(l) Schizophrenia;

(2) Bipolar disorder;

(3) Pervasive developmental disorder, or autism;

(4) Paranoia;

(5) Panic disorder;

(6) Obsessive-compulsive disorder;

(7) Major depressive disorder;

(8)__Eating disorders, including bulimia and anorexia;

(9)__Attention deficit and disruptive behavior disorders;

(10)__Tic disorders; and

(11)__Substance abuse-related disorders.

C.__"Child" means any person under 19 years of age.

D.__"Day treatment services" includes psychoeducational, physiological, psychological and psychosocial concepts, techniques and processes to maintain or develop functional skills of clients provided to individuals and groups for periods of more than 2 hours but less than 24 hours per day.

E.__"Health benefit plan" means:

(1)__ Policies, contracts or certificates for hospital or medical benefits that are offered, renewed, amended, executed, continued, delivered or issued for delivery in this State to an employer or individual on a group or individual basis or on an individual or group subscription basis and__that provide coverage for residents of this State;

(2)__Nonprofit hospital or medical service or indemnity plans;

(3)__Health maintenance organization subscriber or group master contracts;

(4)__ Preferred provider plans;

(5)__Health benefit plans offered or administered by the State or by any__subdivision or instrumentality of the State;

(6)__Multiple employer welfare arrangements or associations located in this State or another state that cover residents of this State who are eligible employees; or

(7)__Employer self-insured plans that are not exempt pursuant to the__federal Employee Retirement Income Security Act provisions.

"Health benefit plan" does not include accident-only insurance; fixed indemnity insurance; credit health insurance; Medicare supplement policies; Civilian Health and Medical Program of the Uniformed Services supplement policies; long-term care insurance; disability income insurance; workers' compensation or similar insurance; disease-specific insurance; automobile medical payment insurance; dental insurance; or vision insurance.

F.__"Home support services" means rehabilitative services, treatment services and living skills services provided for a person with a biologically based mental illness.__"Home support services" may be provided in a community setting or the person's current place of residence and are services that promote the integration of the person into the community, sustain the person in the person's current living situation or another living situation of the person's choosing and enhance the quality of the person's life.__ "Home support services" may be provided directly to the person or indirectly through collateral contact or by telephone contact or other means on behalf of the person.__ "Home support services" include, but are not limited to:

(1)__Case management services and assertive community treatment services;

(2)__Medication education and monitoring;

(3)__Crisis intervention and resolution services and follow-up services; and

(4)__Individual, group and family counseling services.

G.__"Inpatient services" includes, but is not limited to, a range of physiological, psychological and other intervention concepts, techniques and processes in a community mental health psychiatric inpatient unit, general hospital psychiatric unit or psychiatric hospital licensed by the Department of Human Services or accredited public hospital to restore psychosocial functioning sufficient to allow maintenance and support of a person suffering from a biologically based mental illness in a less restrictive setting.

H.__"Inpatient treatment" means mental health or substance abuse services delivered on a 24-hour per day basis in a hospital, accredited public hospital, alcohol or drug rehabilitation facility, intermediate care facility, community mental health psychiatric inpatient unit, general hospital psychiatric unit or psychiatric hospital licensed by the Department of Human Services.

I.__"Intermediate care facility" means a licensed, residential public or private facility that is not a hospital and that is operated primarily for the purpose of providing a continuous, structured, 24-hour per day, state- approved program of inpatient substance abuse services.

J.__"Mental health services" means treatment for biologically based mental illnesses.

K.__"Outpatient care" means care rendered by a state- licensed, approved or certified detoxification, residential treatment or outpatient program, or partial hospitalization program on a periodic basis, including, but not limited to, patient diagnosis, assessment and treatment, individual, family and group counseling and educational and support services.

L.__"Outpatient services" includes, but is not limited to, screening, evaluation, consultations, diagnosis and treatment involving use of psychoeducational, physiological, psychological and psychosocial evaluative and interventive concepts, techniques and processes provided to individuals and groups.

M.__"Person suffering from a biologically based mental illness" means a person whose psychobiological processes are impaired severely enough to manifest problems in the areas of social, psychological or biological functioning.__Such a person has a disorder of thought, mood, perception, orientation or memory that impairs judgment, behavior,

capacity to recognize or ability to cope with the ordinary demands of life.__The person manifests an impaired capacity to maintain acceptable levels of functioning in the area of intellect, emotion or physical well-being.

N.__"Preexisting condition" means a condition existing during a specified period immediately preceding the effective date of coverage, which would have caused an ordinarily prudent person to seek medical advice, diagnosis, care or treatment or a condition for which medical advice, diagnosis, care or treatment was recommended or received during a specified period immediately preceding the effective date of coverage.

O.__"Preexisting condition provision" means a provision in a health benefit plan that denies, excludes or limits benefits for an enrollee for expenses or services related to a preexisting condition.

P.__"Provider" means those individuals included in Title 24- A, section 2744, subsection 1 and a licensed physician, an accredited public hospital or psychiatric hospital or a community agency licensed at the comprehensive service level by the Department of Mental Health, Mental Retardation and Substance Abuse Services.__All agencies or institutional providers named in this paragraph shall ensure that services are supervised by a psychiatrist, licensed psychologist or master's degree-level clinician, licensed in the State to practice at the independent level, who meets Department of Mental Health, Mental Retardation and Substance Abuse Services standards for the provision of supervision.

Q.__"Residential treatment" means services at a facility that provides care 24 hours daily to one or more patients, including, but not limited to, room and board; medical, nursing and dietary services; patient diagnosis, assessment and treatment; individual, family and group counseling; and educational and support services, including a designated unit of a licensed health care facility providing any and all other services specified in this paragraph to patients with biologically based mental illnesses.

