3923.282 Health coverage plans - biologically based mental illness.

(A) As used in this section:

(1) "Biologically based mental illness" means schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, and panic disorder, as these terms are defined in the most recent edition of the diagnostic and statistical manual of mental disorders published by the American psychiatric association.

(2) "Plan of health coverage" includes any private or public employer group self-insurance plan that provides payment for health care benefits for other than specific diseases or accidents only, which benefits are not provided by contract with a sickness and accident insurer or health insuring corporation.

(B) Notwithstanding section 3901.71 of the Revised Code, and subject to division (F) of this section, each plan of health coverage shall provide benefits for the diagnosis and treatment of biologically based mental illnesses on the same terms and conditions as, and shall provide benefits no less extensive than, those provided under the plan of health coverage for the treatment and diagnosis of all other physical diseases and disorders, if both of the following apply:

(1) The biologically based mental illness is clinically diagnosed by a physician authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery; a psychologist licensed under Chapter 4732. of the Revised Code; a professional clinical counselor, professional counselor, or independent social worker licensed under Chapter 4757. of the Revised Code; or a clinical nurse specialist licensed under Chapter 4723. of the Revised Code whose nursing specialty is mental health.

(2) The prescribed treatment is not experimental or investigational, having proven its clinical effectiveness in accordance with generally accepted medical standards.

(C) Division (B) of this section applies to all coverages and terms and conditions of the plan of health coverage, including, but not limited to, coverage of inpatient hospital services, outpatient services, and medication; maximum lifetime benefits; copayments; and individual and family deductibles.

(D) This section does not apply to a plan of health coverage if federal law supersedes, preempts, prohibits, or otherwise precludes its application to such plans. This section does not apply to long-term care, hospital indemnity, disability income, or medicare supplement plans of health coverage, or to any other supplemental benefit plans of health coverage.

(E) Nothing in this section shall be construed as prohibiting an employer from taking any of the following actions in connection with a plan of health coverage:

(1) Negotiating separately with mental health care providers with regard to reimbursement rates and the delivery of health care services;

(2) Managing the provision of benefits for the diagnosis or treatment of biologically based mental illnesses through the use of pre-admission screening, by requiring beneficiaries to obtain authorization prior to treatment, or through the use of any other mechanism designed to limit coverage to that treatment determined to be necessary;

(3) Enforcing the terms and conditions of a plan of health coverage.

(F) An employer that offers a plan of health coverage is not required to provide benefits for the diagnosis and treatment of biologically based mental illnesses in combination with benefits for the treatment and diagnosis of all other physical diseases and disorders as described in division (B) of this section if both of the following apply:

(1) The employer submits documentation certified by an independent member of the American academy of actuaries to the superintendent of insurance showing that incurred claims for diagnostic and treatment services for biologically based mental illnesses for a period of at least six months independently caused the employer's costs for claims and administrative expenses for the coverage of all other physical diseases and disorders to increase by more than one per cent per year.

(2) The superintendent of insurance determines from the documentation and opinion submitted pursuant to division (F) of this section, that incurred claims for diagnostic and treatment services for biologically based mental illnesses for a period of at least six months independently caused the employer's costs for claims and administrative expenses for the coverage of all other physical diseases and disorders to increase by more than one per cent per year.

Any determination made by the superintendent under this division is subject to Chapter 119. of the Revised Code.

Effective Date: 03-30-2007