CHAPTER 275

FORMERLY

HOUSE BILL NO. 156

AS AMENDED BY

HOUSE AMENDMENT NO. 2 AS AMENDED BY HOUSE AMENDMENT NO. 1 TO HOUSE AMENDMENT NO. 2; HOUSE AMENDMENT NOS. 3,4 AND 6 AND SENATE AMENDMENT NO. 1

AN ACT TO AMEND TITLE 18 OF THE DELAWARE CODE RELATING TO HEALTH INSURANCE.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF DELAWARE:

Section 1. Amend Chapter 33 of Title 18 of the Delaware Code by adding a new section thereto to read as follows:

"§3343. Insurance Coverage for Serious Mental Illness.

a. Definitions. For the purposes of this section, the following words and phrases shall have the following meanings:

1. 'Carrier' means any entity that provides health insurance in this State. For the purposes of this section, carrier includes an insurance company, health service corporation, health maintenance organization and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation.

2. 'Health benefit plan' means any hospital or medical policy or certificate, major medical expense insurance, health service corporation subscriber contract or health maintenance organization subscriber contract. Health benefit plan does not include accident-only, credit, dental, vision, Medicaid plans, long-term care or disability income insurance, coverage issued as a supplement to liability insurance, worker's compensation or similar insurance or automobile medical payment insurance.

'Health benefit plan' shall not include policies or certificates of specified disease, hospital confinement indemnity or limited benefit health insurance, provided that the carrier offering such policies or certificates complies with the following:

a. The carrier files on or before March 1 of each year a certification with the Commissioner that contains the statement and information described in paragraph b. of this subdivision.

b. The certification required in paragraph a. of this subdivision shall contain the following:

1. A statement from the carrier certifying that policies or certificates described in this subdivision are being offered and marketed as supplemental health insurance and not as a substitute for hospital or medical expense insurance or major medical expense insurance.

2. A summary description of each policy or certificate described in this subdivision, including the average annual premium rates (or range of premium rates in cases where premiums vary by age, gender or other factors) charged for such policies and certificates in this State.

c. In the case of a policy or certificate that is described in this subdivision and that is offered for the first time in this State on or after January 1, 1999, the carrier files with the Commissioner the information and statement required in paragraph b. of this subdivision at least 30 days prior to the date such a policy or certificate is issued or delivered in this State.

3. 'Serious mental illness' means any of the following biologically based mental illnesses: schizophrenia; bipolar disorder; obsessive-compulsive disorder; major depressive disorder; panic disorder; anorexia nervosa; bulimia nervosa; schizo affective disorder and delusional disorder. In determining whether this Section applies, the diagnostic criteria set out in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders shall be utilized to determine whether a beneficiary of a health benefit plan is suffering from a Serious Mental Illness. This Section shall not apply to coverage or benefits for the treatment of alcoholism or other drug dependencies. Further, this Section shall not apply to coverage or benefits for the treatment of alcoholism or other drug dependencies through the diagnosis or treatment of one or more serious mental illnesses.

b. Coverage of Serious Mental Illnesses. Carriers shall provide coverage for serious mental illnesses in all health benefit plans delivered or issued for delivery in this State. Subject to the provisions of subsections a, and c through h of this Section, no carrier may issue for delivery, or deliver, in this State any health benefit plan containing terms that place a greater financial burden on an insured for covered services provided in the diagnosis and treatment of a serious mental illness than for covered services provided in the diagnosis and treatment of any other illness or disease covered by the health benefit plan. By way of example, such terms include deductibles, co-pays, monetary limits, co-insurance factors, limits in the numbers of visits, limits in the length of inpatient stays, durational limits or limits in the coverage of prescription medicines.

c. Eligibility for Coverage. A health benefit plan may condition coverage of services provided in the diagnosis and treatment of a serious mental illness on the further requirements that the service(s): (1) must be rendered by a mental health professional licensed or certified by the State Board of Licensing or in a mental health facility licensed by the State or substantially similar licensing entities in other states (2) must be medically necessary and; (3) must be covered services subject to any administrative requirements of the health benefit plan. A health benefit plan may further condition coverage of services provided in the diagnosis and treatment of a serious mental illness in the same manner and to the same extent as coverage for all other illnesses and diseases is conditioned. Such conditions may include, by way of example, and not by way of limitation, precertification and referral requirements.

d. Benefit Management. A carrier may, directly or by contract with another qualified entity, manage the benefit prescribed by subsection b in order to limit coverage of services provided in the diagnosis and treatment of a serious mental illness to those services that are deemed medically necessary. The management of benefits for serious mental illnesses may be by methods used for the management of benefits provided for other medical conditions, or may be by management methods unique to mental health benefits. Such may include, by way of example and not limitation; pre-admission screening, prior authorization of services, utilization review and the development and monitoring of treatment plans.

