RS 22:1066

§1066. Parity in the application of certain limits to mental health benefits A.(1) In the case of a group health plan, or health insurance coverage offered in connection with such a plan, that provides both medical and surgical benefits and mental health benefits: (a) If the plan or coverage does not include an aggregate lifetime limit on substantially all medical and surgical benefits, the plan or coverage may not impose any aggregate lifetime limit on mental health benefits. (b) If the plan or coverage includes an aggregate lifetime limit on substantially all medical and surgical benefits, in this Paragraph referred to as the "applicable lifetime limit", the plan or coverage shall do one of the following: (i) Apply the applicable lifetime limit both to the medical and surgical benefits to which it otherwise would apply and to mental health benefits and not distinguish in the application of such limit between such medical and surgical benefits and mental health benefits. (ii) Not include any aggregate lifetime limit on mental health benefits that is less than the applicable lifetime limit. (c) In the case of a plan or coverage that is not described in Subparagraph (a) or (b) of this Paragraph and that includes no or different aggregate lifetime limits on different categories of medical and surgical benefits, the commissioner shall establish rules under which Subparagraph (b) of this Paragraph is applied to such plan or coverage with respect to mental health benefits by substituting for the applicable lifetime limit an average aggregate lifetime limit that is computed taking into account the weighted average of the aggregate lifetime limits applicable to such categories. (2) In the case of a group health plan, or health insurance coverage offered in connection with such a plan, that provides both medical and surgical benefits and mental health benefits: (a) If the plan or coverage does not include an annual limit on substantially all medical and surgical benefits, the plan or coverage may not impose any annual limit on mental health benefits. (b) If the plan or coverage includes an annual limit on substantially all medical and surgical benefits, in this Paragraph referred to as the "applicable annual limit", the plan or coverage shall do one of the following: (i) Apply the applicable annual limit both to medical and surgical benefits to which it otherwise would apply and to mental health benefits and not distinguish in the application of such limit between such medical and surgical benefits and mental health benefits. (ii) Not include any annual limit on mental health benefits that is less than the applicable annual limit. (c) In the case of a plan or coverage that is not described in Subparagraph (a) or (b) of this Paragraph that includes no or different annual limits on different categories of medical and surgical benefits, the plan shall comply with all applicable federal regulations under which Subparagraph (b) of this Paragraph is applied to such plan or coverage with respect to mental health benefits by substituting for the applicable annual limit an average annual limit that is computed taking into account the weighted average of the annual limits applicable to such categories. B. Except as provided in Subsection A of this Section, nothing in this Section shall be construed to do the any of the following: (1) Require a group health plan, or health insurance coverage offered in connection with such a plan, to provide any mental health benefits. (2) Affect the terms and conditions of a group health plan, or health insurance coverage offered in connection with such a plan, that provides mental health benefits. Terms and conditions shall include cost sharing, limits on numbers of visits or days of coverage, and requirements relating to medical necessity, relating to the amount, duration, or scope of mental health benefits under the plan or coverage. C.(1) This Section shall not apply to any group health plan, and group health insurance coverage offered in connection with a group health plan, for any plan year of a small employer. (2) This Section shall not apply with respect to a group health plan, or health insurance coverage offered in connection with a group health plan, if the application of this Section to such plan or to such coverage results in an increase in the cost under the plan or for such coverage of at least one percent. D. In the case of a group health plan that offers a participant or beneficiary two or more benefit package options under the plan, the requirements of this Section shall be applied separately with respect to each such option. E. For purposes of this Section, the following terms are defined as follows: (1) "Aggregate lifetime limit" means a dollar limitation on the total amount that may be paid with respect to such benefits under the plan or health insurance coverage with respect to an individual or other coverage unit. (2) "Annual limit" means a dollar limitation on the total amount of benefits that may be paid with respect to such benefits in a twelve-month period under the plan or health insurance coverage with respect to an individual or other coverage unit. (3) "Medical or surgical benefits" means benefits with respect to medical or surgical services, as defined under the terms of the plan or coverage, as the case may be, but does not include mental health benefits. (4) "Mental health benefits" means benefits with respect to mental health services, as defined under the terms of the plan or coverage, as the case may be, but does not include benefits with respect to treatment of substance abuse or chemical dependency. F. Repealed by Acts 2001, No. 66, §1, eff. Sept. 30, 2001. Acts 1997, No. 1138, §1, eff. July 14, 1997; Acts 1999, No. 30, §1; Acts 2001, No. 66, §1, eff. Sept. 30, 2001; Redesignated from R.S. 22:250.5 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2010, No. 919, §1, eff. Jan. 1, 2011. NOTE: Former R.S. 22:1066 redesignated as R.S. 22:843 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.