Mandated Outpatient Mental Health and Alcoholism Treatment Benefits

WILLIAM F. WELD GOVERNOR ARGEO PAUL CELLUCCI LIEUTENANT GOVERNOR COMMONWEALTH OF MASSACHUSETTS DIVISION OF INSURANCE 470 Atlantic Avenue • Boston, MA 02210-2223 (617) 521-7794- FAX (617) 521-7770 TTY /TDD(617) 521-7490 LINDA RUTHARDT COMMISSIONER # Bulletin 97-04 To: Commercial Insurance Carriers, Blue Cross and Blue Shield of Massachusetts (BCBSMA) and Health Maintenance Organizations (HMOs) From: Commissioner Linda Ruthardt RE: Mandated Outpatient Mental Health and Alcoholism Treatment Benefits DATE: April 23, 1997 The purpose of this bulletin is to remind commercial carriers, BCBSMA and HMOs that that all health plans are required to provide coverage, to the extent of $500.00 over a twelve month period, for both: (1) outpatient mental health treatment and; (2) outpatient treatment for alcoholism. M.G.L. c. 175, §47B, M.G.L. c. 176A, §8A, M.G.L. c. 176B, §4A and M.G.L. c. 176G §4 mandate that commercial carriers, BCBSMA and HMOs provide coverage, to the extent of $500.00 over a twelve month period, for outpatient mental health benefits. The Division has, in the past, accepted eight individual visits as the service equivalent of $500.00. The Division would like to clarify that coverage for eight individual visits as the service equivalent of $500.00 is acceptable only if the mental health provider's usual and customary service charge is $62.50. If, however, the mental health provider is able to document that his/her usual and customary service charge is less than $62.50 for a visit, then commercial insurance carriers, BCBSMA and HMOs are required to cover as many visits as necessary to provide the covered person with a minimum of $500.00 worth of outpatient mental health benefits at the provider's usual and customary rate of reimbursement. , however, the mental health provider is able to document that his/her usual and customary service charge is less than $62.50 for a visit, then commercial insurance carriers, BCBSMA and HMOs are required to cover as many visits as necessary to provide the covered person with a minimum of $500.00 worth of outpatient mental health benefits at the provider's usual and customary rate of reimbursement. In addition, commercial carriers, BCBSMA and HMOs must provide coverage for outpatient alcoholism treatment benefits to the extent of $500.00 over a twelve month period as set forth in M.G.L. c. 175, §110(H), M.G.L. c. 176A, §10, M.G.L. c. 176B, §4A½ and M.G.L. c. 176G §4. The Division has, in the past, accepted eight individual visits as the service equivalent of $500.00. The Division would like to clarify that coverage for eight individual visits as the service equivalent of $500.00 is acceptable only if the alcoholism treatment provider's usual and customary service charge is $62.50. If, however, the alcoholism treatment provider is able to document that his/her usual and customary service charge is less than $62.50 for a visit, then commercial insurance carriers, BCBSMA and HMOs are required to cover as many visits as necessary to provide the covered person with a minimum of $500.00 worth of alcoholism treatment benefits at the provider's usual and customary rate of reimbursement. Any questions regarding this bulletin may be directed to the Health Unit of the State Rating Bureau at (617) 521-7349.