R.__"Treatment" means services, including diagnostic evaluation, medical, psychiatric and psychological care, and psychotherapy for biologically based mental illnesses rendered by a hospital, alcohol or drug rehabilitation facility, intermediate care facility, mental health treatment center or a professional, licensed in this State to diagnose and treat conditions defined in the Diagnostic

and Statistical Manual of Mental Disorders, as periodically revised or subsequent publication.

Sec. 5. 24 MRSA §2325-A, sub-§§4 and 5, as enacted by PL 1983, c. 515, §4, are amended to read:

4. Requirement. Every nonprofit hospital or medical service organization which that issues individual or group health care contracts providing coverage for hospital care to residents of this State shall provide benefits as required in this section to any subscriber or other person covered under those contracts for conditions arising from mental illness. The requirements of this section apply to every health benefit plan that provides coverage for a family member of the insured or the subscriber that is offered, renewed, amended, executed, continued, delivered or issued for delivery in this State to an employer or individual on a group or individual basis.

5. Services. Each individual or group contract shall must provide, at a minimum, for the following benefits for a person suffering from a mental or nervous condition illness:

A. Inpatient care treatment and services;

B. Day treatment services; and

C. Outpatient care, treatment and services.;

D.__Home support services; and

E.__Residential treatment.

Sec. 6. 24 MRSA §2325-A, sub-§5-A, as amended by PL 1989, c. 490, §1, is repealed.

Sec. 7. 24 MRSA §2325-A, sub-§5-C, as amended by PL 1995, c. 625, Pt. B, §6 and affected by §7 and amended by c. 637, §1, is further amended to read:

5-C. Coverage for treatment for certain mental illnesses. Coverage for medical treatment for biologically based mental illnesses listed in paragraph A is subject to this subsection.

A. All individual and group contracts must provide, at a minimum, benefits according to paragraph B, subparagraph (1) for a person receiving medical treatment for any of the following mental illnesses diagnosed by a licensed allopathic or osteopathic physician or a licensed psychologist who is trained and has received a doctorate in

psychology specializing in the evaluation and treatment of human behavior: biologically based mental illnesses.

(1) Schizophrenia;

(2) Bipolar disorder;

(3) Pervasive developmental disorder, or autism;

(4) Paranoia;

(5) Panic disorder;

(6) Obsessive-compulsive disorder; or

(7) Major depressive disorder.

B. All individual and group policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State on or after July 1, 1996 must provide benefits that meet the requirements of this paragraph. For purposes of this paragraph, all contracts are deemed renewed no later than the next yearly anniversary of the contract date.

(1) The contracts must provide benefits for the treatment and diagnosis of biologically based mental illnesses under terms and conditions that are no less extensive than equal to the benefits provided for medical treatment for physical illnesses.

(2) At the request of a nonprofit hospital or medical service organization, a provider of medical or psychiatric treatment for biologically based mental illness shall furnish data substantiating that initial or continued treatment is medically or psychiatrically necessary and appropriate. When making the determination of whether treatment is medically or psychiatrically necessary and appropriate, the provider shall use the same criteria for medical treatment for biologically based mental illness as for medical treatment for physical illness under the group contract.

(3)__The benefits and coverage required under this paragraph must be provided as one set of benefits and coverage covering biologically based mental illness must have the same terms and conditions as the benefits and coverage for physical illnesses covered under the policy or contract subject to this section and may be delivered under a managed care system.

(4)__A policy, contract or certificate subject to this paragraph may not have separate lifetime maximums for physical illnesses and biologically based mental illnesses; separate deductibles and coinsurance amounts for physical illnesses and biologically based mental illnesses; separate out-of-pocket limits in a benefit period of not more than 12 months for physical illnesses and biologically based mental illnesses; or separate office visitation limits for physical illnesses and biologically based mental illnesses.

(5)__A health benefit plan may not impose a limitation on coverage or benefits for biologically based mental illnesses unless that same limitation is also imposed identically on the coverage and benefits for physical illnesses covered under the policy or contract.

(6)__Any copayments required under a policy or contract for benefits and coverage for biologically based mental illnesses must be actuarially equivalent to any coinsurance requirements or if there are no coinsurance requirements, the copayment may not be greater than any copayment required under the policy or contract for a benefit or coverage for a physical illnesses.

(7)__A health benefit plan__may not limit coverage for a preexisting condition that is a biologically based mental illness.

(8)__For the purposes of this paragraph, a medication management visit associated with a biologically based mental illness must be covered in the same manner as a medication management visit for the treatment of a physical illness and may not be counted in the calculation of any maximum outpatient treatment visit limits.

This subsection does not apply to policies, contracts and certificates covering employees of employers with 20 or fewer employees, whether the group policy is issued to the employer, to an association, to a multiple-employer trust or to another entity.

This subsection may not be construed to allow coverage and benefits for the treatment of alcoholism or other drug dependencies through the diagnosis of a mental illness listed in paragraph A.

Sec. 8. 24 MRSA §2325-A, sub-§5-D, as amended by PL 1995, c. 637, §2, is repealed.

Sec. 9. 24 MRSA §2325-A, sub-§§6 and 7, as enacted by PL 1983, c. 515, §4, are amended to read:

6. Contracts; providers. Subject to the approval by the Superintendent of Insurance pursuant to section 2305, a nonprofit hospital or medical service organization incorporated under this chapter shall offer contracts to providers, as described under Title 24-A, section 2744, authorizing the provision of mental health services within the scope of the provider's licensure and within the scope of this section.

