40-2258. Group policies; mental illness, alcoholism, drug abuse or substance use disorder; limitations; exceptions; definitions.
40-2258
40-2258. Group policies;mental illness, alcoholism, drug abuse or substance use disorder; limitations;exceptions; definitions.(a) An accident and sickness insurer which offers coveragethrough a group policy or certificate of coverage providing hospital,medical or surgical expense benefitspursuant to K.S.A. 40-2209, and amendments thereto, whichincludes mental illness or alcoholism, drug abuse or othersubstance usedisorderbenefits shall be subject to the following requirements:
(1) If the policy does not include an aggregate lifetime limit onsubstantially all hospital, medical and surgical expense benefits, the policymay not impose any aggregate lifetime limit on mental illnessor alcoholism,drug abuse or other substance use disorder benefits;
(2) if the policy includes an aggregate lifetime limit on substantially allhospital, medical and surgical expense benefits the plan shall either: (A)Applythe applicable lifetime limit both to the hospital, medical and surgicalexpensebenefits to which it otherwise would apply and to mentalillness oralcoholism, drug abuse or other substance use disorderbenefits andnot distinguished in the application of such limit between such hospital,medical and surgical expense benefits and mentalillness oralcoholism, drug abuse or other substance use disorderbenefits; or (B) notinclude any aggregate lifetimelimit on mental illness or alcoholism, drug abuse or othersubstance usedisorder benefits that is less than the applicable lifetime limiton hospital, medical and surgical expense benefits;
(3) if the policy does not include an annual limit on substantially allhospital, medical and surgical expense benefits, the plan or coverage may notimpose any annual limit on mental illness or alcoholism, drugabuse or othersubstance use disorder benefits; and
(4) if the policy includes an annual limit on substantially all hospital,medical and surgical expense benefits the policy shall either: (A) Apply theapplicable annual limit both to hospital, medical and surgical expense benefitsto which it otherwise would apply and to mental illness oralcoholism, drugabuse or other substance use disorder benefits and notdistinguish in the application of such limit between such hospital, medical andsurgical expense benefits and mental illness or alcoholism,drug abuse orother substance use disorder benefits; or (B) not include anyannual limit on mentalillness or alcoholism, drug abuse or other substance use disorderbenefits thatis less than the applicable annual limit.
(b) If the group policy providing hospital, medical or surgical expensebenefits is not otherwise covered by subsection (a) and either does not apply alifetime or annual benefit or applies different lifetime or annual benefits todifferent categories of hospital, medical and surgical expense benefits, thecommissioner may adopt rules and regulations under which subsections (a)(2) and(a)(4) are applied to such policies with respect to mentalillness oralcoholism, drug abuse or other substance use disorder benefits bysubstituting for the applicable lifetime or annual limits an average limit thatis computed taking into account the weighted average of the lifetime or annuallimits applicable to such categories.
(c) Nothing in this section shall be construed as either:
(1) Requiring an accident and sickness policy to offer mentalillness or alcoholism, drug abuse or other substance use disorderbenefitsexcept as otherwise required by K.S.A. 40-2,105a, andamendmentsthereto; or
(2) affecting any terms and conditions of a policy which does include mentalillness or alcoholism, drug abuse or other substance use disorderbenefits including provisions regarding cost sharing, limits on thenumber of visits or days of coverage, requirements relating to medicalnecessity, requirements relating to the amount, duration or scope of mentalillness or alcoholism, drug abuse or other substance use disorderbenefitsunder the plan or coverage, except as specifically provided in subsection (a).
(d) This section shall not apply to any group accident and health insurancepolicy which is sold to a small employer as defined in K.S.A. 40-2209,andamendments thereto.
(e) This section shall not apply with respect to a group policy providinghospital, medical or surgical expense benefits if the application of thissection will result in an increase in the cost under the plan of at least2% in the case of the first plan year in which this section is applied and1% in the case of each subsequent plan year.Determinations as to increases in actual costs under a plan shall be madeand certified by a qualified and licensed actuary who is a member in goodstanding of the American academy of actuaries. All such determinations shall bein a written report prepared by the actuary.
(f) In the case of a group policy providing hospital, medical or surgicalexpense benefits that offers an eligible employee, member or dependent two ormore benefit package options under the policy, subsections (a) and (b) shall beapplied separately with respect to each such option.
(g) As used in this section:
(1) "Aggregate lifetime limit" means, with respect to benefits under a grouppolicy providing hospital, medical or surgical expense benefits, a dollarlimitation on the total amount that may be paid with respect to such benefitsunder the policy with respect to an eligible employee, member or dependent;
(2) "annual limit" means, with respect to benefits under a group policyproviding hospital, medical or surgical expense benefits, a dollar limitationon the total amount of benefits that may be paid with respect to such benefitsin a 12-month period under the policy with respect to an eligible employee,member or dependent;
(3) "hospital, medical or surgical expense benefits" means benefits withrespect to hospital, medical or surgical services, as defined under the termsof the policy;
(4) "mental illness benefits" means benefits withrespect to mental healthservices, as defined under the terms of the policy;
(5) "alcoholism, drug abuse or substance use disorder benefits" meansbenefits with respect to services for the treatment of alcoholism, drug abuseor other substance use disorders, as defined under the terms of the policy;
(6) "mental illness, alcoholism, drug abuse or substance use" means disordersspecified in the diagnostic and statistical manual of mental disorders, fourthedition, (DSM-IV, 1994) of the American psychiatric association.
(h) This section shall be effective for group policies providing hospital,medical or surgical expense benefits which are entered into or renewed afterJanuary 1, 1998.
(i) The commissioner is hereby authorized to adopt such rules andregulations as may be necessary to carry out the provisions of this section.
History: L. 1997, ch. 190, § 13;L. 2002, ch. 158, § 19;L. 2003, ch. 88, § 1;L. 2004, ch. 157, § 1;L. 2005, ch. 163, § 11;L. 2006, ch. 123, § 1;L. 2007, ch. 25, § 1;L. 2008, ch. 13, § 1;L. 2009, ch. 136, § 9; Nov. 1.