Application of utilization review programs to mandated benefits for the treatment of mental illness, alcoholism, and drug dependency

Bulletin 159

Application of utilization review programs to mandated benefits for the treatment of mental

illness, alcoholism, and drug dependency

January 17, 1989

BULLETIN SUMMARY

Utilization review programs are no longer required to treat all hospitalizations and institutional

confinements for treatment of

alcoholism, drug dependency, and mental illness as emergency services. However, even if there is

non-compliance with a utilization review program, benefits for alcoholism, drug dependency, and

mental illness may not be reduced below the statutory minimums.

POLICY

Maine law requires that group health insurance and health care contracts, policies, and certificates

provide benefits for the treatment of alcoholism, drug dependency, and mental illness. See 24

M.R.S.A. Sections 2325-A and 2329, 24-A M.R.S.A. Sections 2842 and 2843 and Bureau of Insurance

Rules Chapters 320 and 330. The Superintendent of Insurance has not approved and will not approve

any policy, contract, or certificate which would reduce the benefits for the treatment of

alcoholism, drug dependency, or mental illness ("the covered illnesses") below the minimums

established by Rules Chapters 320 and 330.

A utilization review program is a program whereby the insured, subscriber, or other covered person is

required to be prospectively evaluated through a prehospital admission certification, pre-inpatient

service eligibility program, or any similar pre-utilization review or screening procedure prior to the

delivery of contemplated hospitalization, inpatient or outpatient health care or medical services. A

program of continued stay review, discharge planning, or any similar concurrent review program is

also a utilization review program.

The Superintendent has required utilization review programs to treat all hospitalizations and other

institutional confinements for treatment of the covered illnesses as emergency services

hospitalization, inpatient or outpatient health care or medical services. A

program of continued stay review, discharge planning, or any similar concurrent review program is

also a utilization review program.

The Superintendent has required utilization review programs to treat all hospitalizations and other

institutional confinements for treatment of the covered illnesses as emergency services. Recognizing

that many mental illness, alcoholism and drug dependency related hospitalizations, and other

institutional confinements are not of an emergency nature the Superintendent will no longer require all

utilization review programs to treat all hospitalizations and other institutional confinements for

treatment of the covered illnesses as emergency services. A recommended hospitalization or

institutional confinement for treatment of a covered illness which is not a medical emergency may be

treated the same as any other illness by a utilization review program with the exception that

application of penalties or reduced benefits for non-compliance with the program may not reduce the

benefits provided for the treatment of a covered illness below the mandatory minimum standards. A

group health insurance or health care contract, policy, or certificate which does not provide benefits

above the mandatory minimum benefit standards can have no penalties or reduced benefits for non-

compliance with the utilization review program.

A utilization review program may define a medical emergency with respect to the covered illnesses no

more restrictively than the unexpected onset of a medical condition which if not treated immediately

could reasonably be expected to result in loss of life or serious impairment of an individual's bodily

functions.

Joseph A. Edwards

Superintendent of Insurance

NOTE: This bulletin is intended solely for informational purposes. It is not intended to set forth legal

rights, duties or privileges nor is it intended to provide legal advice

t of a medical condition which if not treated immediately

could reasonably be expected to result in loss of life or serious impairment of an individual's bodily

functions.

Joseph A. Edwards

Superintendent of Insurance

NOTE: This bulletin is intended solely for informational purposes. It is not intended to set forth legal

rights, duties or privileges nor is it intended to provide legal advice. Readers are encouraged to

consult applicable statutes and regulations and to contact the Bureau of Insurance if additional

information is needed.