Pennsylvania Statutes Title 40 P.S. Insurance § 764g. Mental illness coverage

(a) As used in this section:

(1)  “Serious mental illness” means any of the following mental illnesses as defined by the American Psychiatric Association in the most recent edition of the Diagnostic and Statistical Manual:  schizophrenia, bipolar disorder, obsessive-compulsive disorder, major depressive disorder, panic disorder, anorexia nervosa, bulimia nervosa, schizoaffective disorder and delusional disorder.

(2)  “Health insurance policy” means any group health, sickness or accident policy or subscriber contract or certificate issued by an entity subject to one (1) of the following:

(i) This act.

(ii) The act of December 29, 1972 (P.L. 1701, No. 364),  1 known as the “Health Maintenance Organization Act.”

(iii) 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations) or 63 (relating to professional health services plan corporations).

(b) This section shall apply to any health insurance policy offered, issued or renewed on or after the effective date of this section in this Commonwealth to groups of fifty (50) or more employes:  Provided, that this section shall not include the following policies:  accident only, fixed indemnity, limited benefit, credit, dental, vision, specified disease, Medicare supplement, CHAMPUS (Civilian Health and Medical Program for the Uniformed  2 Services) supplement, long-term care, disability income, workers' compensation or automobile medical payment.

(c) Health insurance policies covered under this section shall provide coverage for serious mental illnesses that meet at a minimum the following standards:

(1) coverage for serious mental illnesses shall include at least thirty (30) inpatient and sixty (60) outpatient days annually;

(2) a person covered under such policies shall be able to convert coverage of inpatient days to outpatient days on a one-for-two basis;

(3) there shall be no difference in either the annual or lifetime dollar limits in coverage for serious mental illnesses and any other illnesses;

(4) cost-sharing arrangements, including, but not limited to, deductibles and copayments for coverage of serious mental illnesses, shall not prohibit access to care.  The department shall set up a method to determine whether any cost-sharing arrangements violate this subsection.

(d) The Legislative Budget and Finance Committee shall undertake a study of the cost and benefits of this section eighteen (18) months after the effective date of this section.  The committee shall prepare a report of its study for the General Assembly on or before June 30, 2001, and every two years thereafter.  3  Such study and report shall include, but not be limited to, an analysis of the following:  the effect on policy premiums;  the cost benefit of extending this act to all group health insurance policies offered in this Commonwealth;  the cost benefit of this enhanced level of coverage for mental illness and the cost benefit to those employers who offer policies with more liberal benefits;  the identity of employers who, after the effective date of this section, provide reduced mental health insurance benefits to employes and who provided  4 more liberal mental health insurance benefits than provided in this act;  an analysis of any mental illnesses enumerated under axis 1 of the Current Diagnostic and Statistical Manual of Mental Disorders not covered under this section, with specific consideration of whether any of them should be included in the definition of serious mental illness;  actions taken by the department to assure health insurance policies are in compliance with this section and that quality and access to treatment for mental health conditions are not compromised by providing coverage under this section;  identify any segments of this Commonwealth's population that may be excluded from access to treatment for mental health conditions;  and an analysis of the use of medical services resulting from the provision of access to mental health treatment as provided by this section.

(1) The department shall fully cooperate and provide all nonconfidential data, records, reports and information that the committee may request in connection with this study.

(2) The study and report authorized in paragraph (1) must be actuarially sound and subject to peer review by the American Academy of Actuaries.  Any assumptions upon which the study and the report are based must be common to the current health insurance market in Pennsylvania.

1 40 P.S. § 1551 et seq.
2 “Uniform” in enrolled bill.
3 Pursuant to Act 2015, June 30, P.L. 85, No. 13, § 1(1), imd. effective, the Legislative Budget and Finance Committee shall no longer undertake studies and prepare reports of the studies for the General Assembly under 40 P.S. § 764g(d).
4 “provide” in enrolled bill.

Cite this article: FindLaw.com - Pennsylvania Statutes Title 40 P.S. Insurance § 764g. Mental illness coverage - last updated January 01, 2019 | https://codes.findlaw.com/pa/title-40-ps-insurance/pa-st-sect-40-764g.html


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