38.2-3412.1 - Coverage for mental health and substance abuse services.
§ 38.2-3412.1. Coverage for mental health and substance abuse services.
A. As used in this section:
"Adult" means any person who is 19 years of age or older.
"Alcohol or drug rehabilitation facility" means a facility in which astate-approved program for the treatment of alcoholism or drug addiction isprovided. The facility shall be either (i) licensed by the State Board ofHealth pursuant to Chapter 5 (§ 32.1-123 et seq.) of Title 32.1 or by theDepartment of Behavioral Health and Developmental Services pursuant toArticle 2 (§ 37.2-403 et seq.) of Chapter 4 of Title 37.2 or (ii) a stateagency or institution.
"Child or adolescent" means any person under the age of 19 years.
"Inpatient treatment" means mental health or substance abuse servicesdelivered on a twenty-four-hour per day basis in a hospital, alcohol or drugrehabilitation facility, an intermediate care facility or an inpatient unitof a mental health treatment center.
"Intermediate care facility" means a licensed, residential public orprivate facility that is not a hospital and that is operated primarily forthe purpose of providing a continuous, structured twenty-four-hour per day,state-approved program of inpatient substance abuse services.
"Medication management visit" means a visit no more than 20 minutes inlength with a licensed physician or other licensed health care provider withprescriptive authority for the sole purpose of monitoring and adjustingmedications prescribed for mental health or substance abuse treatment.
"Mental health services" or "mental health benefits" means treatment formental, emotional or nervous disorders.
"Mental health treatment center" means a treatment facility organized toprovide care and treatment for mental illness through multiple modalities ortechniques pursuant to a written plan approved and monitored by a physician,clinical psychologist, or a psychologist licensed to practice in thisCommonwealth. The facility shall be (i) licensed by the Commonwealth, (ii)funded or eligible for funding under federal or state law, or (iii)affiliated with a hospital under a contractual agreement with an establishedsystem for patient referral.
"Outpatient treatment" means mental health or substance abuse treatmentservices rendered to a person as an individual or part of a group while notconfined as an inpatient. Such treatment shall not include services deliveredthrough a partial hospitalization or intensive outpatient program as definedherein.
"Partial hospitalization" means a licensed or approved day or eveningtreatment program that includes the major diagnostic, medical, psychiatricand psychosocial rehabilitation treatment modalities designed for patientswith mental, emotional, or nervous disorders, and alcohol or other drugdependence who require coordinated, intensive, comprehensive andmulti-disciplinary treatment. Such a program shall provide treatment over aperiod of six or more continuous hours per day to individuals or groups ofindividuals who are not admitted as inpatients. Such term shall also includeintensive outpatient programs for the treatment of alcohol or other drugdependence which provide treatment over a period of three or more continuoushours per day to individuals or groups of individuals who are not admitted asinpatients.
"Substance abuse services" or "substance use disorder benefits" meanstreatment for alcohol or other drug dependence.
"Treatment" means services including diagnostic evaluation, medical,psychiatric and psychological care, and psychotherapy for mental, emotionalor nervous disorders or alcohol or other drug dependence rendered by ahospital, alcohol or drug rehabilitation facility, intermediate carefacility, mental health treatment center, a physician, psychologist, clinicalpsychologist, licensed clinical social worker, licensed professionalcounselor, licensed substance abuse treatment practitioner, licensed marriageand family therapist or clinical nurse specialist who renders mental healthservices. Treatment for physiological or psychological dependence on alcoholor other drugs shall also include the services of counseling andrehabilitation as well as services rendered by a state certified alcoholism,drug, or substance abuse counselor or substance abuse counseling assistant,limited to the scope of practice set forth in § 54.1-3507.1 or 54.1-3507.2,respectively, employed by a facility or program licensed to provide suchtreatment.
