar limits, deductibles and co-insurance factors of the basic insurance policy or coverage. Benefits shall include:

(1) detoxification benefits of at least five days per occurrence;

(2) inpatient and partial institutional rehabilitation benefits of up to 28 days or day equivalents per occurrence with up to at least 56 days or day equivalents per person per lifetime. For the purpose of this subchapter "partial institutional rehabilitation" means a service of more than two, but less than twenty-four hours that can reasonably be expected to lead to full or partial recovery of the patient. Two partial institutional rehabilitation days equal one inpatient day.

(3) reasonable outpatient rehabilitation benefits of at least 90 hours per occurrence for the patient including the patient's family where necessary with up to at least 180 hours per lifetime of the patient.

(b) Notwithstanding the provisions of subsection (a) of this section a plan, policy or contract for health insurance shall limit benefits by requiring:

(1) provision of outpatient or partial institutional rehabilitation benefits before eligibility for inpatient rehabilitation benefits, when appropriate;

(2) detoxification benefits in a hospital only when nonhospital detoxification is certified as inappropriate by a physician;

(3) inpatient rehabilitation benefits in a hospital only when non-hospital rehabilitation treatment is certified as inappropriate by a substance abuse counselor who is not an employee of the hospital;

(4) preauthorization for inpatient rehabilitation benefits.

(c) Nothing in this chapter shall limit insurers, subject to the approval of the department of banking, insurance, securities, and health care administration, from contracting selectively but fairly with and among providers for the provision of the benefits set out in this subchapter.

(d) For purposes of this subchapter, "insurer" means any insurance company which provides health insurance as defined in section 3301(a)(2) of Title 8 and includes nonprofit hospital and medical service plan corporations and health maintenance organizations. (Added 1981, No. 176 (Adj. Sess.); amended 1985, No. 75, § 3, eff. March 1, 1986; 1989, No. 225 (Adj. Sess.), § 25(a); 1995, No. 180 (Adj. Sess.), § 38(a).)