This Section shall not be interpreted to require a carrier to employ the same benefit management procedures for serious mental illnesses that are employed for the management of other illnesses or diseases covered by the health benefit plan or to require parity or equivalence in the rate, or dollar value of, claims denied.

e. Exclusions. This Section shall not apply to plans or policies not within the definition of health benefit plan, as set out in subsection a.2, above.

f. Out of Network Services. Where a health benefit plan provides benefits for the diagnosis and treatment of serious mental illnesses within a network of providers and where a beneficiary of the health benefit plan obtains services consisting of diagnosis and treatment of a serious mental illness outside of the network of providers, the provisions of this section shall not apply. The health benefit plan may contain terms and conditions applicable to out of network services without reference to the provisions of this section.'

Section 2. Amend Chapter 35 of Title 18 of the Delaware Code by adding a new section thereto to read as follows:

'§3566. Insurance Coverage for Serious Mental Illness.'

a. Definitions. For the purposes of this section, the following words and phrases shall have the following meanings:

1. 'Carrier' means any entity that provides health insurance in this State. For the purposes of this section, carrier includes an insurance company, health service corporation, health maintenance organization and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation.

2. 'Health benefit plan' means any hospital or medical policy or certificate, major medical expense insurance, health service corporation subscriber contract or health maintenance organization subscriber contract. Health benefit plan does not include accident-only, credit, dental, vision, Medicaid plans, long-term care or disability income insurance, coverage issued as a supplement to liability insurance, worker's compensation or similar insurance or automobile medical payment insurance.

'Health benefit plan' shall not include policies or certificates or specified disease, hospital confinement indemnity or limited benefit health insurance, provided that the carrier offering such policies or certificates complies with the following:

a. The carrier files on or before March 1 of each year a certification with the Commissioner that contains the statement and information described in paragraph b. of this subdivision.

b. The certification required in paragraph a. of this subdivision shall contain the following:

1. A statement from the carrier certifying that policies or certificates described in this subdivision are being offered and marketed as supplemental health insurance and not as a substitute for hospital or medical expense insurance or major medical expense insurance.

2. A summary description of each policy or certificate described in this subdivision, including the average annual premium rates (or range of premium rates in cases where premiums vary by age, gender or other factors) charged for such policies and certificates in this State.

c. In the case of a policy or certificate that is described in this subdivision and that is offered for the first time in this State on or after January 1, 1999, the carrier files with the Commissioner the information and statement required in paragraph b. of this subdivision at least 30 days prior to the date such a policy or certificate is issued or delivered in this State.

3. 'Serious mental illness' means any of the following biologically based mental illnesses: schizophrenia; bipolar disorder, obsessive-compulsive disorder, major depressive disorder; panic disorder, anorexia nervosa; bulimia nervosa; schizo affective disorder and delusional disorder. In determining whether this Section applies the diagnostic criteria set out in the most recent edition of the Diagnostic and Statistical Manual shall be utilized to determine whether a beneficiary of a health benefit plan is suffering from a Serious Mental Illness. This Section shall not apply, or be interpreted to apply, to coverage or benefits for the treatment of alcoholism or other drug dependencies. Further, this Section shall not apply to coverage or benefits for the treatment of alcoholism or other drug dependencies through the diagnosis or treatment of one or more serious mental illnesses.

