(A) Every policy of group sickness and accident insurance providing hospital, surgical, or medical expense coverage for other than specific diseases or accidents only, and delivered, issued for delivery, or renewed in this state on or after January 1, 1979, shall provide for each eligible person under the policy who resides in this state, outpatient, inpatient, and intermediate primary care benefits for alcoholism that are at least equal to five hundred fifty dollars in any calendar year or twelve month period. The services shall be legally performed by or under the clinical supervision of a licensed physician or a licensed psychologist, whether performed in an office, in a hospital, in a community mental health facility, or in an alcoholism treatment facility so long as the hospital, community mental health facility, or alcoholism treatment facility is approved by the joint commission on accreditation of hospitals or certified by the department of health.
(B) The benefits mandated by division (A) of this section shall be subject to reasonable contract limitations and may be subject to reasonable deductibles and co-insurance costs. Persons entitled to such benefit under more than one service or insurance contract may be limited to a single five hundred fifty dollar benefit for services under all contracts.
(C) For an eligible person, who receives treatment for alcoholism from an approved or certified alcoholism treatment facility, to remain entitled to the benefits mandated by division (A) of this section, a licensed physician or a licensed psychologist shall every three months certify that such person needs to continue utilizing such treatment.
(D) In order to qualify for participation under division (A) of this section, every facility specified in such division shall have in effect a plan for utilization review and a plan for peer review and every person specified in such division shall have in effect a plan for peer review. Such plans shall have the purpose of ensuring high quality patient care and effective and efficient utilization of available health facilities and services. Such person or facility shall also have in effect a program of rehabilitation or a program of rehabilitation and detoxification.
(E) Nothing in this section shall be construed to require an insurer to pay benefits which are greater than usual, customary, and reasonable.
Effective Date: 09-05-2001
This section is set out twice. See also § 3923.29 , as amended by 130th General Assembly File No. TBD, HB 232, §1, eff. 7/10/2014.