§1043. Severe mental illness and other mental disorders; policy provisions; minimum
requirements; group, blanket, and association policies
A.
(1)(a) Any hospital, health, or medical expense insurance policy, hospital or
medical service contract, employee welfare benefit plan, contract or other agreement with
a health maintenance organization or a preferred provider organization, health and accident
insurance policy, or any other insurance contract of this type in this state, including a group
insurance plan, a self-insurance plan, and the Office of Group Benefits programs, delivered
or issued for delivery in this state on or after January 1, 2000, shall include benefits payable
for the treatment of severe mental illness under the same circumstances and conditions or
greater as benefits are
Free access — add to your briefcase to read the full text and ask questions with AI
§1043. Severe mental illness and other mental disorders; policy provisions; minimum
requirements; group, blanket, and association policies
A.(1)(a) Any hospital, health, or medical expense insurance policy, hospital or
medical service contract, employee welfare benefit plan, contract or other agreement with
a health maintenance organization or a preferred provider organization, health and accident
insurance policy, or any other insurance contract of this type in this state, including a group
insurance plan, a self-insurance plan, and the Office of Group Benefits programs, delivered
or issued for delivery in this state on or after January 1, 2000, shall include benefits payable
for the treatment of severe mental illness under the same circumstances and conditions or
greater as benefits are paid under those policies, contracts, benefit plans, agreements, or
programs for all other diagnoses, illnesses, or accidents.
(b) For purposes of this Section, "severe mental illness" shall include any of the
following diagnosed severe mental illnesses:
(i) Schizophrenia or schizoaffective disorder.
(ii) Bipolar disorder.
(iii) Repealed by Acts 2008, No. 648, §2.
(iv) Panic disorder.
(v) Obsessive-compulsive disorder.
(vi) Major depressive disorder.
(vii) Anorexia/bulimia.
(viii) Repealed by Acts 2008, No. 648, §2.
(ix) Intermittent explosive disorder.
(x) Posttraumatic stress disorder.
(xi) Psychosis NOS (not otherwise specified) when diagnosed in a child under
seventeen years of age.
(xii) Rett's Disorder.
(xiii) Tourette's Disorder.
(2)(a) Any issuer of a group, blanket, or association policy, contract, benefit plan,
agreement, or program specified in Paragraph (1) of this Subsection shall also offer to the
policyholder an optional provision in the policy, contract, benefit plan, agreement, or
program which states that benefits shall be payable for the treatment of mental disorders
other than severe mental illness as defined in Paragraph (1) under the same circumstances
and conditions as benefits are paid under those policies, contracts, benefit plans, agreements,
or programs for all other diagnoses, illnesses, or accidents.
(b) If the policyholder elects not to purchase this optional coverage, the issuer shall
not be required to notify the policyholder in any renewal, reinstatement, or modified policy,
contract, benefit plan, agreement, or program as to the availability of the optional coverage.
However, the policyholder may request the optional coverage in writing on any anniversary
date of the policy, contract, benefit plan, agreement, or program.
(3)(a) The provisions of this Section shall apply only to group, blanket, and
association policies.
(b) The provisions of this Section shall not apply to health insurance individual
policies or contracts; limited benefit health insurance policies or contracts; and short term
health insurance policies or contracts.
(4) These benefits shall be payable when the treatment or services are rendered by
a physician licensed under the provisions of R.S. 37:1261 et seq., psychologist licensed under
the provisions of R.S. 37:2351 et seq., medical psychologist licensed under the provisions
of R.S. 37:1360.51 et seq., or when the treatment or services are rendered by a licensed
clinical social worker licensed under the provisions of R.S. 37:2701 et seq., who is a member
of a national clinical social work registry.
(5) A policy, contract, benefit plan, agreement, or program shall be in compliance
with the requirements of Paragraph (1) of this Subsection if it includes the following
benefits:
(a) Forty-five inpatient days per covered individual per calendar year. However, a
policy, contract, benefit plan, agreement, or program may provide a method to allow a
covered individual to exchange two days of partial hospitalization or two days of residential
treatment center hospitalization for each inpatient day of treatment.
(b) Fifty-two outpatient visits per covered individual per calendar year, including the
intensive outpatient program. However, a policy, contract, benefit plan, agreement, or
program may provide a method to allow a covered individual to exchange one inpatient day
of treatment for four outpatient visits or exchange four outpatient visits for one inpatient day
of treatment.
B. Whenever any such policies, contracts, programs, or plans provide for the
reimbursement of health-related services that can be lawfully performed by a licensed clinical
social worker, licensed under the provisions of R.S. 37:2701 et seq., the insured or other
person entitled to benefits under such policy, contract, program, or plan shall be entitled to
reimbursement for such services performed by a board-certified social worker
notwithstanding any provisions of the policy, contract, program, or plan to the contrary.
C. No policy, contract, benefit plan, agreement, or program issued or entered into
pursuant to this Section shall contain any provision for a waiting period in excess of sixty
days from its effective date before benefits are payable for the treatment of severe mental
illness or other mental disorders.
D. Nothing in this Section shall be construed to prohibit management of the
provision of benefits for mental disorders through such methods as preadmission screening
prior to the authorization of services or any other mechanism designed to limit coverage for
services for mental disorders only to those deemed medically necessary by a licensed mental
health professional.