§ 58-3-220. Mental illness benefits coverage. - North Carolina Statutes

§ 58‑3‑220. Mental illness benefits coverage.

(a)        Mental HealthEquity Requirement. – Except as provided in subsection (b), an insurer shallprovide in each group health benefit plan benefits for the necessary care andtreatment of mental illnesses that are no less favorable than benefits forphysical illness generally, including application of the same limits. Forpurposes of this subsection, mental illnesses are as diagnosed and defined inthe Diagnostic and Statistical Manual of Mental Disorders, DSM‑IV, or asubsequent edition published by the American Psychiatric Association, exceptthose mental disorders coded in the DSM‑IV or subsequent edition assubstance‑related disorders (291.0 through 292.2 and 303.0 through305.9), those coded as sexual dysfunctions not due to organic disease (302.70through 302.79), and those coded as "V" codes. For purposes of thissubsection, "limits" includes deductibles, coinsurance factors, co‑payments,maximum out‑of‑pocket limits, annual and lifetime dollar limits,and any other dollar limits or fees for covered services.

(b)        Minimum RequiredBenefits. – Except as provided in subsection (c), a group health benefit planmay apply durational limits to mental illnesses that differ from durationallimits that apply to physical illnesses. A group health benefit plan shallprovide at least the following minimum number of office visits and combinedinpatient and outpatient days for all mental illnesses and disorders not listedin subsection (c), as diagnosed and defined in the Diagnostic and StatisticalManual of Mental Disorders, DSM‑IV, or a subsequent edition published bythe American Psychiatric Association, except those mental disorders coded inthe DSM‑IV or subsequent edition as substance‑related disorders(291.0 through 292.2 and 303.0 through 305.9), those coded as sexualdysfunctions not due to organic disease (302.70 through 302.79), and thosecoded as "V" codes:

(1)        Thirty combinedinpatient and outpatient days per year.

(2)        Thirty office visitsper year.

(c)        Durational limitsfor the following mental illnesses shall be subject to the same limits asbenefits for physical illness generally:

(1)        Bipolar Disorder.

(2)        Major DepressiveDisorder.

(3)        Obsessive CompulsiveDisorder.

(4)        Paranoid and OtherPsychotic Disorder.

(5)        SchizoaffectiveDisorder.

(6)        Schizophrenia.

(7)        Post‑TraumaticStress Disorder.

(8)        Anorexia Nervosa.

(9)        Bulimia.

(d)        Nothing in thissection prevents an insurer from offering a group health benefit plan thatprovides greater than the minimum required benefits, as set forth in subsection(b).

(e)        Nothing in thissection requires an insurer to cover treatment or studies leading to or inconnection with sex changes or modifications and related care.

(f)         Weighted Average.– If a group health benefit plan contains annual limits, lifetime limits, co‑payments,deductibles, or coinsurance only on selected physical illness and injurybenefits, and these benefits do not represent substantially all of the physicalillness and injury benefits under the group health benefit plan, then theinsurer may impose limits on the mental health benefits based on a weightedaverage of the respective annual, lifetime, co‑payment, deductible, orcoinsurance limits on the selected physical illness and injury benefits. Theweighted average shall be calculated in accordance with rules adopted by theCommissioner.

(g)        Nothing in thissection prevents an insurer from applying utilization review criteria todetermine medical necessity as defined in G.S. 58‑50‑61 as long asit does so in accordance with all requirements for utilization review programsand medical necessity determinations specified in that section, including theoffering of an insurer appeal process and, where applicable, health benefitplan external review as provided for in Part 4 of Article 50 of Chapter 58 ofthe General Statutes.

(h)        Definitions. – Asused in this section:

(1)        "Health benefitplan" has the same meaning as in G.S. 58‑3‑167.

(2)        "Insurer"has the same meaning as in G.S. 58‑3‑167.

(3)        "Mentalillness" has the same meaning as in G.S. 122C‑3(21), with a mentaldisorder defined in the Diagnostic and Statistical Manual of Mental Disorders,DSM‑IV, or subsequent editions published by the American PsychiatricAssociation, except those mental disorders coded in the DSM‑IV orsubsequent editions as substance‑related disorders (291.0 through 292.9and 303.0 through 305.9), those coded as sexual dysfunctions not due to organicdisease (302.70 through 302.79), and those coded as "V" codes.

(i)         Notwithstandingany other provisions of this section, a group health benefit plan that coversboth medical and surgical benefits and mental health benefits shall, withrespect to the mental health benefits, comply with all applicable standards ofSubtitle B of Title V of Public Law 110‑343, known as the Paul Wellstoneand Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.

(j)         Subsection (i) ofthis section applies only to a group health benefit plan covering a largeemployer as defined in G.S. 58‑68‑25(a)(10).  (2007‑268, s. 2; 2009‑382,s. 19.)