PRINTER'S NO. 1666
No. 1448 Session of 1991
INTRODUCED BY MICHLOVIC, DURHAM, MURPHY, DeWEESE, CAPPABIANCA,
KOSINSKI, FAJT, BELFANTI, RITTER, BLAUM, KENNEY, GEIST,
TIGUE, STEIGHNER, FLICK, FOX, MARKOSEK, JOHNSON, MELIO,
PRESTON, THOMAS, COWELL, DALEY, VEON, JAMES, DeLUCA, HECKLER,
E. Z. TAYLOR, PETRONE, TRELLO, KUKOVICH, BISHOP, JOSEPHS,
McGEEHAN, NAHILL, BILLOW, BELARDI, PISTELLA, TANGRETTI,
VAN HORNE AND LEVDANSKY, MAY 15, 1991
REFERRED TO COMMITTEE ON INSURANCE, MAY 15, 1991
AN ACT
1 Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
2 act relating to insurance; amending, revising, and
3 consolidating the law providing for the incorporation of
4 insurance companies, and the regulation, supervision, and
5 protection of home and foreign insurance companies, Lloyds
6 associations, reciprocal and inter-insurance exchanges, and
7 fire insurance rating bureaus, and the regulation and
8 supervision of insurance carried by such companies,
9 associations, and exchanges, including insurance carried by
10 the State Workmen's Insurance Fund; providing penalties; and
11 repealing existing laws," providing for optional benefits for
12 the treatment of mental disorders.
13 The General Assembly of the Commonwealth of Pennsylvania
14 hereby enacts as follows:
15 Section 1. The act of May 17, 1921 (P.L.682, No.284), known
16 as The Insurance Company Law of 1921, is amended by adding an
17 article to read:
18 ARTICLE VI-B.
19 OPTIONAL BENEFITS FOR THE TREATMENT
20 OF MENTAL DISORDERS.
1 Section 601-B. Legislative Intent.--In recognition of the
2 present limitations on flexible treatment of mental disorders
3 under health care benefit plans, the General Assembly declares
4 its intent to encourage the appropriate, individualized, cost-
5 effective treatment of mental disorders. Health care benefits
6 for medically necessary therapeutic treatment options shall be
7 available as an alternative to inpatient care to the extent of
8 the dollar and value-of-service limits of the coverage for
9 mental disorders in the health care benefit plan, so as to
10 assure flexible, effective treatment of mental disorders. To the
11 extent possible, a portion of inpatient benefits shall be
12 preserved. Where consistent with the therapeutic treatment
13 plans, less expensive therapeutic services shall be preferred.
14 Section 602-B. Definitions.--As used in this article the
15 following words and phrases shall have the meanings given to
16 them in this section:
17 "Health care benefit plan." Any health or sickness or
18 accident insurance policy providing hospital or medical or
19 surgical coverage and any subscriber contract or certificate
20 issued by an entity which provides hospital or medical/surgical
21 coverage which is subject to this act, to the act of December
22 29, 1972 (P.L.1701, No.364), known as the "Health Maintenance
23 Organization Act"; to the act of July 29, 1977 (P.L.105, No.38),
24 known as the "Fraternal Benefit Society Code"; or to 40 Pa.C.S.
25 Ch. 61 (relating to hospital plan corporations) or 63 (relating
26 to professional health services plan corporations).
27 "Inpatient services." The provision of necessary therapeutic
28 services twenty-four (24) hours a day in a treatment facility
29 according to individualized treatment plans.
30 "Mental disorder." A clinically significant behavioral or
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1 psychological syndrome or pattern occurring in a person which is
2 associated with a painful symptom; which is associated with
3 impairment in an important area of functioning; which is
4 associated with a significantly increased risk of suffering
5 death, pain, disability or important loss of freedom; and which
6 is considered a manifestation of a behavioral, psychological or
7 biological dysfunction in the person. The term excludes a
8 psychological syndrome or pattern that is merely an expectable
9 response to a particular event; deviant behavior that is not a
10 symptom of a behavioral, psychological or biological
11 dysfunction; and a conflict between an individual and society
12 that is not a symptom of a behavioral, psychological or
13 biological dysfunction. Use of the term does not imply that
14 mental disorders are unrelated to physical or biological factors
15 or processes.
