§ 31–3102. Coverage.

(a) Except as described in subsection (b) of this section, each health insurer that offers individual or group health plans or certificates issued or delivered in the District to an employer or individual shall provide coverage for the medical and psychological treatment of drug abuse, alcohol abuse, and mental illness.

(b) The requirements of this chapter shall not apply to dread disease policies, student policies, nursing home policies, and home health care policies.

(c) Covered benefits for drug abuse, alcohol abuse, and mental illness in insurance policies and contracts subject to this chapter shall be limited to inpatient, residential, and outpatient services certified as necessary by a physician, psychologist, advanced practice registered nurse, or social worker.

(d) Before an insured party may qualify to receive benefits under this chapter, a physician, psychologist, advanced practice registered nurse, or social worker shall certify that the individual has a drug addiction or an alcohol addiction or a mental illness and prescribe appropriate treatment, which may include referral to other treatment providers.

(e) All drug abuse, alcohol abuse, and mental illness treatment or services eligible for health insurance coverage shall be subject to peer review procedures. These procedures may be initiated by a health insurer in the course of reviewing claims for payment.

(f) Repealed.

(g) All individual health benefit plans or certificates shall offer coverage for the medical and psychological treatment of drug abuse, alcohol abuse, and mental illness. Coverage shall be offered for at least the minimum levels set forth in §§ 31-3103 and 31-3104.

(h) Group health benefit plans or certificates that are the result of collective bargaining between a legally-certified union and the employer shall be required to include coverage for inpatient and outpatient treatment of drug abuse, alcohol abuse, and mental illness. The minimum levels of coverage set forth in §§ 31-3103 and 31-3104 shall not apply to those group health benefit plans or certificates until 5 years from February 28, 1987, unless the Mayor requests the Council to extend the exemption to a time certain and the Council, by resolution, approves the extension.

(i) If a large group health benefit plan offers a participant or beneficiary 2 or more benefit package options under the plan, the requirements of this chapter shall be applied separately to each option.

(j) A health insurer may require that substance abuse and mental illness insurance coverage shall be provided through a managed care system.

(Feb. 28, 1987, D.C. Law 6-195, § 3, 34 DCR 491; Apr. 30, 1988, D.C. Law 7-104, § 21, 35 DCR 147; Mar. 16, 1993, D.C. Law 9-192, § 2(a), (b), 39 DCR 9007; Mar. 23, 1995, D.C. Law 10-247, § 3, 42 DCR 457; Oct. 21, 2000, D.C. Law 13-178, § 2(b), 47 DCR 6844; Mar. 8, 2007, D.C. Law 16-242, § 2(b), 54 DCR 601; Apr. 24, 2007, D.C. Law 16-305, § 42, 53 DCR 6198.)

Prior Codifications

1981 Ed., § 35-2302.

Section References

This section is referenced in § 31-3103, § 31-3104, and § 31-3110.

Effect of Amendments

D.C. Law 13-178 added subsec. (i).

D.C. Law 16-242 rewrote subsecs. (a) and (b); in subsec. (e), substituted “a health insurer” for “an insurer”; repealed subsec. (f); in subsec. (g), substituted “health benefit plans or certificates” for “subscriber contracts or policies”; in subsec. (h), substituted “health benefit plans or certificates” for “health insurance policies or contracts”; in subsec. (i), substituted “health benefit plan” for “health plan”; and added subsec. (j).

D.C. Law 16-305, in subsec. (d), substituted “has a drug addiction or an alcohol addiction or a mental illness” for “is suffering from drug abuse, alcohol abuse, or mental illness”.

Emergency Legislation

For temporary amendment of section, see § 2(b) of the Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage Emergency Amendment Act of 1998 (D.C. Act 12-274, February 19, 1998, 45 DCR 1526), and § 2(b) of the Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage Second Emergency Amendment Act of 1998 (D.C. Act 12-546, December 18, 1998, 46 DCR 497).

Temporary Legislation

For temporary (225 day) amendment of section, see § 2(b) of Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage Temporary Amendment Act of 1998 (D.C. Law 12-108, May 8, 1998, law notification 45 DCR 3259).