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<section article="gin" article_name="Insurance" number="15-802" title_number="15" title_name="Health Insurance" subtitle_number="8" subtitle_name="Required Health Insurance Benefits">
  <level label="a">
    <level label="1">
      <text>In this section the following words have the meanings indicated.</text>
    </level>
    <level label="2">
      <text>“Alcohol misuse” has the meaning stated in § 8–101 of the Health – General Article.</text>
    </level>
    <level label="3">
      <text>“ASAM criteria” means the most recent edition of the American Society of Addiction Medicine treatment criteria for addictive, substance–related, and co–occurring conditions that establishes guidelines for placement, continued stay and transfer or discharge of patients with addiction and co–occurring conditions.</text>
    </level>
    <level label="4">
      <text>“Drug misuse” has the meaning stated in § 8–101 of the Health – General Article.</text>
    </level>
    <level label="5">
      <text>“Grandfathered health plan coverage” has the meaning stated in 45 C.F.R. § 147.140.</text>
    </level>
    <level label="6">
      <text>“Health benefit plan” means:</text>
      <level label="i">
        <text>for a group or blanket plan, a health benefit plan as defined in § 15–1401 of this title;</text>
      </level>
      <level label="ii">
        <text>for an individual plan, a health benefit plan as defined in § 15–1301(l) of this title; or</text>
      </level>
      <level label="iii">
        <text>short–term limited duration insurance as defined in § 15–1301(s) of this title.</text>
      </level>
    </level>
    <level label="7">
      <text>“Managed care system” means a system of cost containment methods that a carrier uses to review and preauthorize a treatment plan developed by a health care provider for a covered individual in order to control utilization, quality, and claims.</text>
    </level>
    <level label="8">
      <text>“Partial hospitalization” means the provision of medically directed intensive or intermediate short–term treatment:</text>
      <level label="i">
        <text>to an insured, subscriber, or member;</text>
      </level>
      <level label="ii">
        <text>in a licensed or certified facility or program;</text>
      </level>
      <level label="iii">
        <text>for mental illness, emotional disorders, drug misuse, or alcohol misuse; and</text>
      </level>
      <level label="iv">
        <text>for a period of less than 24 hours but more than 4 hours in a day.</text>
      </level>
    </level>
    <level label="9">
      <text>“Small employer” has the meaning stated in § 31–101 of this article.</text>
    </level>
  </level>
  <level label="b">
    <text>With the exception of small employer grandfathered health plan coverage, this section applies to each individual, group, and blanket health benefit plan that is delivered or issued for delivery in the State by an insurer, a nonprofit health service plan, or a health maintenance organization.</text>
  </level>
  <level label="c">
    <text>A health benefit plan subject to this section shall provide at least the following benefits for the diagnosis and treatment of a mental illness, emotional disorder, drug use disorder, or alcohol use disorder:</text>
    <level label="1">
      <text>inpatient benefits for services provided in a licensed or certified facility, including hospital inpatient and residential treatment center benefits;</text>
    </level>
    <level label="2">
      <text>partial hospitalization benefits; and</text>
    </level>
    <level label="3">
      <text>outpatient and intensive outpatient benefits, including all office visits, diagnostic evaluation, opioid treatment services, medication evaluation and management, and psychological and neuropsychological testing for diagnostic purposes.</text>
    </level>
  </level>
  <level label="d">
    <level label="1">
      <text>The benefits under this section are required only for expenses arising from the treatment of mental illnesses, emotional disorders, drug misuse, or alcohol misuse if, in the professional judgment of health care providers:</text>
      <level label="i">
        <text>the mental illness, emotional disorder, drug misuse, or alcohol misuse is treatable; and</text>
      </level>
      <level label="ii">
        <text>the treatment is medically necessary.</text>
      </level>
    </level>
    <level label="2">
      <text>The benefits required under this section:</text>
      <level label="i">
        <text>shall be provided as one set of benefits covering mental illnesses, emotional disorders, drug misuse, and alcohol misuse;</text>
      </level>
      <level label="ii">
        <text>shall comply with 45 C.F.R. § 146.136(a) through (d) and 29 C.F.R. § 2590.712(a) through (d);</text>
      </level>
      <level label="iii">
        <text>subject to paragraph (3) of this subsection, may be delivered under a managed care system; and</text>
      </level>
      <level label="iv">
        <text>for partial hospitalization under subsection (c)(2) of this section, may not be less than 60 days.</text>
      </level>
    </level>
    <level label="3">
      <text>The benefits required under this section may be delivered under a managed care system only if the benefits for physical illnesses covered under the health benefit plan are delivered under a managed care system.</text>
    </level>
    <level label="4">
      <text>The processes, strategies, evidentiary standards, or other factors used to manage the benefits required under this section must be comparable as written and in operation to, and applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used to manage the benefits for physical illnesses covered under the health benefit plan.</text>
    </level>
    <level label="5">
      <text>An insurer, nonprofit health service plan, or health maintenance organization shall use the ASAM criteria for all medical necessity and utilization management determinations for substance use disorder benefits.</text>
    </level>
  </level>
  <level label="e">
    <text>An entity that issues or delivers a health benefit plan subject to this section shall provide on its website and annually in print to its insureds or members:</text>
    <level label="1">
      <text>notice about the benefits required under this section and the federal Mental Health Parity and Addiction Equity Act; and</text>
    </level>
    <level label="2">
      <text>notice that the insured or member may contact the Administration for further information about the benefits.</text>
    </level>
  </level>
  <level label="f">
    <text>An entity that issues or delivers a health benefit plan subject to this section shall:</text>
    <level label="1">
      <text>post a release of information authorization form on its website; and</text>
    </level>
    <level label="2">
      <text>provide a release of information authorization form by standard mail within 10 business days after a request for the form is received.</text>
    </level>
  </level>
</section>