16 "Optional benefits." Outpatient services, partial
17 hospitalization, inpatient services provided in other than
18 hospital settings and other types of services in lieu of
19 inpatient services covered under a health care benefit plan.
20 "Outpatient services." A nonresidential treatment modality
21 which is provided on an ambulatory basis to patients with mental
22 disorders and shall be construed to include necessary
23 therapeutic services carried out according to an individualized
24 treatment plan.
25 "Partial hospitalization services." The provision of
26 necessary therapeutic services to patients according to an
27 individualized treatment plan. Partial hospitalization patients
28 require less than twenty-four (24) hours a day care but more
29 intensive and comprehensive services than are offered in
30 outpatient care. Partial hospitalization is provided on a
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1 planned and regularly scheduled basis for a minimum of three (3)
2 hours but less than twenty-four (24) hours in any one day.
3 "Severe mental disorder." Acute, chronic or recurrent mental
4 disorder. The term includes organic mental disorders,
5 schizophrenic disorders, disorders known as bipolar disorders
6 and recurrent major depression.
7 "Treatment facility." A facility licensed by the Department
8 of Health or the Department of Public Welfare.
9 Section 603-B. Optional Benefits.--Any individual covered
10 under a health care benefit plan providing for the treatment of
11 mental disorders may elect optional benefits. Optional benefits
12 shall not exceed the dollar value or value-of-service unit,
13 whichever is applicable, limits of inpatient services provided
14 for coverage of mental disorders under the health care benefit
15 plan. Decisions concerning optional benefits management shall be
16 considered when consistent with the therapeutic treatment plan.
17 Use of alternative benefits may not be required if they are
18 inconsistent with the therapeutic treatment plan.
19 Section 604-B. Administrative Costs.--All costs associated
20 with the implementation of this article, including the costs of
21 review and appeal, shall be recovered through premiums.
22 Section 605-B. Lifetime Maximum Benefits.--An individual
23 electing optional benefits for the treatment of severe mental
24 disorders under section 603-B shall be eligible for renewability
25 of lifetime limits imposed by the health care benefit plan for
26 the treatment of mental disorders in the same manner in which
27 benefit limitations are renewed for medical disorders other than
28 mental disorders.
29 Section 606-B. Eligibility to Receive Reimbursement.--An
30 individual eligible to receive reimbursement for services
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1 provided during treatment of mental disorders is limited to:
2 (1) Treatment facilities licensed by the Department of
3 Health or the Department of Public Welfare.
4 (2) Licensed health care professionals who are currently
5 eligible to receive reimbursement.
6 Section 607-B. Regulations.--The Insurance Commissioner may
7 promulgate regulations reasonably necessary to carry out the
8 purposes of this article.
9 Section 608-B. Preservation of Certain Benefits.--Nothing in
10 this article shall prevent a health care benefit plan from
11 offering optional benefits for conditions other than mental
12 disorders, including behavioral and psychological conditions
13 which are not attributable to a mental disorder but which may
14 appropriately be the focus of professional attention or
15 treatment. Nothing in this article shall prevent a health care
16 benefit plan from offering benefits under its health care
17 benefit plan for conditions which have a demonstrable organic
18 origin.
19 Section 609-B. Conduct of Managed Care Review Process and
20 Administration of Optional Benefits.--A health care benefit plan
21 must be submitted to the Insurance Commissioner for approval of
22 the criteria to be applied by the plan or its subsidiaries or
23 subcontractors prior to granting authorization for the use of
24 optional benefits. Review criteria must contain a description of
25 the process for application and consideration of the optional
26 benefits, as well as the rights of the subscribers, dependent
27 beneficiaries and practitioners to appeal denial of benefits
28 decisions. The plan must identify participants in the review
29 process, establish time frames for implementation of the
30 application and appeal process and provide safeguards to prevent
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1 inappropriate release of confidential information provided by
2 the practitioner with the written informed consent of the
3 beneficiary and patient.
4 Section 2. The addition of Article VI-B of this act shall
5 apply to insurance policies issued or renewed on or after the
6 effective date of this act.
7 Section 3. This act shall take effect in 120 days.
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