D.C. Mun. Regs. tit. 26, r. 26-A1901

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 26-A1901 - METHOD OF PAYMENT

1901.1

If an insurance policy or plan includes deductibles, copayments, or annual and lifetime limitations for alcohol abuse, drug abuse and mental illness coverage which are separate and distinct from those imposed for the treatment of physical illness, the following shall apply:

(a) The methods for determining level of payment or reimbursement for services, or for the types of facility charges, shall be consistent with those for physical illness and shall take into account the usual, customary, and reasonable charges for the services rendered;

(b) The policy or plan shall apply deductibles, copayments, and annual or lifetime dollar limits which are no less favorable than those applied to physical illness generally; and

(c) The levels and types of payment or reimbursement shall be subject to review by the Commissioner pursuant to § 10(b) and (c) of the Act, D.C. Code §§ 35 -2309(b) and (c).

1901.2

Co-payment and deductible plans shall not set limits which are contrary to benefits set forth in § 5(b) of the Act, D.C. Code § 35-2304(b), and mental illness benefits shall not have a lifetime limit which is less than eighty thousand ($80,000) dollars or one third of the lifetime maximum for physical illness, whichever is greater.

1901.3

Before an insured may qualify for benefits under these rules, a licensed physician, psychologist, or social worker shall certify that:

(a) the insured requires treatment for drug abuse, alcohol abuse, or other mental illness; and

(b) an inpatient, residential, outpatient, and treatment program is medically or psychologically necessary.

1901.4

Certifications from licensed physicians, psychologists, or social workers, when certifying that the services are medically or psychologically necessary, shall include, but not be limited to, the following information:

(a) The name, address, telephone number, and social security number of the patient;

(b) The actual condition or illness complained of;

(c) The duration of the illness;

(d) History of the treatment of the illness;

(e) The names of any prior attending physician(s);

(f) A description of the illness from the most recent edition of the International Classification of Disease or the Diagnostic and Statistics Manual of the American Psychiatric Association;

(g) A description of the medical or psychological treatment called for by the references used to describe the illness;

(h) The duration of treatment;

(i) A designation of the type of providers capable of rendering the Treatment; and

(j) A designation of the setting, or facility type, in which the treatment would be suitable.

1901.5

If an insurer reimburses a type of provider for rendering medical services, then it shall reimburse the same type of provider for rendering similar service for drug abuse, alcohol abuse and mental illness.

D.C. Mun. Regs. tit. 26, r. 26-A1901

Final Rulemaking published at 36 DCR 4922 (July 14, 1989)