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H.B. 35
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CATASTROPHIC MENTAL HEALTH
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INSURANCE COVERAGE
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2000 GENERAL SESSION
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STATE OF UTAH
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Sponsor: Judy Ann Buffmire
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AN ACT RELATING TO INSURANCE; DEFINING TERMS; REQUIRING THAT HEALTH
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INSURANCE POLICIES APPLY THE SAME LIFETIME LIMITS, ANNUAL PAYMENT
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LIMITS, AND OUT-OF-POCKET LIMITS TO MENTAL HEALTH CONDITIONS AS APPLY
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TO PHYSICAL HEALTH CONDITIONS; PERMITTING THE USE OF MANAGED CARE
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AND OTHER DEVICES TO ENSURE THAT TREATMENT IS MEDICALLY NECESSARY
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AND CLINICALLY APPROPRIATE; APPLYING EXISTING LAWS TO HEALTH
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MAINTENANCE ORGANIZATIONS THAT USE PREFERRED PROVIDER CONTRACTS
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IN PROVIDING MENTAL HEALTH SERVICES; REQUIRING THAT SERVICES BE
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PROVIDED BY LICENSED THERAPISTS AND FACILITIES; PERMITTING EMPLOYERS
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TO SEEK A HARDSHIP EXEMPTION; IMPOSING DUTIES ON THE COMMISSIONER TO
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ADOPT RULES, ENFORCE THE ACT, AND CONDUCT A STUDY; AND PROVIDING A
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REPEAL DATE.
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This act affects sections of Utah Code Annotated 1953 as follows:
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AMENDS:
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63-55-231, as last amended by Chapter 131, Laws of Utah 1999
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ENACTS:
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31A-22-625, Utah Code Annotated 1953
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Be it enacted by the Legislature of the state of Utah:
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Section 1.
Section
31A-22-625
is enacted to read:
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31A-22-625. Catastrophic coverage of mental health conditions.
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(1) As used in this section:
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(a) (i) "Mental health condition" means any condition or disorder involving mental illness
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that falls under any of the diagnostic categories listed in the mental disorders section of the
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International Classification of Diseases, as periodically revised.
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(ii) "Mental health condition" does not include the following when diagnosed as the
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primary or substantial reason or need for treatment:
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(A) marital or family problem;
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(B) social, occupational, religious, or other social maladjustment;
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(C) conduct disorder;
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(D) chronic adjustment disorder;
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(E) psychosexual disorder;
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(F) chronic organic brain syndrome;
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(G) personality disorder;
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(H) developmental disorder or learning disability; or
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(I) mental retardation.
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(b) (i) "Rate, term, or condition" means any lifetime limit, annual payment limit, episodic
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limit, inpatient or outpatient service limit, and out-of-pocket limit.
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(ii) "Rate, term, or condition" does not include any deductible, copayment, or coinsurance
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prior to reaching any maximum out-of-pocket limit.
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(iii) Out-of-pocket expenses for mental health conditions and physical health conditions
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shall apply equally to any out-of-pocket limit within a policy or contract.
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(2) This section shall apply to:
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(a) health insurance policies and health maintenance organization contracts issued or
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renewed after January 1, 2001; and
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(b) health plans, as a matter of contract, that the state offers to its employees after July 1,
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2001.
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(3) Except as provided in Subsection (5), a policy or contract:
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(a) shall provide coverage for the diagnosis and treatment of mental health conditions; and
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(b) may not establish any rate, term, or condition that places a greater financial burden on
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an insured for the diagnosis and treatment of a mental health condition than for the diagnosis and
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treatment of a covered physical health condition.
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(4) (a) A policy or contract may provide coverage for the diagnosis and treatment of
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mental health conditions through a managed care organization or system, regardless of whether
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the policy or contract uses a managed care organization or system for the treatment of physical
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health conditions, provided that the managed care organization or system is in compliance with
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the rules adopted by the commissioner pursuant to Subsection (7)(b).
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(b) Notwithstanding Sections
31A-8-103
,
31A-22-618
, and any other provision of this
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title, a health maintenance organization contract shall be subject to Sections
31A-22-617
and
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31A-22-618
in providing coverage for the diagnosis and treatment of mental health conditions to
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the extent that the contract uses preferred health care provider contracts to provide such coverage.
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(c) Nothing in this section may be construed as prohibiting an insurer from managing the
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provision of covered benefits for mental health conditions to that which is medically necessary and
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clinically appropriate.
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(d) To be eligible for coverage under this section, a diagnosis or treatment of a mental
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health condition must be rendered:
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(i) by a mental health therapist as defined in Section
58-60-102
; or
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(ii) in a health care facility licensed or otherwise authorized to provide mental health
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services pursuant to Title 26, Chapter 21, Health Care Facility Licensing and Inspection Act, or
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Title 62A, Chapter 2, Licensure of Programs and Facilities, that provides a program for the
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treatment of a mental health condition pursuant to a written plan.
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(5) (a) An employer that provides a policy or contract to two or more employees that is
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subject to this section may request a hardship exemption from the commissioner.
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(b) The commissioner may only grant a hardship exemption if the employer shows by clear
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and convincing evidence that compliance with this section over the course of 12 or more months
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has put the continued viability of the employer's business into question.
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(c) Administrative proceedings held in relation to this Subsection (5) shall comply with
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Section
31A-2-203.5
.
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(6) The commissioner may disapprove any policy or contract that the commissioner
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determines to be inconsistent with the provisions of this section.
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(7) The commissioner shall adopt rules to ensure that:
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(a) timely and appropriate access to mental health treatment is available; and
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(b) administrative and clinical protocols do not serve to reduce access to medically
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necessary and clinically appropriate mental health treatment for any insured.
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(8) (a) The commissioner shall perform a study before November 1, 2004, to assess the
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impact of this section on insurers, employers, providers, and consumers of mental health services.
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(b) The commissioner shall report the findings of the study before November 1, 2004, to:
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(i) the Health and Human Services Interim Committee; and
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(ii) the Business, Labor, and Economic Development Interim Committee.
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(9) Nothing in this section may be construed as restricting the ability of an insurer to offer
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greater coverage or benefits for the diagnosis and treatment of mental health conditions than is
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required by this section.
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(10) This section shall be repealed in accordance with Section
63-55-231
.
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Section 2.
Section
63-55-231
is amended to read:
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63-55-231. Repeal dates, Title 31A.
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(1) Section
31A-2-208.5
, Comparison tables, is repealed July 1, 2005.
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(2) Section
31A-22-315
, Motor Vehicle Insurance Reporting, is repealed July 1, 2000.
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(3) Title 31A, Chapter 31, Insurance Fraud Act, is repealed July 1, 2007.
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(4) Section
31A-22-625
, Catastrophic Coverage of Mental Health Conditions, is repealed
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July 1, 2011.
Legislative Review Note
as of 1-7-00 11:47 AM
A limited legal review of this legislation raises no obvious constitutional or statutory concerns.