7. Limits; coinsurance; deductibles. Any policy or contract which that provides coverage for the services required by this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent with the requirements of this section only to the extent that these maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions are equal to those established for physical illness and conform with the requirements of subsection 5-C.

Sec. 10. 24 MRSA §2325-A, sub-§10 is enacted to read:

10.__Transition. The provisions of this section do not limit the provision of specialized services for individuals with mental illness who are covered by Medicaid, supercede the provisions of federal law, federal or state Medicaid policy or the terms and conditions imposed on any Medicaid waiver granted to the State with respect to the provision of services to individuals with mental illness and affect any annual health insurance plan until its date of renewal or any health insurance plan governed by a collective bargaining agreement or employment contract until the expiration of that contract.

Sec. 11. 24-A MRSA §2749-C, as amended by PL 1995, c. 637, §3, is further amended to read:

§2749-C. Mandated coverage for certain mental illnesses

1. Coverage for treatment for certain mental illnesses. Coverage for medical treatment for biologically based mental illnesses listed in paragraph A by all individual policies is subject to this section. For purposes of this section, "biologically based mental illness" has the same meaning as defined in section 2843, subsection 3-A.

A. All individual policies must make available coverage providing, at a minimum, provide benefits according to paragraph B, subparagraph (1) for a person receiving medical treatment for any of the following biologically based mental illnesses diagnosed by a licensed allopathic or osteopathic

physician or a licensed psychologist who is trained and has received a doctorate in psychology specializing in the evaluation and treatment of human behavior:

(1) Schizophrenia;

(2) Bipolar disorder;

(3) Pervasive developmental disorder, or autism;

(4) Paranoia;

(5) Panic disorder;

(6) Obsessive-compulsive disorder; or

(7) Major depressive disorder.;

(8)__Attention deficit and disruptive behavior disorders;

(9)__Tic disorders;

(10)__Eating disorders, including bulimia and anorexia; and

(11)__Substance abuse-related disorders.

B. All individual policies and contracts executed, delivered, issued for delivery, continued or renewed in this State on or after July 1, 1996 must make available coverage providing provide benefits that meet the requirements of this paragraph. For purposes of this paragraph, all contracts are deemed renewed no later than the next yearly anniversary of the contract date.

(1) The offer of coverage contracts must provide benefits for the treatment and diagnosis of biologically based mental illnesses under terms and conditions that are no less extensive than equal to the benefits provided for medical treatment for physical illnesses.

(2) At the request of a reimbursing insurer, a provider of medical or psychiatric treatment for biologically based mental illness shall furnish data substantiating that initial or continued treatment is medically or psychiatrically necessary and appropriate. When making the determination of whether treatment is medically or psychiatrically necessary and

appropriate, the provider shall use the same criteria for medical or psychiatric treatment for mental illness as for medical treatment for physical illness under the individual policy.

(3)__The benefits and coverage required under this paragraph must be provided as one set of benefits and coverage covering biologically based mental illness, must have the same terms and conditions as the benefits and coverage for physical illnesses covered under the policy or contract and may be delivered under a managed care system.

(4)__A policy or contract subject to this paragraph may not have separate lifetime maximums for physical illnesses and biologically based mental illnesses; separate deductibles and coinsurance amounts for physical illnesses and biologically based mental illnesses; separate out-of-pocket limits in a benefit period of not more than 12 months for physical illnesses and biologically based mental illnesses; or separate office visitation limits for physical diseases and disorders and biologically based mental illnesses.

(5)__A health benefit plan may not impose a limitation on coverage or benefits for biologically based mental illnesses unless that same limitation is also imposed identically on the coverage and benefits for physical illnesses covered under the policy or contract.

(6)__Any copayments required under a policy or contract for benefits and coverage for biologically based mental illnesses must be actuarially equivalent to any coinsurance requirements or if there are no coinsurance requirements, the copayment may not be greater than any copayment required under the policy or contract for a benefit or coverage for a physical illness.

(7)__A health benefit plan may not limit coverage for a preexisting condition, as defined in section 2843, subsection 3-A, that is a biologically based mental illness.

(8)__For the purposes of this paragraph, a medication management visit associated with a biologically based mental illness must be covered in the same manner as a medication management visit for the treatment of a physical illness and may not be counted in the calculation of any maximum outpatient treatment visit limits.

This subsection may not be construed to allow coverage and benefits for the treatment of alcoholism or other drug dependencies through the diagnosis of a mental illness listed in paragraph A.

2. Contracts; providers. Subject to approval by the superintendent pursuant to section 2305, an insurer incorporated under this chapter shall offer contracts to providers, as described by section 2744, authorizing the provision of mental health services within the scope of the provider's licensure.

3. Limits; coinsurance; deductibles. A policy or contract that provides coverage for the services required by this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent with the requirements of this section only to the extent that these maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions are equal to those established for physical illness and conform with requirements of subsection 1, paragraph B.

4. Reports to the superintendent. Every insurer subject to this section shall report its experience for each calendar year to the superintendent no later than April 30th of the following year. The report must be in a form prescribed by the superintendent and include the amount of claims paid in this State for the services required by this section and the total amount of claims paid in this State for individual health care policies, both separated according to those paid for inpatient, day treatment and outpatient services. The superintendent shall compile this data for all insurers in an annual report.

5. Application. Except as otherwise provided, the requirements of this section apply to all policies and contracts executed, delivered, issued for delivery, continued or renewed in this State on or after July 1, 1996. For purposes of this section, all policies are deemed renewed no later than the next yearly anniversary of the contract date. Nothing in this section applies to accidental injury, specified disease, hospital indemnity, Medicare supplement, long-term care or other limited benefit health insurance policies.

