§ 38a-488a — Mandatory coverage for the diagnosis and treatment of mental or nervous conditions. Exceptions. Benefits payable re type of provider or facility. State's claim against proceeds. Direct reimbursement for certain covered services rendered by certain out-of-network providers.

Connecticut § 38a-488a

• Jurisdiction: Connecticut
• Title 38a: Insurance
• Ch. 700c: Health Insurance

Text

(a) For the purposes of this section: (1) (A) “Mental or nervous conditions” means mental disorders, as defined in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”. (B) “Mental or nervous conditions” does not include (i) intellectual disability, (ii) specific learning disorders, (iii) motor disorders, (iv) communication disorders, (v) caffeine-related disorders, (vi) relational problems, and (vii) other conditions that may be a focus of clinical attention, that are not otherwise defined as mental disorders in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”. (2) “Benefits payable” means the usual, customary and reasonable charges for treatment deemed necessary under generally accepted medical standards, except that in the case of a managed care plan, as defined in section 38a-478 , “benefits payable” means the payments agreed upon in the contract between a managed care organization, as defined in section 38a-478 , and a provider, as defined in section 38a-478 . (3) “Acute treatment services” means twenty-four-hour medically supervised treatment for a substance use disorder, that is provided in a medically managed or medically monitored inpatient facility. (4) “Clinical stabilization services” means twenty-four-hour clinically managed postdetoxification treatment, including, but not limited to, relapse prevention, family outreach, aftercare planning and addiction education and counseling. (b) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for the diagnosis and treatment of mental or nervous conditions. Benefits payable include, but need not be limited to: (1) General inpatient hospitalization, including in state-operated facilities; (2) Medically necessary acute treatment services and medically necessary clinical stabilization services; (3) General hospital outpatient services, including at state-operated facilities; (4) Psychiatric inpatient hospitalization, including in state-operated facilities; (5) Psychiatric outpatient hospital services, including at state-operated facilities; (6) Intensive outpatient services, including at state-operated facilities; (7) Partial hospitalization, including at state-operated facilities; (8) Intensive, home-based or evidence-based services designed to address specific mental or nervous conditions in a child or adolescent; (9) Evidence-based family-focused therapy that specializes in the treatment of juvenile substance use disorders; (10) Short-term family therapy intervention; (11) Nonhospital inpatient detoxification; (12) Medically monitored detoxification; (13) Ambulatory detoxification; (14) Inpatient services at psychiatric residential treatment facilities; (15) Rehabilitation services provided in residential treatment facilities, general hospitals, psychiatric hospitals or psychiatric facilities; (16) Observation beds in acute hospital settings; (17) Psychological and neuropsychological testing conducted by an appropriately licensed health care provider; (18) Trauma screening conducted by a licensed behavioral health professional; (19) Depression screening, including maternal depression screening, conducted by a licensed behavioral health professional; and (20) Substance use screening conducted by a licensed behavioral health professional. (c) No such policy shall establish any terms, conditions or benefits that place a greater financial burden on an insured for access to diagnosis or treatment of mental or nervous conditions than for diagnosis or treatment of medical, surgical or other physical health conditions, or prohibit an insured from obtaining or a health care provider from being reimbursed for multiple screening services as part of a single-day visit to a health care provider or a multicare institution, as defined in section 19a-490 . (d) In the case of benefits payable for the services of a licensed physician, such benefits shall be payable for the same services when such services are lawfully rendered by a psychologist licensed under the provisions of chapter 383 or by such a licensed psychologist in a licensed hospital or clinic or an advanced practice registered nurse licensed under the provisions of chapter 378. (e) In the case of benefits payable for the services of a licensed physician or psychologist, such benefits shall be payable for the same services when such services are rendered by: (1) A clinical social worker who is licensed under the provisions of chapter 383b and who has passed the clinical examination of the American Association of State Social Work Boards and has completed at least two thousand hours of post-master's social work experience in a nonprofit agency qualifying as a tax-exempt organization under Section 501(c) of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as from time to time amended, in a municipal, state or federal agency or in an institution licensed by the Department of Public Health under section 19a-490 ; (2) A social worker who was certified as an independent social worker under the provisions of chapter 383b prior to October 1, 1990; (3) A licensed marital and family therapist who has completed at least two thousand hours of post-master's marriage and family therapy work experience in a nonprofit agency qualifying as a tax-exempt organization under Section 501(c) of the Internal Revenue Code of 1986 or any subsequent corresponding internal revenue code of the United States, as from time to time amended, in a municipal, state or federal agency or in an institution licensed