38.2-3412.1:01 - Coverage for biologically based mental illness
§ 38.2-3412.1:01. Coverage for biologically based mental illness.
A. Notwithstanding the provisions of § 38.2-3419, each insurer proposing toissue group accident and sickness insurance policies providing hospital,medical and surgical, or major medical coverage on an expense-incurred basis;each corporation providing group accident and sickness subscriptioncontracts; and each health maintenance organization providing a health careplan for health care services shall provide coverage for biologically basedmental illnesses.
B. Except for group health insurance coverage issued to a large employer asdefined in § 38.2-3431, benefits for biologically based mental illnesses maybe different from benefits for other illnesses, conditions or disorders ifsuch benefits meet the medical criteria necessary to achieve the sameoutcomes as are achieved by the benefits for any other illness, condition ordisorder that is covered by such policy or contract. Group health insurancecoverage issued to a large employer shall provide mental health and substanceuse disorder benefits in parity with the medical and surgical benefitscontained in the coverage in accordance with the Mental Health Parity andAddiction Equity Act of 2008 (P.L. 110-343).
C. Coverage for biologically based mental illnesses shall neither bedifferent nor separate from coverage for any other illness, condition ordisorder for purposes of determining deductibles, benefit year or lifetimedurational limits, benefit year or lifetime dollar limits, lifetime episodesor treatment limits, copayment and coinsurance factors, and benefit yearmaximum for deductibles and copayment and coinsurance factors.
D. Nothing shall preclude the undertaking of usual and customary proceduresto determine the appropriateness of, and medical necessity for, treatment ofbiologically based mental illnesses under this option, provided that all suchappropriateness and medical necessity determinations are made in the samemanner as those determinations made for the treatment of any other illness,condition or disorder covered by such policy or contract.
E. For purposes of this section, a "biologically based mental illness" isany mental or nervous condition caused by a biological disorder of the brainthat results in a clinically significant syndrome that substantially limitsthe person's functioning; specifically, the following diagnoses are definedas biologically based mental illness as they apply to adults and children:schizophrenia, schizoaffective disorder, bipolar disorder, major depressivedisorder, panic disorder, obsessive-compulsive disorder, attention deficithyperactivity disorder, autism, and drug and alcoholism addiction.
F. The provisions of this section shall not apply to (i) short-term travel,accident only, limited or specified disease policies, (ii) short-termnonrenewable policies of not more than six months' duration, (iii) policies,contracts, or plans issued in the individual market or small group markets toemployers with 25 or fewer employees, or (iv) policies or contracts designedfor issuance to persons eligible for coverage under Title XVIII of the SocialSecurity Act, known as Medicare, or any other similar coverage under state orfederal governmental plans.
G. The requirements of this section shall apply to all insurance policies,subscription contracts, and health care plans delivered, issued for delivery,reissued or extended on or after January 1, 2000, and to all such policies,contracts or plans to which a term is changed or any premium adjustment ismade on or after such date.
(1999, c. 941; 2000, c. 725; 2004, c. 156; 2010, c. 693.)