6.__Transition.__The provisions of this section do not limit the provision of specialized services for individuals with mental illness who are covered by Medicaid, supercede the provisions of federal law, federal or state Medicaid policy or the terms and conditions imposed on any Medicaid waiver granted to the State with respect to the provision of services to individuals with mental illness and affect any annual health insurance plan until its date of renewal or any health insurance plan governed by a

collective bargaining agreement or employment contract until the expiration of that contract.

Sec. 12. 24-A MRSA §2843, sub-§1, ¶C, as enacted by PL 1983, c. 515, §6, is repealed and the following enacted in its place:

C.__Typical health coverage in this State continues to discriminate against mental illness and those coping with such illnesses despite repeated efforts to mandate equal coverage.__Discrimination takes the form of limiting or denying coverage with nonexistent or limited benefits compared to provisions for other illnesses, which are not limited or denied; and

Sec. 13. 24-A MRSA §2843, sub-§2, ¶¶A and B, as enacted by PL 1983, c. 515, §6, are amended to read:

A. Promote Require that every health benefit plan offered, amended, delivered, continued, executed, issued for delivery or renewed in this State provide coverage and benefits for biologically based mental illness and substance abuse programs equal to or exceeding the coverage and benefits available under health benefit plans for the diagnosis and treatment of all other covered physical illnesses and to ensure equitable and nondiscriminatory health coverage benefits for all forms of illness, including mental and emotional disorders, which that are of significant consequence to the health of Maine people and which can be treated in a cost effective cost-effective manner;

B. Assure Ensure that victims of mental and other illnesses have access to and choice of appropriate treatment at the earliest point of illness in least restrictive settings, including coverage for inpatient treatment, outpatient services, day treatment services, outpatient care, residential treatment, home support services, crisis intervention and resolution care, medication, maximum lifetime benefits, copayments, home visits, individual and family deductibles and coinsurance;

Sec. 14. 24-A MRSA §2843, sub-§3, as amended by PL 1995, c. 560, Pt. K, §82 and affected by §83, is repealed.

Sec. 15. 24-A MRSA §2843, sub-§3-A is enacted to read:

3-A.__Definitions.__For purposes of this section, unless the context otherwise indicates, the following terms have the following meanings.

A.__"Adult" means any person who is 19 years of age or older.

B.__"Biologically based mental illness" means any mental or nervous condition caused by a biological disorder of the brain that results in a clinically significant syndrome that substantially limits the person's functioning.__ "Biologically based mental illness" includes, but is not limited to, any of the following illnesses for which the diagnostic criteria are prescribed in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, as periodically revised, or subsequent publication as the illnesses apply to adults and children:

(1)__Schizophrenia;

(2)__Bipolar disorder;

(3)__Pervasive developmental disorder, or autism;

(4)__Paranoia;

(5)__Panic disorder;

(6)__Obsessive-compulsive disorder;

(7)__Major depressive disorder;

(8)__Attention deficit and disruptive behavior disorders;

(9)__Eating disorders, including bulimia and anorexia;

(10)__Tic disorders; or

(11)__Substance abuse-related disorders.

C.__"Child" means any person under 19 years of age.

D.__"Day treatment services" includes psychoeducational, physiological, psychological and psychosocial concepts, techniques and processes necessary to maintain or develop functional skills of clients provided to individuals and groups for periods of more than 2 hours but less than 24 hours per day.

E.__"Health benefit plan" means:

a.(1)__Policies, contracts or certificates for hospital or medical benefits that are offered, renewed, amended, executed, continued, delivered or issued for delivery

b.in this State to an employer or individual on a group or individual basis or on an individual or group subscription basis and that provide coverage for residents of this State;

c.

(2)__Nonprofit hospital or medical service organization plans;

d.

(3)__Health maintenance organization subscriber or group master contracts;

e.

(4)__Preferred provider plans;

f.

(5)__Health benefit plans offered or administered by the State or by any g. subdivision or instrumentality of the State;

h.

(6)__Multiple employer welfare arrangements or associations located in this State or another state that cover residents of this State who are eligible employees; or

(7)__i.Employer self-insured plans that are not exempt pursuant to the__federal Employee Retirement Income Security Act provisions.

"Health benefit plan" does not include accident-only insurance; fixed indemnity insurance; credit health insurance; Medicare supplement policies; Civilian Health and Medical Program of the Uniformed Services supplement policies; long-term care insurance; disability income insurance; workers' compensation or similar insurance; disease-specific insurance; automobile medical payment insurance; dental insurance; or vision insurance.

F.__"Home support services" means rehabilitative services, treatment services and living skills services provided for a person with a biologically based mental illness.__Home support services may be provided in a community setting or the person's current place of residence and are services that promote the integration of the person into the community, sustain the person in the person's current living situation or another living situation of the person's choosing and enhance the quality of the person's life. Home support services may be provided directly to the person or indirectly through collateral contact or by telephone contact or other means on behalf of the person.__"Home support services" include, but are not limited to:

i.(1)__Case management services and assertive community treatment services;

ii.

(2)__Medication education and monitoring;

iii.

(3)__Crisis intervention and resolution services and follow-up services; and

iv.

(4)__Individual, group and family counseling services.

G.__"Inpatient services" includes, but is not limited to, a range of physiological, psychological and other intervention concepts, techniques and processes in a community mental health psychiatric inpatient unit, general hospital psychiatric unit or psychiatric hospital licensed by the Department of Human Services or accredited public hospital to restore psychosocial functioning sufficient to allow maintenance and support of the client in a less restrictive setting.

H.__"Inpatient treatment" means mental health or substance abuse services delivered on a 24-hour per day basis in a hospital, accredited public hospital, alcohol or drug rehabilitation facility, intermediate care facility, community mental health psychiatric inpatient unit, general hospital psychiatric unit or psychiatric hospital licensed by the Department of Human Services.