by the Department of Public Health under section 19a-490 ; (4) A marital and family therapist who was certified under the provisions of chapter 383a prior to October 1, 1992; (5) A licensed alcohol and drug counselor, as defined in section 20-74s , or a certified alcohol and drug counselor, as defined in section 20-74s ; (6) A licensed professional counselor; or (7) An advanced practice registered nurse licensed under the provisions of chapter 378. (f) (1) In the case of benefits payable for the services of a licensed physician, such benefits shall be payable for (A) services rendered in a child guidance clinic or residential treatment facility by a person with a master's degree in social work or by a person with a master's degree in marriage and family therapy under the supervision of a psychiatrist, physician, licensed marital and family therapist, or licensed clinical social worker who is eligible for reimbursement under subdivisions (1) to (4), inclusive, of subsection (e) of this section; (B) services rendered in a residential treatment facility by a licensed or certified alcohol and drug counselor who is eligible for reimbursement under subdivision (5) of subsection (e) of this section; (C) services rendered in a residential treatment facility by a licensed professional counselor who is eligible for reimbursement under subdivision (6) of subsection (e) of this section; or (D) services rendered in a residential treatment facility by a licensed advanced practice registered nurse who is eligible for reimbursement under subdivision (7) of subsection (e) of this section. (2) In the case of benefits payable for the services of a licensed psychologist under subsection (e) of this section, such benefits shall be payable for (A) services rendered in a child guidance clinic or residential treatment facility by a person with a master's degree in social work or by a person with a master's degree in marriage and family therapy under the supervision of such licensed psychologist, licensed marital and family therapist, or licensed clinical social worker who is eligible for reimbursement under subdivisions (1) to (4), inclusive, of subsection (e) of this section; (B) services rendered in a residential treatment facility by a licensed or certified alcohol and drug counselor who is eligible for reimbursement under subdivision (5) of subsection (e) of this section; (C) services rendered in a residential treatment facility by a licensed professional counselor who is eligible for reimbursement under subdivision (6) of subsection (e) of this section; or (D) services rendered in a residential treatment facility by a licensed advanced practice registered nurse who is eligible for reimbursement under subdivision (7) of subsection (e) of this section. (g) In the case of benefits payable for the service of a licensed physician practicing as a psychiatrist or a licensed psychologist, under subsection (e) of this section, such benefits shall be payable for outpatient services rendered (1) in a nonprofit community mental health center, as defined by the Department of Mental Health and Addiction Services, in a nonprofit licensed adult psychiatric clinic operated by an accredited hospital or in a residential treatment facility; (2) under the supervision of a licensed physician practicing as a psychiatrist, a licensed psychologist, a licensed marital and family therapist, a licensed clinical social worker, a licensed or certified alcohol and drug counselor, a licensed professional counselor or a licensed advanced practice registered nurse who is eligible for reimbursement under subdivisions (1) to (7), inclusive, of subsection (e) of this section; and (3) within the scope of the license issued to the center or clinic by the Department of Public Health or to the residential treatment facility by the Department of Children and Families. (h) Except in the case of emergency services, services rendered to an insured at an urgent crisis center, as defined in section 38a-477aa , or services for which an individual has been referred by a physician or an advanced practice registered nurse affiliated with a health care center, nothing in this section shall be construed to require a health care center to provide benefits under this section through facilities that are not affiliated with the health care center. (i) In the case of any person admitted to a state institution or facility administered by the Department of Mental Health and Addiction Services, Department of Public Health, Department of Children and Families or the Department of Developmental Services, the state shall have a lien upon the proceeds of any coverage available to such person or a legally liable relative of such person under the terms of this section, to the extent of the per capita cost of such person's care. Except in the case of emergency services, the provisions of this subsection shall not apply to coverage provided under a managed care plan, as defined in section 38a-478 . (j) Reimbursement for covered services rendered in this state by an out-of-network health care provider for the diagnosis or treatment of a substance use disorder shall be paid under the insured's individual health insurance policy directly to the provider if the provider is otherwise eligible for reimbursement for such services. The insured who received such services shall be deemed to have made an assignment to such provider of such insured's coverage reimbursement benefits and other rights under the policy. In no event shall such provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from or have any recourse against the insured for such services, except that such provider may collect any copayments, deductibles or other out-of-pocket expenses that the insured is required to pay under the policy. See Sec. 38a-514 for similar provisions re group policies.

