§1043.  Severe mental illness and other mental disorders; policy provisions; minimum requirements; group, blanket, and association policies

A.(1)(a)  Any hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, contract or other agreement with a health maintenance organization or a preferred provider organization, health and accident insurance policy, or any other insurance contract of this type in this state, including a group insurance plan, a self-insurance plan, and the Office of Group Benefits programs, delivered or issued for delivery in this state on or after January 1, 2000, shall include benefits payable for the treatment of severe mental illness under the same circumstances and conditions or greater  as benefits are paid under those policies, contracts, benefit plans, agreements, or programs for all other diagnoses, illnesses, or accidents.

(b)  For purposes of this Section, "severe mental illness" shall include any of the following diagnosed severe mental illnesses:

(i)  Schizophrenia or schizoaffective disorder.

(ii)  Bipolar disorder.

(iii)  Repealed by Acts 2008, No. 648, §2.

(iv)  Panic disorder.

(v)  Obsessive-compulsive disorder.

(vi)  Major depressive disorder.

(vii)   Anorexia/bulimia.

(viii)  Repealed by Acts 2008, No. 648, §2.

(ix)  Intermittent explosive disorder.

(x)  Posttraumatic stress disorder.

(xi)  Psychosis NOS (not otherwise specified) when diagnosed in a child under seventeen years of age.

(xii)  Rett's Disorder.

(xiii)  Tourette's Disorder.

(2)(a)  Any issuer of a group, blanket, or association policy, contract, benefit plan, agreement, or program specified in Paragraph (1) of this Subsection shall also offer to the policyholder an optional provision in the policy, contract, benefit plan, agreement, or program which states that benefits shall be payable for the treatment of mental disorders other than severe mental illness as defined in Paragraph (1) under the same circumstances and conditions as benefits are paid under those policies, contracts, benefit plans, agreements, or programs for all other diagnoses, illnesses, or accidents.

(b)  If the policyholder elects not to purchase this optional coverage, the issuer shall not be required to notify the policyholder in any renewal, reinstatement, or modified policy, contract, benefit plan, agreement, or program as to the availability of the optional coverage.  However, the policyholder may request the optional coverage in writing on any anniversary date of the policy, contract, benefit plan, agreement, or program.

(3)(a)  The provisions of this Section shall apply only to group, blanket, and association policies.

(b)  The provisions of this Section shall not apply to health insurance individual policies or contracts; limited benefit health insurance policies or contracts; and short term health insurance policies or contracts.

(4)  These benefits shall be payable when the treatment or services are rendered by a physician licensed under the provisions of R.S. 37:1261 et seq., psychologist licensed under the provisions of R.S. 37:2351 et seq., medical psychologist licensed under the provisions of R.S. 37:1360.51 et seq., or when the treatment or services are rendered by a licensed clinical social worker licensed under the provisions of R.S. 37:2701 et seq., who is a member of a national clinical social work registry.

(5)  A policy, contract, benefit plan, agreement, or program shall be in compliance with the requirements of Paragraph (1) of this Subsection if it includes the following benefits:

(a)  Forty-five inpatient days per covered individual per calendar year. However, a policy, contract, benefit plan, agreement, or program may provide a method to allow a covered individual to exchange two days of partial hospitalization or two days of residential treatment center hospitalization for each inpatient day of treatment.

(b)  Fifty-two outpatient visits per covered individual per calendar year, including the intensive outpatient program. However, a policy, contract, benefit plan, agreement, or program may provide a method to allow a covered individual to exchange one inpatient day of treatment for four outpatient visits or exchange four outpatient visits for one inpatient day of treatment.

B.  Whenever any such policies, contracts, programs, or plans provide for the reimbursement of health-related services that can be lawfully performed by a licensed clinical social worker, licensed under the provisions of R.S. 37:2701 et seq., the insured or other person entitled to benefits under such policy, contract, program, or plan shall be entitled to reimbursement for such services performed by a board-certified social worker notwithstanding any provisions of the policy, contract, program, or plan to the contrary.

C.  No policy, contract, benefit plan, agreement, or program issued or entered into pursuant to this Section shall contain any provision for a waiting period in excess of sixty days from its effective date before benefits are payable for the treatment of severe mental illness or other mental disorders.

D.  Nothing in this Section shall be construed to prohibit management of the provision of benefits for mental disorders through such methods as preadmission screening prior to the authorization of services or any other mechanism designed to limit coverage for services for mental disorders only to those deemed medically necessary by a licensed mental health professional.

Added by Acts 1981, No. 411, §1, eff. Jan. 1, 1982; Acts 1985, No. 213, §1; Acts 1999, No. 1285, §1, eff. Jan. 1, 2000; Acts 1999, No. 1309, §4, eff. Jan. 1, 2000; Acts 2001, No. 1178, §2, eff. June 29, 2001; Acts 2003, No. 129, §1, eff. May 28, 2003; Acts 2004, No. 51, §1; Redesignated from R.S. 22:669 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2008, No. 648, §2; Acts 2009, No. 251, §5, eff. Jan. 1, 2010; Acts 2010, No. 919, §1, eff. Jan. 1, 2011.