I.__"Intermediate care facility" means a licensed, residential public or private facility that is not a hospital and that is operated primarily for the purpose of providing a continuous, structured, 24-hour per day, state- approved program of inpatient substance abuse services.

J.__"Mental health services" means treatment for biologically based mental illnesses.

K.__"Outpatient care" means care rendered by a state- licensed, approved or certified detoxification, residential treatment or outpatient program, or partial hospitalization program on a periodic basis, including, but not limited to, patient diagnosis, assessment and treatment, individual, family and group counseling and educational and support services.

L.__"Outpatient services" includes, but is not limited to, screening, evaluation, consultations, diagnosis and treatment involving use of psychoeducational, physiological, psychological and psychosocial evaluative and interventive

concepts, techniques and processes provided to individuals and groups.

M.__"Person suffering from a biologically based mental illness" means a person whose psychobiological processes are impaired severely enough to manifest problems in the areas of social, psychological or biological functioning. Such a person has a disorder of thought, mood, perception, orientation or memory that impairs judgment, behavior, capacity to recognize or ability to cope with the ordinary demands of life.__The person manifests an impaired capacity to maintain acceptable levels of functioning in the areas of intellect, emotion or physical well-being.

N.__"Preexisting condition" means a condition existing during a specified period immediately preceding the effective date of coverage, which would have caused an ordinarily prudent person to seek medical advice, diagnosis, care or treatment or a condition for which medical advice, diagnosis, care or treatment was recommended or received during a specified period immediately preceding the effective date of coverage.

O.__"Preexisting condition provision" means a provision in a health benefit plan that denies, excludes or limits benefits for an enrollee for expenses or services related to a preexisting condition.

P.__"Provider" means individuals included in section 2835 and a licensed physician with 3 years approved residency in psychiatry, an accredited public hospital or psychiatric hospital or a community agency licensed at the comprehensive service level by the Department of Mental Health, Mental Retardation and Substance Abuse Services.__All agency or institutional providers named in this paragraph shall ensure that services are supervised by a psychiatrist or licensed psychologist or master's degree-level clinician, licensed in the State to practice at the independent level, who meets Department of Mental Health, Mental Retardation and Substance Abuse Service standards for the provision of supervision.

Q.__"Residential treatment" means services at a facility that provides care 24 hours daily to one or more patients, including, but not limited to, room and board; medical, nursing and dietary services; patient diagnosis, assessment and treatment; individual, family and group counseling; and educational and support services, including a designated unit of a licensed health care facility providing any and

all other services specified in this paragraph to a person suffering from a biologically based mental illness.

R.__"Treatment" means services, including diagnostic evaluation, medical, psychiatric and psychological care, and psychotherapy for biologically based mental illnesses rendered by a hospital, alcohol or drug rehabilitation facility, intermediate care facility, mental health treatment center or a professional, licensed in this State to diagnose and treat conditions defined in the Diagnostic and Statistical Manual of Mental Disorders, as periodically revised or subsequent publication.

Sec. 16. 24-A MRSA §2843, sub-§§4 and 5, as enacted by PL 1983, c. 515, §6, are amended to read:

4. Requirement. Every insurer which that issues group health care contracts providing coverage for hospital care to residents of this State shall provide benefits as required in this section to any subscriber or other person covered under those contracts for conditions arising from mental illness. The requirements of this section apply to every health benefit plan that provides coverage for a family member of the insured or the subscriber that is offered, renewed, amended, executed, continued, delivered or issued for delivery in this State to an employer on a group basis.

5. Services. Each group contract shall must provide, at a minimum, for the following benefits for a person suffering from a mental or nervous condition illness:

A. Inpatient care treatment and services;

B. Day treatment services; and

C. Outpatient care, treatment and services.;

D.__Home support services; and

E.__Residential treatment.

Sec. 17. 24-A MRSA §2843, sub-§5-A, as amended by PL 1989, c. 490, §4, is repealed.

Sec. 18. 24-A MRSA §2843, sub-§5-C, as amended by PL 1995, c. 625, Pt. B, §8 and affected by §9 and amended by c. 637, §4, is further amended to read:

5-C. Coverage for treatment for certain mental illnesses. Coverage for medical treatment for biologically based mental illnesses listed in paragraph A is subject to this subsection.

A. All group contracts must provide, at a minimum, benefits according to paragraph B, subparagraph (1) for a person receiving medical treatment for any of the following mental illnesses diagnosed by a licensed allopathic or osteopathic physician or a licensed psychologist who is trained and has received a doctorate in psychology specializing in the evaluation and treatment of human behavior: biologically based mental illness.

(1) Schizophrenia;

(2) Bipolar disorder;

(3) Pervasive developmental disorder, or autism;

(4) Paranoia;

(5) Panic disorder;

(6) Obsessive-compulsive disorder; or

(7) Major depressive disorder.

B. All policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State on or after July 1, 1996 must provide benefits that meet the requirements of this paragraph. For purposes of this paragraph, all contracts are deemed renewed no later than the next yearly anniversary of the contract date.

(1) The contracts must provide benefits for the treatment and diagnosis of biologically based mental illnesses under terms and conditions that are no less extensive than equal to the benefits provided for medical treatment for physical illnesses.

(2) At the request of a nonprofit hospital or medical service organization reimbursing insurer, a provider of medical or psychiatric treatment for biologically based mental illness shall furnish data substantiating that initial or continued treatment is medically or psychiatrically necessary and appropriate. When making the determination of whether treatment is medically or psychiatrically necessary and appropriate, the provider shall use the same criteria for medical or psychiatric treatment for biologically based mental illness as for

medical treatment for physical illness under the group contract.

