§ 26.1-36-09 — Group health policy and health service contract mental disorder coverage

1. An insurance company, nonprofit health service corporation, or health maintenance
organization may not deliver, issue, execute, or renew any health insurance policy or
health service contract on a group or blanket or franchise or association basis unless
the policy or contract provides benefits, of the same type offered under the policy or
contract for other illnesses, for health services to any person covered under the policy
or contract, for the diagnosis, evaluation, and treatment of mental disorder and other
related illness, which benefits meet or exceed the benefits provided in subsection 2.
2. a. The benefits must be provided for each of the following services: inpatient
treatment, treatment by partial hospitalization, residential treatment, and
outpatient treatment.
b. In the case of benefits provided for inpatient treatment, the benefits must be
provided for a minimum of forty-five days of services covered under this section
and section 26.1-36-08 in any calendar year if provided by a hospital as defined
under section 52-01-01 and rules of the department of health and human services
pursuant thereto offering treatment for the prevention or cure of mental disorder
or other related illness. An insurance provider may require an individualized
treatment plan from the inpatient treatment service provider which indicates that
the course of treatment is the most appropriate and least restrictive form of
treatment available in the community.
c. In the case of benefits provided for partial hospitalization, the benefits must be
provided for a minimum of one hundred twenty days of services covered under
this section and section 26.1-36-08 in any calendar year. Partial hospitalization
must be provided by a hospital as defined under section 52-01-01 and rules of
the department of health and human services pursuant thereto or by a state-
operated behavioral health clinic licensed under section 50-06-05.2, offering
treatment for the prevention or cure of mental disorder or other related illness. For
services provided in state-operated behavioral health clinics, charges must be
reasonably similar to the charges for care provided by hospitals as defined in this
subsection.
d. In the case of benefits provided for residential treatment, the benefits must be
provided for a minimum of one hundred twenty days of services covered under
this section in any calendar year. Residential treatment services must be provided
by a hospital as defined under section 52-01-01 and rules of the department of
health and human services; by a state-operated behavioral health clinic licensed
under section 50-06-05.2 offering treatment for the prevention or cure of mental
disorder or other related illness; or by a residential treatment program. For
services provided in a state-operated behavioral health clinic, charges must be
reasonably similar to the charges for care provided by a hospital as defined in this
subsection.

e. Any individual receiving residential treatment services who requires residential
treatment service beyond the minimum of one hundred twenty days may trade
unused inpatient treatment benefits provided for under subdivision b. For the
purpose of computing the period for which benefits are payable, each day of
inpatient treatment is equivalent to two days of treatment by a residential
treatment program; provided, however, that no more than twenty-three days of
the inpatient treatment benefits required by this section may be traded for
residential treatment services.
f. (1) In the case of benefits provided for outpatient treatment, the benefits must
be provided for a minimum of thirty hours for services covered under this
section in any calendar year if the treatment services are provided within the
scope of licensure by a nurse who holds advanced licensure with a scope of
practice within mental health or if the diagnosis, evaluation, and treatment
services are provided within the scope of licensure by a licensed physician,
a licensed psychologist who is eligible for listing on the national register of
health service providers in psychology, a licensed professional clinical
counselor who is qualified in the clinical mental health counseling specialty
in this state, or a licensed independent clinical social worker.
(2) A person who is qualified for third-party payment by the board of social work
examiners on August 1, 1997, is exempt from paragraph 1.
(3) Upon the request of an insurance company, a nonprofit health service
corporation, or a health maintenance organization, the North Dakota board
of social work examiners shall provide to the requesting entity information to
certify that a licensed certified social worker meets the qualifications
required under this section.
(4) The insurance company, nonprofit health service corporation, or health
maintenance organization may not establish a deductible or a copayment for
the first five hours in any calendar year, and may not establish a copayment
greater than twenty percent for the remaining hours. The deductible
limitation of this paragraph does not apply to a high-deductible health plan
used to establish a health savings account pursuant to and as defined in
section 223 of the Internal Revenue Code [26 U.S.C. 223].
(5) If the services are provided by a provider outside a preferred provider
network without a referral from within the network, the insurance company,
nonprofit health service corporation, or health maintenance organization
may establish a copayment greater than twenty percent for only those hours
after the first five hours in any calendar year.
g. "Partial hospitalization" means continuous treatment for at least three hours, but
not more than twelve hours, in any twenty-four-hour period and includes the
medically necessary treatment services provided by licensed professionals under
the supervision of a licensed physician.
h. "Residential treatment" has the same meaning as provided in section 25-03.2-01,
but only applies to individuals under twenty-one years of age.
3. This section does not prevent any insurance company, nonprofit health service
corporation, or health maintenance organization from issuing, delivering, or renewing,
at its option, any policy or contract containing provisions similar to those required by
this section, when the policy or contract is not subject to such provisions.