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    OpenPayerPolicy UpdatesPsychiatry/Behavioral HealthNorth Dakota Mental Illness Coverage | OpenPayer
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    CurrentNorth Dakota Insurance DepartmentPolicy N/A

    Chapter 26–39 of North Dakota Century Code, on Mental Illness, Etc.

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    This bulletin provides administrative interpretations regarding insurance benefits for mental illness and related treatment, including benefit eligibility, covered persons, equivalence to benefits for other illnesses, inpatient treatment, and partial hospitalization.

    Policy Summary
    PayerNorth Dakota Insurance Department
    PolicyChapter 26–39 of North Dakota Century Code, on Mental Illness, Etc.
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJuly 1, 1975
    Next Review DateN/A
    Key ActionEnsure inpatient and partial hospitalization combinations are directed by a physician and are most advantageous to the covered person.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    70 daysAnnual inpatient benefit
    140 daysAnnual partial hospitalization benefit
    1:2Inpatient-to-partial hospitalization equivalency
    50%Partial hospitalization daily benefit

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    Spouses and children
    Additional eligible covered persons

    Mental Illness Benefit Equivalence

    Equivalent Benefits for Mental Illness

    Mental illness benefits must be equivalent to benefits provided under the policy for other illnesses.

    Benefit equivalence: When a policy provides daily room-and-board hospital benefits for other illnesses, it must provide equivalent room-and-board benefits, including equivalent general nursing services, for mental illness. When it provides physician medical services for other illnesses, it must provide equivalent physician services for mental illness. When it provides diagnostic or evaluation services for other illnesses, it must provide equivalent diagnostic or evaluation services for mental illness.

    Professionally trained specialists other than physicians may perform physician, diagnostic, or evaluation services when approved and directed by a physician.

    Inpatient and Partial Hospitalization Benefits

    When the policy provides the regular daily room-and-board hospital benefit for other illnesses, mental illness benefits must satisfy one of the following equivalent benefit structures.

    Annual treatment benefit options

    • Inpatient option: At least 70 days of inpatient treatment in any calendar year.at least 70 days
    • Partial hospitalization option: At least 140 days of partial hospitalization in any calendar year.at least 140 days
    • Equivalent combination option: A combination of inpatient treatment and partial hospitalization using the one-to-two day equivalency.1 inpatient day = 2 partial hospitalization days

      The combination is determined according to the covered person’s needs and must be most advantageous to that person.

    Partial Hospitalization Daily Benefit

    Partial hospitalization benefits must be equivalent to the applicable inpatient benefit.

    Partial hospitalization payment equivalence: The maximum dollar amount of benefit for each day of partial hospitalization must equal one half of the maximum dollar amount provided for each day of inpatient treatment.50% of the inpatient daily maximum

    Medical services of physicians, if available under the policy, are also provided during partial hospitalization.

    Benefit Limits and Equivalencies

    Annual inpatient treatment benefit
    Minimum benefitAt least 70 days of inpatient treatment
    Benefit periodAny calendar year
    ApplicabilityApplies when the policy provides the regular daily room-and-board hospital benefit for other illnesses
    Annual partial hospitalization benefit
    Minimum benefitAt least 140 days of partial hospitalization
    Benefit periodAny calendar year
    ApplicabilityApplies when the policy provides the regular daily room-and-board hospital benefit for other illnesses

    Policy Interpretation Overview

    This bulletin provides the North Dakota Insurance Department’s administrative interpretation of Chapter 26–39 of the North Dakota Century Code concerning insurance coverage for mental illness and related treatment. It addresses covered persons, equivalence between mental-health benefits and benefits for other illnesses, and coverage for inpatient treatment and partial hospitalization. Where comparable hospital benefits are provided for other illnesses, the policy must provide equivalent mental-health benefits, with inpatient and partial-hospitalization benefits coordinated according to the covered person’s needs and physician direction. It became effective July 1, 1975.

    Defined Terms and Covered Persons

    Licensed treatment facility
    Statutory termLicensed hospital
    InterpretationRead as licensed treatment facility
    PurposeThe interpretation conforms to the definition in Subsection 1 of Section 26–39–01
    Partial hospitalization
    TermPartial hospitalization
    InterpretationInterpreted liberally from the standpoint of the covered person
    ScopeThe interpretation remains within the definition in Subsection 2 of Section 26–39–01

    Inpatient and Partial Hospitalization Levels of Care

    Partial Hospitalization Treatment Modality

    Partial Hospitalization Treatment Modality

    Partial hospitalization is covered under the applicable annual benefit and equivalency requirements.

    Partial hospitalization benefit: Partial hospitalization must be covered when the policy provides the applicable regular daily room-and-board hospital benefit for other illnesses, subject to the stated annual benefit and equivalency rules.At least 140 days annually, or an equivalent combination with inpatient treatment

    The treatment combination is based on the covered person’s needs, under physician direction, and must be most advantageous to the covered person.

    Annual Mental Illness Treatment Limits

    Mental illness treatment
    Inpatient optionAt least 70 inpatient treatment days in any calendar year
    Partial hospitalization optionAt least 140 partial hospitalization days in any calendar year
    Equivalent combinationInpatient and partial hospitalization days may be combined using one inpatient day for two partial hospitalization days, according to the covered person’s needs and physician direction
    Policy Summary
    PayerNorth Dakota Insurance Department
    PolicyChapter 26–39 of North Dakota Century Code, on Mental Illness, Etc.
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJuly 1, 1975
    Next Review DateN/A
    Key ActionEnsure inpatient and partial hospitalization combinations are directed by a physician and are most advantageous to the covered person.
    SourceLink
    On This Page
    Mental Illness Benefit EquivalenceBenefit Limits and EquivalenciesPolicy Interpretation OverviewDefined Terms and Covered PersonsInpatient and Partial Hospitalization Levels of CarePartial Hospitalization Treatment ModalityAnnual Mental Illness Treatment Limits
    Treatment-day equivalency
    Inpatient-to-partial equivalencyOne inpatient day may be provided in lieu of two partial hospitalization days
    Partial-to-inpatient equivalencyTwo partial hospitalization days may be provided in lieu of one inpatient day
    Combination basisThe combination must be based on the covered person’s needs, upon the direction of a physician, and be most advantageous to the covered person
    Partial hospitalization daily benefit
    Daily benefitEqual to one half of the maximum dollar amount provided for each day of inpatient treatment
    Benefit comparisonRepresents the partial hospitalization equivalent of the regular daily room-and-board benefit, including general nursing services
    Physician servicesMedical services of physicians, if available under the policy, are provided during partial hospitalization
    Covered persons
    Covered personsPersons covered or to be covered under the applicable provision
    Family members includedSpouses and children of eligible employees or members
    Qualifying groupsAn employer, association, or other group