PA 08-125—sSB 167
Insurance and Real Estate Committee
Public Safety and Security Committee
AN ACT CONCERNING BENEFITS FOR INPATIENT TREATMENT OF SERIOUS MENTAL OR NERVOUS CONDITIONS
SUMMARY: This act expands the benefits payable under a group health insurance policy for treatment received in a residential treatment facility by (1) eliminating a three-day hospital stay prerequisite for a child or adolescent with a serious mental illness and (2) extending benefits to adults.
It replaces the term “serious mental illness” with “serious mental or nervous condition” and removes from the term's definition a requirement that the person have shown recent disturbed behavior. It requires benefits be paid when a physician, psychiatrist, psychologist, or clinical social worker assesses the person and determines that he or she cannot appropriately, safely, or effectively be treated in other specified settings. (Due to federal preemption, state benefit mandates do not apply to self-insured plans. )
EFFECTIVE DATE: January 1, 2009
The act requires benefits to be payable under group health policies, including HMO contracts, for treatment an insured person receives while confined at a residential treatment facility when he or she:
1. has a serious mental or nervous condition (one that substantially impairs the person's thought, perception of reality, emotional process, or judgment or grossly impairs his or her behavior) and
2. a physician, psychiatrist, psychologist, or clinical social worker has assessed the person and determined that he or she cannot appropriately, safely, or effectively be treated in an acute care, partial hospitalization, intensive outpatient, or other outpatient setting.
Prior law required group policies to cover an insured person's treatment at a residential treatment facility only when he or she:
1. had a serious mental illness (one that substantially impairs the person's thought, perception of reality, emotional process, or judgment or grossly impairs his or her behavior as demonstrated by recent disturbed behavior);
2. was confined in a hospital because of the illness for the three days before being admitted to the residential treatment facility; and
3. without treatment at a residential treatment facility for children and adolescents, would require additional hospital confinement.
MENTAL OR NERVOUS CONDITION
By law, “mental or nervous conditions” are mental disorders, as defined in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders" (DSM-IV-TR).
Such conditions do not include (1) mental retardation, (2) learning disorders, (3) motor skills disorders, (4) communication disorders, (5) caffeine-related disorders, (6) relational problems, and (7) additional conditions that may be a focus of clinical attention that are not otherwise defined as mental disorders in the DSM-IV-TR.
General Coverage Requirement
The law prohibits group policies from establishing any provisions that place a greater financial burden on an insured for the diagnosis or treatment of mental or nervous conditions than for the diagnosis or treatment of medical, surgical, or other physical health conditions.
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