(3)__The benefits and coverage required under this paragraph must be provided as one set of benefits and coverage covering biologically based mental illness, must have the same terms and conditions as the benefits and coverage for physical illnesses covered under the policy or contract subject to this section and may be delivered under a managed care system.

(4)__A policy or contract subject to this paragraph may not have separate maximums for physical illnesses and biologically based mental illnesses; separate deductibles and coinsurance amounts for physical illnesses and biologically based mental illnesses; separate out-of-pocket limits in a benefit period of not more than 12 months for physical illnesses and biologically based mental illnesses; or separate office visitation limits for physical illnesses and biologically based mental illnesses.

(5)__A health benefit plan may not impose a limitation on coverage or benefits for biologically based mental illnesses unless that same limitation is also imposed identically on the coverage and benefits for physical illnesses covered under the policy or contract.

(6)__Any copayments required under a policy or contract for benefits and coverage for biologically based mental illnesses must be actuarially equivalent to any coinsurance requirements or if there are no coinsurance requirements, the copayment may not be greater than any copayment required under the policy or contract for a benefit or coverage for a physical illness.

(7)__A health benefit plan may not limit coverage for a preexisting condition that is a biologically based mental illness.

(8)__For the purposes of this paragraph, a medication management visit associated with a biologically based mental illness must be covered in the same manner as a medication management visit for the treatment of a physical illness and may not be counted in the calculation of any maximum outpatient treatment visit limits.

This subsection does not apply to policies, contracts and certificates covering employees of employers with 20 or fewer

employees, whether the group policy is issued to the employer, to an association, to a multiple-employer trust or to another entity.

This subsection may not be construed to allow coverage and benefits for the treatment of alcoholism or other drug dependencies through the diagnosis of a mental illness listed in paragraph A.

Sec. 19. 24-A MRSA §2843, sub-§5-D, as amended by PL 1995, c. 637, §5, is repealed.

Sec. 20. 24-A MRSA §2843, sub-§6, as enacted by PL 1983, c. 515, §6, is amended to read:

6. Limits; coinsurance; deductibles. Any policy or contract which that provides coverage for the services required by this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions only to the extent that these provisions are not inconsistent with the requirements of this section maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions are equal to those established for physical illness and conforms with the requirements of subsection 5-C, paragraph B.

Sec. 21. 24-A MRSA §2843, sub-§9 is enacted to read:

9.__Transition.__The provisions of this section do not limit the provision of specialized services for individuals with mental illness who are covered by Medicaid, supercede the provisions of federal law, federal or state Medicaid policy or the terms and conditions imposed on any Medicaid waiver granted to the State with respect to the provision of services to individuals with mental illness and affect any annual health insurance plan until its date of renewal or any health insurance plan governed by a collective bargaining agreement or employment contract until the expiration of that contract.

Sec. 22. 24-A MRSA §4234-A, sub-§1, ¶C, as enacted by PL 1995, c. 407, §10, is repealed and the following enacted in its place:

C.__Typical health coverage in this State continues to discriminate against mental illness and those coping with such illnesses despite repeated efforts to mandate equal coverage.__Discrimination takes the form of limiting or denying coverage with nonexistent or limited benefits compared to provisions for other illnesses, which are not limited or denied; and

Sec. 23. 24-A MRSA §4234-A, sub-§2, ¶¶A and B, as enacted by PL 1995, c. 407, §10, are amended to read:

A. Promote Require that every health benefit plan that is offered, amended, delivered, continued, executed, issued for delivery or renewed in this State provide coverage and benefits for biologically based mental illness and substance abuse problems equal to or exceeding the coverage and benefits available under health benefit plans for the diagnosis and treatment of all other covered physical illnesses and to ensure equitable and nondiscriminatory health coverage benefits for all forms of illness, including mental and emotional disorders, that are of significant consequence to the health of people of the State and that can be treated in a cost-effective manner;

B. Ensure that victims of mental and other illnesses have access to and choice of appropriate treatment at the earliest point of illness in the least restrictive settings, including coverage for inpatient treatment, outpatient services, day treatment services, outpatient care, residential treatment,__home support services, crisis intervention and resolution care, medication, maximum lifetime benefits, copayments, coverage of home visits, individual and family deductibles and coinsurance;

Sec. 24. 24-A MRSA §4234-A, sub-§3, as amended by PL 1999, c. 256, Pt. O, §3, is repealed.

Sec. 25. 24-A MRSA §4234-A, sub-§3-A is enacted to read:

3-A.__Definitions.__For purposes of this section, unless the context otherwise indicates, the following terms have the following meanings.

A.__"Adult" means any person who is 19 years of age or older.

B.__"Biologically based mental illness" means any mental or nervous condition caused by a biological disorder of the brain that results in a clinically significant syndrome that substantially limits the person's functioning.__ "Biologically based mental illness" includes, but is not limited to, any of the following illnesses for which the diagnostic criteria are prescribed in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, as periodically revised, or subsequent publication as the illnesses apply to adults and children:

(1)__Schizophrenia;

(2)__Bipolar disorder;

(3)__Pervasive developmental disorder, or autism;

(4)__Paranoia;

(5)__Panic disorder;

(6)__Obsessive-compulsive disorder;

(7)__Major depressive disorder;

(8)__Attention deficit and disruptive behavior disorders;

(9)__Tic disorders;

(10)__Eating disorders, including bulimia and anorexia; and

(11)__Substance abuse-related disorders.

C.__"Child" means any person under 19 years of age.

