Every person, the state and any of its instrumentalities, any county, township, school district, or other political subdivisions and any of its instrumentalities, and any municipal corporation and any of its instrumentalities, which provides payment for health care benefits for any of its employees resident in this state, which benefits are not provided by contract with an insurer qualified to provide sickness and accident insurance, or a health insuring corporation, shall include the following benefits in its plan of health care benefits commencing on or after January 1, 1979:
(A) If such plan of health care benefits provides payment for the treatment of mental or nervous disorders, then such plan shall provide benefits for services on an outpatient basis for each eligible employee and dependent for mental or emotional disorders, or for evaluations, that are at least equal to the following:
(1) Payments not less than five hundred fifty dollars in a twelve-month period, for services legally performed by or under the clinical supervision of a licensed physician or a licensed psychologist, whether performed in an office, in a hospital, or in a community mental health facility so long as the hospital or community mental health facility is approved by the joint commission on accreditation of healthcare organizations, the council on accreditation for children and family services, the rehabilitation accreditation commission, or, until two years after the effective date of this amendment, certified by the department of mental health as being in compliance with standards established under division (H) of section 5119.01 of the Revised Code;
(2) Such benefit shall be subject to reasonable limitations, and may be subject to reasonable deductibles and co-insurance costs.
(3) In order to qualify for participation under this division, every facility specified in this division shall have in effect a plan for utilization review and a plan for peer review and every person specified in this 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.
(4) Such payment for benefits shall not be greater than usual, customary, and reasonable.
(5) (a) Services performed under the clinical supervision of a licensed physician or licensed psychologist, in order to be reimbursable under the coverage required in division (A) of this section, shall meet both of the following requirements:
(i) The services shall be performed in accordance with a treatment plan that describes the expected duration, frequency, and type of services to be performed;
(ii) The plan shall be reviewed and approved by a licensed physician or licensed psychologist every three months.
(b) Payment of benefits for services reimbursable under division (A)(5)(a) of the section shall not be restricted to services described in the treatment plan or conditioned upon standards of a licensed physician or licensed psychologist, which at least equal the requirements of division (A)(5)(a) of this section.
(B) Payment for benefits for alcoholism treatment for outpatient, inpatient, and intermediate primary care for each eligible employee and dependent that are at least equal to the following:
(1) Payments not less than five hundred fifty dollars in a twelve-month period for services legally performed by or under the clinical supervision of a licensed physician or licensed psychologist, whether performed in an office, or in a hospital or a community mental health facility or 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;
(2) The benefits provided under this division shall be subject to reasonable limitations and may be subject to reasonable deductibles and co-insurance costs.
(3) A licensed physician or licensed psychologist shall every three months certify a patient's need for continued services performed by such facilities.
(4) In order to qualify for participation under this division, every facility specified in this division shall have in effect a plan for utilization review and a plan for peer review and every person specified in this division shall have in effect a plan for peer review. Such plans shall have the purpose of ensuring high quality patient care and efficient utilization of available health facilities and services. Such person or facilities shall also have in effect a program of rehabilitation or a program of rehabilitation and detoxification.
(5) Nothing in this section shall be construed to require reimbursement for benefits which is greater than usual, customary, and reasonable.
HISTORY: 137 v S 90 (Eff 8-30-78); 138 v H 900 (Eff 7-1-80); 139 v S 336 (Eff 8-23-82); 142 v S 124 (Eff 10-1-87); 147 v S 67 (Eff 6-4-97); 149 v H 94. Eff 6-6-2001.
The effective date is set by section 206 of HB 94.
Cross-References to Related Sections
Multiple employer welfare arrangement shall comply with all laws applicable to self-funded programs, RC § 1739.05.
Ohio Adminstrative Code
Department of alcohol and drug addiction services -
Standards for program services. OAC ch. 3793:2-1.
Client records; minimum requirements for program certification or licensure. OAC 3793:2-1-06.
Department of mental health -
Standards for agencies, program services subject to mandated insurance coverage -
Agency certification; procedure. OAC 5122-25-03, 5122-25-04.
Individualized service plan ("ISP") and progress notes. OAC 5122-27-04.
Personnel qualifications. OAC 5122-26-07.
Research Aids
Specific coverage requirements:
O-Jur3d: Ins § 1255
Am-Jur2d: Ins §§ 548, 628
----------