31A-22-658. Health care provider behavioral health treatment -- Single case agreement.

508 words·~2 min read·/ut/title-31a/chapter-22/31a-22-658

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

Effective 5/3/2023

(1)As used in this section:

(a)"Mental health condition" means the same as that term is defined in Section 31A-22-649.5 .

(b)"Mental health provider" means:

(i)a mental health therapist, as defined in Section 58-60-102 ; or

(ii)an individual practicing within the scope of practice described in Title 58, Chapter 60, Part 5, Substance Use Disorder Counselor Act .

(c)"Mental health treatment" means treatment for a mental health condition.

(a)Except as provided in Subsection

(3), and subject to Subsections

(4)and

(5), beginning January 1, 2024, a health benefit plan that offers coverage for mental health treatment shall, upon request of a health benefit plan enrollee who is employed as a health care provider, offer a single case agreement that allows the enrollee to receive covered mental health treatment from an out-of-network mental health provider selected by the enrollee.

(b)A single case agreement described in Subsection (2)(a) shall:

(i)reimburse the out-of-network mental health provider for the covered mental health treatment at the equivalent out-of-network rate set by the health benefit plan, subject to the member cost-sharing requirements imposed by the health benefit plan;

(ii)include the same coinsurance, copayments, and deductibles that would be applied for the mental health treatment if the mental health treatment was provided by a mental health provider who is a network provider;

(iii)include the terms that a network provider is subject to under the health benefit plan; and

(iv)define the length and scope of the single case agreement.

(a)Subsection

(2)does not apply if:

(A)the health benefit plan has network providers for the covered mental health treatment; and

(B)the network providers described in Subsection (3)(a)(i) do not provide the covered mental health treatment in the location where the enrollee works as a health care provider; or

(ii)the enrollee selects a mental health provider for the covered mental health treatment who the health benefit plan knows or reasonably suspects has committed a fraudulent insurance act as described in Section 31A-31-103 .

(b)For purposes of this Subsection

(3), the location where an enrollee works as a health care provider includes all locations or facilities of the enrollee's employer.

(4)Mental health treatment provided pursuant to a single case agreement under this section:

(a)shall be:

(i)within the out-of-network mental health provider's scope of practice; and

(ii)a service that is otherwise covered under the enrollee's health benefit plan; and

(b)may not be experimental.

(a)An enrollee shall request a single case agreement under Subsection

(2)prior to receiving mental health treatment from an out-of-network mental health provider.

(b)With a request for a single case agreement under Subsection

(2), an enrollee shall provide information about where the enrollee works as a health care provider sufficient for the health benefit plan to determine whether the circumstances described in Subsection (3)(a)(i) exist.

Enacted by Chapter 449 , 2023 General Session