D.__"Day treatment services" includes psychoeducational, physiological, psychological and psychosocial concepts, techniques and processes necessary to maintain or develop functional skills of clients provided to individuals and groups for periods of more than 2 hours but less than 24 hours a day.

E.__"Health benefit plan" means:

(1)__Policies, contracts or certificates for hospital or medical benefits that are offered, renewed, amended, executed, continued, delivered or issued for delivery in this State to an employer or individual on a group or individual basis or on an individual or group subscription basis and that provide coverage for residents of this State;

(2)__Nonprofit hospital or medical service organization plans;

(3)__Health maintenance organization subscriber or group master contracts;

(4)__Preferred provider plans;

(5)__Health benefit plans offered or administered by the State or by any__subdivision or instrumentality of the State;

(6)__Multiple employer welfare arrangements or associations located in this State or another state that cover residents of this State who are eligible employees; or

(7)__Employer self-insured plans that are not exempt pursuant to the__federal Employee Retirement Income Security Act provisions.

"Health benefit plan" does not include accident-only insurance; fixed indemnity insurance; credit health insurance; Medicare supplement policies; Civilian Health and Medical Program of the Uniformed Services supplement policies; long-term care insurance; disability income insurance; workers' compensation or similar insurance; disease-specific insurance; automobile medical payment insurance; dental insurance; or vision insurance.

F.__"Home support services" means rehabilitative services, treatment services and living skills services provided for a person with a biologically based mental illness.__Home support services may be provided in a community setting or the person's current place of residence and are services that promote the integration of the person into the community, sustain the person in the person's current living situation or another living situation of the person's choosing and enhance the quality of the person's life. Home support services may be provided directly to the person or indirectly through collateral contact or by telephone contact or other means on behalf of the person.__"Home support services" include, but are not limited to:

(1)__Case management services and assertive community treatment services;

(2)__Medication education and monitoring;

(3)__Crisis intervention and resolution services and follow-up services; and

(4)__Individual, group and family counseling services.

G.__"Inpatient services" includes, but is not limited to, a range of physiological, psychological and other intervention concepts, techniques and processes used in a community mental health psychiatric inpatient unit, general hospital

psychiatric unit or psychiatric hospital licensed by the Department of Human Services or in an accredited public hospital to restore psychosocial functioning sufficient to allow maintenance and support of the client in a less restrictive setting.

H.__"Inpatient treatment" means mental health or substance abuse services delivered on a 24-hour per day basis in a hospital, accredited public hospital alcohol or drug rehabilitation facility, intermediate care facility, community mental health psychiatric inpatient unit, general hospital psychiatric unit or psychiatric hospital licensed by the Department of Human Services.

I.__"Intermediate care facility" means a licensed, residential public or private facility that is not a hospital and that is operated primarily for the purpose of providing a continuous, structured,24-hour per day, state- approved program of inpatient substance abuse services.

J.__"Mental health services" means treatment for biologically based mental illnesses.

K.__"Outpatient care" means care rendered by a state- licensed, approved or certified detoxification, residential treatment or outpatient program, or partial hospitalization program on a periodic basis, including, but not limited to, patient diagnosis, assessment and treatment, individual, family and group counseling and educational and support services.

L.__"Outpatient services" includes, but is not limited to, screening, evaluation, consultations, diagnosis and treatment involving use of psychoeducational, physiological, psychological and psychosocial evaluative and interventive concepts, techniques and processes provided to individuals and groups.

M.__"Person suffering from a biologically based mental illness" means a person whose psychobiological processes are impaired severely enough to manifest problems in the area of social, psychological or biological functioning. Such a person has a disorder of thought, mood, perception, orientation or memory that impairs judgment, behavior, capacity to recognize or ability to cope with the ordinary demands of life.__The person manifests an impaired capacity to maintain acceptable levels of functioning in the area of intellect, emotion or physical well-being.

N.__"Preexisting condition" means a condition existing during a specified period immediately preceding the effective date of coverage, which would have caused an ordinarily prudent person to seek medical advice, diagnosis, care or treatment or a condition for which medical advice, diagnosis, care or treatment was recommended or received during a specified period immediately preceding the effective date of coverage.

O.__"Preexisting condition provision" means a provision in a health benefit plan that denies, excludes or limits benefits for an enrollee for expenses or services related to a preexisting condition.

P.__"Provider" means an individual included in section 2744, subsection 1, a licensed physician, an accredited public hospital or psychiatric hospital or a community agency licensed at the comprehensive service level by the Department of Mental Health, Mental Retardation and Substance Abuse Services.__All agency or institutional providers named in this paragraph__shall ensure that services are supervised by a psychiatrist or licensed psychologist or master's degree-level clinician, licensed in the State to practice at the independent level, who meets Department of Mental Health, Mental Retardation and Substance Abuse Services standards for the provision of supervision.

Q.__"Residential treatment" means services at a facility that provides care 24 hours daily to one or more patients, including, but not limited to, room and board; medical, nursing and dietary services; patient diagnosis, assessment and treatment; individual, family and group counseling; and educational and support services, including a designated unit of a licensed health care facility providing any and all other services specified in this paragraph to a person suffering from a biologically based mental illness.

R.__"Treatment" means services, including diagnostic evaluation, medical, psychiatric and psychological care, and psychotherapy for biologically based mental illnesses rendered by a hospital, alcohol or drug rehabilitation facility, intermediate care facility, mental health treatment center or a professional, licensed in this State to diagnose and treat conditions defined in the Diagnostic and Statistical Manual of Mental Disorders, as periodically revised or subsequent publication.