b. Coverage of Serious Mental Illness. Carriers shall provide coverage of serious mental illnesses in all health benefit plans delivered or issued for delivery in this State. Subject to the provisions of subsections a, and c through h of this Section, no carrier may issue for delivery, or deliver, in this State any health benefit plan containing terms that place a greater financial burden on an insured for covered services provided in the diagnosis and treatment of a serious mental illness than for covered services provided in the diagnosis and treatment of any other illness or disease covered by the health benefit plan. By way of example, such terms include deductibles, co-pays, monetary limits, co-insurance factors, limits in the numbers of visits, limits in the length of inpatient stays, durational limits or limits in the coverage of prescription medicines.

c. Eligibility for Coverage. A health benefit plan may condition coverage of services provided in the diagnosis and treatment of a serious mental illness on the further requirements that the service(s): (1) must be rendered by a mental health professional licensed or certified by the State Board of Licensing or in a mental health facility licensed by the State or substantially similar licensing entities in other states (2) must be medically necessary and; (3) must be covered services subject to any administrative requirements of the health benefit plan. A health benefit plan may further condition coverage of services provided in the diagnosis and treatment of a serious mental illness in the same manner and to the same extent as coverage for all other illnesses and diseases is conditioned. Such conditions may include, by way of example and not by way of limitation, precertification and referral requirements.

d. Benefit Management. A carrier may, directly or by contract with another qualified entity, manage the benefit prescribed by subsection b in order to limit coverage of services provided in the diagnosis and treatment of a serious mental illness to those services that are deemed medically necessary. The management of benefits for serious mental illnesses may be by methods used for the management of benefits provided for other medical conditions, or may be by management methods unique to mental health benefits. Such may include, by way of example and not limitation; pre-admission screening, prior authorization of services, utilization review and the development and monitoring of treatment plans.

This Section shall not be interpreted to require a carrier to employ the same benefit management procedures for serious mental illnesses that are employed for the management of other illnesses or diseases covered by the health benefit plan or to require parity or equivalence in the rate, or dollar value of, claims denied.

e. Exclusions. This Section shall not apply to plans or policies not within the definition of health benefit plan, as set out in subsection a.2, above.

f. Out of Network Services. Where a health benefit plan provides benefits for the diagnosis and treatment of serious mental illnesses within a network of providers and where a beneficiary of the health benefit plan obtains services consisting of diagnosis and treatment of a serious mental illness outside of the network of providers, the provisions of this section shall not apply. The health benefit plan may contain terms and conditions applicable to out of network services without reference to the provisions of this section."

Section 3. Applicability. This act shall be effective and shall apply only to policies issued for delivery or delivered in Delaware and which cover residents of the State of Delaware, or employees of employers located in Delaware and their dependents.

Section 4. Effective Date. This act will become effective on January 1, 1999 and will apply to policies delivered or renewed in Delaware on or after January I, 1999.

Section 5. On or before January 15, 2001, a panel comprised of the Secretary of the Department of Health and Social Services or his/her designee; the Chair of the Health Care Commission or his/her designee; the Director of the Division of Alcoholism, Drug Abuse and Mental Health or his/her designee; the Insurance Commissioner or his/her designee; the State Budget Director or his/her designee; the Controller General or his/her designee; a representative of the Delaware State Chamber of Commerce; a member of the House and Senate or his/her designee; a mental health professional, to be appointed by the Governor; a member of the managed care industry, to be appointed by the Governor; and two public consumers, to be appointed by the Governor, shall report to the General Assembly on the following:

(i) An estimate of the impact of this Act on health insurance costs.

(ii) A review of the use of mental health insurance benefits by the insured and the impact on the work place.

(iii) Actions taken to assure that health insurance plans are in compliance with this Act and that quality and access to treatment for mental health conditions are not compromised by providing financial parity for such coverage.

(iv) Identification of any segments of Delaware's population that may be excluded from access to treatment for mental health conditions at the level provided by this Act.

(v) Analysis of the use of medical services resulting from the provision of access to mental health treatment as provided by this Act.

This collection and analysis of data shall be the responsibility of the Delaware Health Care Commission and become part of the Delaware Health Information Network.

Section 6. Sunset. This Act shall sunset and automatically be repealed, unless reenacted on or before June 30, 2002.

Section 7. Severability. If any provision of this Act or the application thereof to any person or circumstance is held invalid, such invalidity shall not affect other provisions or applications of the Act which can be given effect without the invalid provision or applications, and, to that end, the provisions of this Act are declared to be severable.

Approved May 14, 1998