Legislative History

(June 18 Sp. Sess. P.A. 97-8, S. 63, 88; P.A. 99-284, S. 27, 60; P.A. 00-135, S. 10, 21; P.A. 02-24, S. 6; P.A. 07-73, S. 2(a); P.A. 12-145, S. 45; P.A. 13-84, S. 3; 13-139, S. 33; P.A. 14-235, S. 57; P.A. 15-226, S. 1; June Sp. Sess. P.A. 15-5, S. 43, 44; P.A. 17-9, S. 3; 17-157, S. 1; June Sp. Sess. P.A. 17-2, S. 202; P.A. 18-68, S. 10; P.A. 19-98, S. 8; P.A. 22-47, S. 43, 53; P.A. 24-24, S. 29.) History: June 18 Sp. Sess. P.A. 97-8 effective July 1, 1997; P.A. 99-284 rewrote Subsec. (a) and referenced Subdivs. (1), (2), (4), (11) and (12) of Sec. 38a-469, deleted reference to biologically-based mental or nervous conditions and definition thereof and replaced with provision for coverage of the diagnosis and treatment of mental or nervous conditions, and defined “mental or nervous conditions”, added new Subsec. (b) re prohibition on terms, conditions or benefits that place a greater financial burden on insured re mental or nervous conditions than for other conditions, added new Subsec. (c) re benefits payable when rendered by a psychologist, added new Subsec. (d) re benefits payable for enumerated providers, added new Subsec. (e) to define “covered expenses”, added new Subsec. (f) re benefits payable for services rendered in certain facilities, added new Subsec. (g) re certain outpatient benefits, added new Subsec. (h) re benefits provided by a health care center, and added new Subsec. (i) re state liens against certain coverage proceeds, effective January 1, 2000; P.A. 00-135 reorganized section and added provisions re licensed professional counselors, effective May 26, 2000; P.A. 02-24 deleted “the” re “post-master's social work experience” in Subsec. (d)(1) and (3); pursuant to P.A. 07-73 “Department of Mental Retardation” was changed editorially by the Revisors to “Department of Developmental Services”, effective October 1, 2007; P.A. 12-145 amended Subsec. (a) to delete “on or after January 1, 2000”, effective June 15, 2012; P.A. 13-84 amended Subsec. (a) by adding provision re coverage for insured diagnosed with autism spectrum disorder prior to release of the fifth edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”, effective June 5, 2013; P.A. 13-139 amended Subsec. (a)(1) by substituting “intellectual disability” for “mental retardation”; P.A. 14-235 amended Subsec. (a) to replace “disability” with “disabilities” in Subdiv. (1), add “specific” in Subdiv. (2), delete “skills” in Subdiv. (3) and replace “additional” with “other” in Subdiv. (7); P.A. 15-226 amended Subsec. (a) by deleting provisions re insurance policy and coverage for insured diagnosed with autism spectrum disorder prior to release of 5th edition of American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”, adding definitions of “benefits payable”, “acute treatment services” and “clinical stabilization services”, and making technical changes, added new Subsec. (b) re coverage requirements, redesignated existing Subsec. (b) as Subsec. (c) and amended same by adding provision re policy not to prohibit insured from obtaining or health care provider from being reimbursed for multiple screening services, redesignated existing Subsec. (c) as Subsec. (d), redesignated existing Subsec. (d) as Subsec. (e) and amended same by adding Subdiv. (7) re advanced practice registered nurse, deleted former Subsec. (e) re definition of “covered expenses”, and made conforming changes in Subsecs. (f) and (g), effective January 1, 2016; June Sp. Sess. P.A. 15-5 amended Subsec. (b) by deleting reference to problematic parenting practices and other family and educational challenges in Subdiv. (9), deleting former Subdiv. (10) re coverage for intensive, family-based and community-based treatment programs, redesignating existing Subdiv. (11) as Subdiv. (10) and amending same to delete “and delinquency”, redesignating existing Subdiv. (12) as Subdiv. (11) and amending same to delete provision re juvenile diversion programs, deleting former Subdivs. (13), (14) and (19) re coverage for other home-based therapeutic interventions for children, chemical maintenance treatment and extended day treatment programs, and redesignating existing Subdivs. (15) to (18) and (20) to (25) as Subdivs. (12) to (21), effective January 1, 2016, and further amended Subsec. (b) by adding Subdivs. (22) to (25) re coverage for intensive, family-based and community-based treatment programs, other home-based therapeutic interventions for children, chemical maintenance treatment and extended day treatment programs, effective January 1, 2017; P.A. 17-9 amended Subsec. (a)(1)(A) by replacing “disabilities” with “disability”; P.A. 17-157 added Subsec. (j) re reimbursement to out-of-network health care provider for diagnosis or treatment of substance use disorder, effective January 1, 2018; June Sp. Sess. P.A. 17-2 amended Subsec. (b) by deleting former Subdiv. (8) re maternal, infant and early childhood home visitation services, redesignating existing Subdivs. (9) to (21) as Subdivs. (8) to (20) and deleting former Subdivs. (22) to (25) re intensive, family-based and community-based treatment programs, other home-based therapeutic interventions for children, chemical maintenance treatment and extended day treatment programs, respectively, effective October 31, 2017; P.A. 18-68 made a technical change in Subsec. (e)(7); P.A. 19-98 amended Subsecs. (d), (g)(2) and (h) by adding references to advanced practice registered nurse, amended Subsec. (f)(1) and (2) by adding Subpara. (D) re services rendered in residential treatment facility by an advanced practice registered nurse and made technical and conforming changes; P.A. 22-47 amended Subsec. (a) by making technical changes, designating existing provisions as Subdiv. (1)(A) and (B), designating existing Subparas. (A) to (G) as clauses (i) to (vii), amended Subsec. (b)(8) by adding “or evidence-based” and “or adolescent”, and amended Subsec. (h) by adding urgent crisis center services as an exception, effective January 1, 2023; P.A. 24-24 made technical changes in Subsec. (b)(19) and (20).