§ 514C.22 — Biologically based mental illness coverage

Iowa § 514C.22

• Jurisdiction: Iowa
• Title XIII: COMMERCE
• Ch. 514C: SPECIAL HEALTH AND ACCIDENT INSURANCE COVERAGES

Text

1. Notwithstanding the uniformity of treatment requirements of section 514C.6, a group
§514C.22, SPECIAL HEALTH AND ACCIDENT INSURANCE COVERAGES 20
policy, contract, or plan providing for third-party payment or prepayment of health, medical,
and surgical coverage benefits issued by a carrier, as defined in section 513B.2, shall provide
coverage benefits for treatment of a biologically based mental illness if either of the following
is satisfied:
a. The policy, contract, or plan is issued to an employer who on at least fifty percent of
the employer’s working days during the preceding calendar year employed more than fifty
full-time equivalent employees. In determining the number of full-time equivalent employees
of an employer, employers who are affiliated or who are able to file a consolidated tax return
for purposes of state taxation shall be considered one employer.
b. The policy, contract, or plan is issued to a small employer as defined in section 513B.2,
and such policy, contract, or plan provides coverage benefits for the treatment of mental
illness.
2. Notwithstanding the uniformity of treatment requirements of section 514C.6, a plan
established pursuant to chapter 509A for public employees shall provide coverage benefits
for treatment of a biologically based mental illness.
3. For purposes of this section, “biologically based mental illness” means the following
psychiatric illnesses:
a. Schizophrenia.
b. Bipolar disorders.
c. Major depressive disorders.
d. Schizo-affective disorders.
e. Obsessive-compulsive disorders.
f. Pervasive developmental disorders.
g. Autism spectrum disorder.
4. The definitions of the biologically based mental illnesses identified in subsection 3 shall
be consistent with definitions provided in the most recent edition of the American psychiatric
association’s diagnostic and statistical manual of mental disorders, as such definitions may
be amended from time to time.
5. This section shall not apply to accident-only, specified disease, short-term hospital
or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement,
long-term care, basic hospital and medical-surgical expense coverage as defined by the
commissioner, disability income insurance coverage, coverage issued as a supplement to
liability insurance, workers’ compensation or similar insurance, or automobile medical
payment insurance, or individual accident and sickness policies issued to individuals or to
individual members of a member association.
6. A carrier or plan established pursuant to chapter 509A may manage the benefits
provided through common methods, including but not limited to providing payment of
benefits or providing care and treatment under a capitated payment system, prospective
reimbursement rate system, utilization control system, incentive system for the use of least
restrictive and least costly levels of care, a preferred provider contract limiting choice of
specific providers, or any other system, method, or organization designed to assure services
are medically necessary and clinically appropriate.
7. a. A group policy, contract, or plan covered under this section shall not impose an
aggregate annual or lifetime limit on biologically based mental illness coverage benefits
unless the policy, contract, or plan imposes an aggregate annual or lifetime limit on
substantially all health, medical, and surgical coverage benefits.
b. A group policy, contract, or plan covered under this section that imposes an aggregate
annual or lifetime limit on substantially all health, medical, and surgical coverage benefits
shall not impose an aggregate annual or lifetime limit on biologically based mental illness
coverage benefits that is less than the aggregate annual or lifetime limit imposed on
substantially all health, medical, and surgical coverage benefits.
c. Notwithstanding paragraphs “a” and “b”, a group policy, contract, or plan covered
under this section shall not impose an aggregate annual or lifetime limit on biologically
based mental illness coverage benefits for autism spectrum disorder.
8. A group policy, contract, or plan covered under this section shall at a minimum allow
for thirty inpatient days and fifty-two outpatient visits annually, and shall not limit the
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number of outpatient visits a covered individual may have with a practitioner for applied
behavior analysis under section 514C.31, or with an autism service provider for treatment
of autism spectrum disorder under section 514C.28. The policy, contract, or plan may also
include deductibles, coinsurance, or copayments, provided the amounts and extent of such
deductibles, coinsurance, or copayments applicable to other health, medical, or surgical
services coverage under the policy, contract, or plan are the same. It is not a violation of this
section if the policy, contract, or plan excludes entirely from coverage benefits for the cost
of providing the following:
a. Marital, family, educational, developmental, or training services.
b. Care that is substantially custodial in nature.
c. Services and supplies that are not medically necessary or clinically appropriate.
d. Experimental treatments.
9. This section applies to third-party payment provider policies or contracts and to plans
established pursuant to chapter 509A that are delivered, issued for delivery, continued, or
renewed in this state on or after January 1, 2006.