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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. 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. Readers are encouraged to consult applicable statutes and regulations and to contact the Bureau of Insurance if additional information is needed.

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Last Updated: September 27, 2010