Sec. 26. 24-A MRSA §4234-A, sub-§§4 and 5, as enacted by PL 1995, c. 407, §10, are amended to read:

4. Requirement. Every health maintenance organization that issues individual or group health care contracts providing coverage for hospital care to residents of this State shall provide benefits as required in this section to any subscriber or other person covered under those contracts for conditions arising from mental illness. The requirements of this section apply to every health benefit plan that provides coverage for a family member of the insured or the subscriber that is offered, renewed, amended, executed, continued, delivered or issued for delivery in this State to an employer or individual on a group or individual basis.

5. Services. Each individual or group contract must provide, at a minimum, the following benefits for a person suffering from a mental or nervous condition illness:

A. Inpatient treatment and services;

B. Day treatment services; and

C. Outpatient care, treatment and services.;

D.__Home support services; and

E.__Residential treatment.

Sec. 27. 24-A MRSA §4234-A, sub-§6, as amended by PL 1995, c. 637, §6, is further amended to read:

6. Coverage for treatment of certain mental illnesses. Coverage for medical treatment for biologically based mental illnesses listed in paragraph A is subject to this subsection.

A. All individual or group contracts must provide, at a minimum, benefits according to paragraph B, subparagraph (1) for a person receiving medical treatment for any of the following biologically based mental illnesses diagnosed by a licensed allopathic or osteopathic physician or a licensed psychologist who is trained and has received a doctorate in psychology specializing in the evaluation and treatment of human behavior.

(1) Schizophrenia;

(2) Bipolar disorder;

(3) Pervasive developmental disorder, or autism;

(4) Paranoia;

(5) Panic disorder;

(6) Obsessive-compulsive disorder; or

(7) Major depressive disorder.

B. All policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State on or after July 1, 1996 must provide benefits that meet the requirements of this paragraph. For purposes of this paragraph, all contracts are deemed renewed no later than the next yearly anniversary of the contract date.

(1) The contracts must provide benefits for the treatment and diagnosis of biologically based mental illnesses under terms and conditions that are no less extensive than equal to the benefits provided for medical treatment for physical illnesses.

(2) At the request of a reimbursing health maintenance organization, a provider of medical or psychiatric treatment for biologically based mental illness shall furnish data substantiating that initial or continued treatment is medically or psychiatrically necessary and appropriate. When making the determination of whether treatment is medically or psychiatrically necessary and appropriate, the provider shall use the same criteria for medical or psychiatric treatment for biologically based mental illness as for medical treatment for physical illness under the group contract.

(3)__The benefits and coverage required under this paragraph must be provided as one set of benefits and coverage covering biologically based mental illness, must have the same terms and conditions as the benefits and coverage for physical illnesses covered under the policy or contract subject to this section and may be delivered under a managed care system.

(4)__The contracts subject to this paragraph may not have separate maximums for physical illnesses and biologically based mental illnesses; separate deductibles and coinsurance amounts for physical illnesses and biologically based mental illnesses; separate out-of-pocket limits in a benefit period of not more than 12 months for physical illnesses and biologically based mental illnesses; or separate office visitation limits for physical illnesses and biologically based mental illnesses.

(5)__A health benefit plan may not impose a limitation on coverage or benefits for biologically based mental illnesses unless that same limitation is also imposed identically on the coverage and benefits for physical illnesses covered under the policy or contract.

(6)__Any copayments required under a policy or contract for benefits and coverage for biologically based mental illnesses must be actuarially equivalent to any coinsurance requirements or if there are no coinsurance requirements, the copayment may not be greater than any copayment required under the policy or contract for a benefit or coverage for a physical illness.

(7)__A health benefit plan may not limit coverage for a preexisting condition that is a biologically based mental illness.

(8) For the purposes of this paragraph, a medication management visit associated with a biologically based mental illness must be covered in the same manner as a medication management visit for the treatment of a physical illness and may not be counted in the calculation of any maximum outpatient treatment visit limits.

This subsection does not apply to policies, contracts or certificates covering employees of employers with 20 or fewer employees, whether the group policy is issued to the employer, to an association, to a multiple-employer trust or to another entity.

This subsection may not be construed to allow coverage and benefits for the treatment of alcoholism and other drug dependencies through the diagnosis of a mental illness listed in paragraph A.

Sec. 28. 24-A MRSA §4234-A, sub-§7, as amended by PL 1995, c. 637, §7, is repealed.

Sec. 29. 24-A MRSA §4234-A, sub-§§8 and 9, as enacted by PL 1995, c. 407, §10, are amended to read:

8. Contracts; providers. Subject to approval by the superintendent pursuant to section 4204, a health maintenance organization incorporated under this chapter shall allow providers, as described in section 2744, to contract, subject to the health maintenance organization's credentialling policy, for the provision of mental health services within the scope of the provider's licensure and within the scope of this section.

9. Limits; coinsurance; deductibles. A policy or contract that provides coverage for the services required by this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions only to the extent that these provisions are not inconsistent with the requirements of this section maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions are equal to those established for physical illness and conform with the requirements of subsection 6, paragraph B.

Sec. 30. 24-A MRSA §4234-A, sub-§12 is enacted to read:

12.__Transition.__The provisions of this section do not limit the provision of specialized services for individuals with mental illness who are covered by Medicaid, supercede the provisions of federal law, federal or state Medicaid policy or the terms and conditions imposed on any Medicaid waiver granted to the State with respect to the provision of services to individuals with mental illness and affect any annual health insurance plan until its date of renewal or any health insurance plan governed by a collective bargaining agreement or employment contract until the expiration of that contract.

SUMMARY

This bill requires all insurance sold in the State to cover certain biologically based mental illnesses under the same terms and conditions as physical illnesses. The bill also increases the list of mental illnesses defined as biologically based by including eating disorders, substance abuse disorders, tic disorders, and attention and disruptive disorders.