B. Except for group health insurance coverage issued to a large employer asdefined in § 38.2-3431, each individual and group accident and sicknessinsurance policy or individual and group subscription contract providingcoverage on an expense-incurred basis for a family member of the insured orthe subscriber shall provide coverage for inpatient and partialhospitalization mental health and substance abuse services as follows:
1. Treatment for an adult as an inpatient at a hospital, inpatient unit of amental health treatment center, alcohol or drug rehabilitation facility orintermediate care facility for a minimum period of 20 days per policy orcontract year.
2. Treatment for a child or adolescent as an inpatient at a hospital,inpatient unit of a mental health treatment center, alcohol or drugrehabilitation facility or intermediate care facility for a minimum period of25 days per policy or contract year.
3. Up to 10 days of the inpatient benefit set forth in subdivisions 1 and 2of this subsection may be converted when medically necessary at the option ofthe person or the parent, as defined in § 16.1-336, of a child or adolescentreceiving such treatment to a partial hospitalization benefit applying aformula which shall be no less favorable than an exchange of 1.5 days ofpartial hospitalization coverage for each inpatient day of coverage. Aninsurance policy or subscription contract described herein that providesinpatient benefits in excess of 20 days per policy or contract year foradults or 25 days per policy or contract year for a child or adolescent mayprovide for the conversion of such excess days on the terms set forth in thissubdivision.
4. The limits of the benefits set forth in this subsection shall not be morerestrictive than for any other illness, except that the benefits may belimited as set out in this subsection.
5. This subsection shall not apply to short-term travel, accident only,limited or specified disease policies or contracts, nor to policies orcontracts designed for issuance to persons eligible for coverage under TitleXVIII of the Social Security Act, known as Medicare, or any other similarcoverage under state or federal governmental plans.
C. Except for group health insurance coverage issued to a large employer asdefined in § 38.2-3431, each individual and group accident and sicknessinsurance policy or individual and group subscription contract providingcoverage on an expense-incurred basis for a family member of the insured orthe subscriber shall also provide coverage for outpatient mental health andsubstance abuse services as follows:
1. A minimum of 20 visits for outpatient treatment of an adult, child oradolescent shall be provided in each policy or contract year.
2. The limits of the benefits set forth in this subsection shall be no morerestrictive than the limits of benefits applicable to physical illness;however, the coinsurance factor applicable to any outpatient visit beyond thefirst five of such visits covered in any policy or contract year shall be atleast 50 percent.
3. For the purpose of this section, medication management visits shall becovered in the same manner as a medication management visit for the treatmentof physical illness and shall not be counted as an outpatient treatment visitin the calculation of the benefit set forth herein.
4. For the purpose of this subsection, if all covered expenses for a visitfor outpatient mental health or substance abuse treatment apply toward anydeductible required by a policy or contract, such visit shall not counttoward the outpatient visit benefit maximum set forth in the policy orcontract.
5. This subsection shall not apply to short-term travel, accident only, orlimited or specified disease policies or contracts, nor to policies orcontracts designed for issuance to persons eligible for coverage under TitleXVIII of the Social Security Act, known as Medicare, or any other similarcoverage under state or federal governmental plans.
D. The provisions of this section shall not be applicable to "biologicallybased mental illnesses," as defined in § 38.2-3412.1:01, unless coverage forany such mental illness is not otherwise available pursuant to the provisions§ 38.2-3412.1:01.
E. The requirements of this section shall apply to all insurance policies andsubscription contracts delivered, issued for delivery, reissued, or extended,or at any time when any term of the policy or contract is changed or anypremium adjustment made.
F. Group health insurance coverage issued to a large employer as defined in §38.2-3431 shall provide mental health and substance use disorder benefits inparity with the medical and surgical benefits contained in the coverage inaccordance with the Mental Health Parity and Addiction Equity Act of 2008(P.L. 110-343).
(1993, c. 132; 1995, c. 270; 1996, c. 41; 1997, c. 901; 1999, c. 941; 2001,c. 460; 2004, c. 156; 2006, c. 638; 2009, cc. 813, 840; 2010, c. 693.)