Timothy's Law

1. WHAT IS TIMOTHY'S LAW?

Timothy's Law is a New York State law that requires many health insurance policies for small groups (those with 50 or fewer participants) issued or delivered in New York State to provide certain minimum benefits for mental illness. Timothy's Law also requires that large-group policies treat certain mental illnesses as they would physical illnesses and injury, for purposes of coverage. In addition, this law requires that health plans give small groups the option to buy additional coverage that is similar to the coverage available for large groups, which treats coverage for certain mental illnesses the same as physical illnesses.

2. WHEN DID TIMOTHY'S LAW START?

Timothy's Law was signed by the governor on December 22, 2006, and it applies to affected health insurance policies issued, renewed or changed on or after January 1, 2007.

3. DOES TIMOTHY'S LAW APPLY TO ALL HEALTH BENEFIT PROGRAMS?

No. The following types of programs are exempt from Timothy's Law:

• Federal Employees Health Benefits Plan
• Healthy New York
• Administrative Services Only (ASO) programs
• Individual direct payment and conversion programs
• Government programs (such as Medicaid, Managed Care, Family Health Plus, Child Health Plus, Medicare Advantage, Medicare Part D)
• Medicare supplement programs

4. HOW DOES TIMOTHY'S LAW AFFECT MY HEALTH INSURANCE BENEFITS?

Whether and how Timothy's Law affects your health benefits depends on your type of coverage.

FOR LARGE GROUP PROGRAMS (more than 50 employees):

Timothy's Law allows you full parity of health benefits for serious emotional disturbances in children and for biologically-based mental illnesses, such as schizophrenia, major depression, bipolar disorders, anorexia and bulimia. Full parity means that these diagnoses are covered with the same day and visit limits, cost-sharing and other coverage terms that apply under your contract for physical illness and injury.

For other types of mental illness, the coverage under Timothy's Law may vary based on your group's contract.

• If your plan's contract covers inpatient hospital care, Timothy's Law entitles you to coverage of at least 30 days of inpatient mental health care and at least 20 outpatient mental health visits, per member, per year. Coverage will be subject to the same cost-sharing and other coverage terms that apply to physical illness and injury. Benefits for biologically-based mental illnesses and serious emotional disturbances in children count toward these inpatient and outpatient limits. If your current benefits are more than these limits, your benefits will not be reduced.
• If your plan's large group contract covers a doctor's services, but not inpatient hospital care, Timothy's Law entitles you to coverage of at least 20 outpatient mental health visits for other types of mental illness beyond the list above, per member, per year. Coverage will be subject to the same cost-sharing and other coverage terms that apply to physical illness and injury. Benefits for biologically-based mental illnesses and serious emotional disturbances in children count toward this outpatient visit limit. If your current benefits are more than these limits, your benefits will not be reduced.

FOR SMALL GROUP PROGRAMS (50 or fewer employees):

Under Timothy's Law, you are covered for at least 30 days of inpatient care and at least 20 outpatient visits per member, per year for all mental, nervous or emotional ailments. Coverage will be subject to the same cost-sharing and coverage terms that apply to physical illness. This coverage is available at no additional cost to your group. Your group will also have the choice of buying additional coverage, at extra cost, that will provide full parity of benefits for serious emotional disturbances in children and for biologically-based mental illnesses, such as schizophrenia, major depression, bipolar disorders, anorexia and bulimia. Full parity means that these diagnoses are covered with the same day and visit limits, cost-sharing, and other coverage terms that apply under your contract for physical illness and injury.

5. WHAT ARE BIOLOGICALLY-BASED MENTAL ILLNESSES?

Under Timothy's Law, biologically-based mental illnesses include:

• Schizophrenia/psychotic disorders
• Major depression
• Bipolar disorder
• Delusional disorders
• Panic disorder
• Obsessive-compulsive disorder
• Bulimia
• Anorexia

6. WHAT ARE SERIOUS EMOTIONAL DISTURBANCES IN CHILDREN?

Under Timothy's Law, serious emotional disturbances are diagnoses of attention deficit disorders (ADD), disruptive behavior disorders, or pervasive development disorders in children under 18 years of age, together with one or more of the following conditions:

• Serious suicidal symptoms or other life-threatening self-destructive behaviors;
• Significant psychotic symptoms (hallucinations, delusions, bizarre behaviors);
• Behavior caused by emotional disturbances that place the child at risk of causing personal injury or significant property damage; or
• Behavior caused by emotional disturbances that place the child at major risk of being removed from the household.

7. HOW DO I KNOW IF THE SERVICES I AM RECEIVING ARE COVERED?

GHI partners with ValueOptions, a leader in managing mental health and substance abuse services, to administer mental health benefits for its members. For coverage questions, you may call ValueOptions at 1-866-271-6403, or call the number for mental health services shown on the back of your ID card.

The Emblem Behavioral Health Services Program administers mental health benefits for members of GHI HMO and HIP. For coverage questions, you may call 1-888-447-2526, or call the mental health services number shown on the back of your ID card

8. I WANT TO SEE A MENTAL HEALTH PROVIDER WHO IS NOT A GHI OR HIP NETWORK PROVIDER. WHERE DO I SEND THE CLAIM?

EPO and HMO programs do not have out-of-network benefits, except in the case of a medical emergency; therefore, the same provisions apply to Timothy's Law.

For Other Program Subscribers:

Claims for mental health or substance abuse services for members in all plans should be sent to:

Emblem Behavioral Health Services Program
PO Box 803
Latham, NY 12210