Health & Safety Code 1374.72; Insurance Code
10144.5. Effective for contracts issued,
amended, or renewed on or after 7/1/00. Does
not apply to Medi-Cal HMOs.
Health plans
must provide coverage for the diagnosis and
medically necessary treatment of severe
mental illness in any person or serious
emotional disturbance of a child. The health
plan may provide the required services
through a separate or specialized health
care service plan.
The benefits
must include:
-
outpatient services;
-
inpatient hospital
services;
-
partial hospital
services;
-
prescription drugs, if the plan covers
prescription drugs.
Benefits that
must be applied equally to all benefits
under the health plan contract include:
-
maximum life
benefits (caps);
-
copayments;
-
individual and family deductibles.
Severe mental
illness includes:
-
schizophrenia;
-
schizoaffective
disorder;
-
bipolar disorder
(manic-depressive illness);
-
major depressive
disorders;
-
panic disorders;
-
obsessive-compulsive
disorder;
-
pervasive
developmental disorder or autism;
-
anorexia nervosa;
-
bulimia
nervosa.
Serious emotional disturbance
of a child is defined as a child who:
(1) has
one or more mental disorders identified
in the DSM, other than a primary
substance abuse disorder or
developmental disorder, that results in
behavior inappropriate to the child's
age according to expected developmental
norms, AND
(2) meets
the criteria specified in Welfare &
Institutions code 5600.3 (a)(2) -- as a
result of the mental disorder, ONE of
the following occurs:
(A) The child
has substantial impairment in at
least two of the following areas:
self-care, school functioning,
family relationships, or ability to
function in the community; AND
either of the following occur:
(i) the
child is at risk of removal from
home or has already been removed
from the home, or
(ii) the mental disorder and
impairments have been present
for more than six months or are
likely to continue for more than
one year without treatment, OR
(B) The
child displays one of the following:
psychotic features, risk of suicide or
risk of violence due to a mental
disorder, OR
(C) The child meets
special education eligibility
requirements (is an "individual with
exceptional needs" identified by an
individualized education program team as
a child with a disability, and the
child's impairment requires instruction,
services, or both, which cannot be
provided with modification of the
regular school program).
