Timothy's Law
By the New York State Insurance Department
New Yorkers with group insurance health coverage may enjoy access to improved mental health benefits due to legislation that went
into effect on January 1, 2007. Chapter 748 of the Laws of 2006, or Timothy's Law, was named after a young boy, Timothy O'Clair, whose
parents were unable to access adequate health insurance coverage to treat his mental illness. The new law requires coverage for inpatient
and outpatient mental health services. The following summarizes some of the key provisions of the law.
Am I entitled to these benefits?
To be entitled to the mental health benefits mandated by Timothy's Law, you must be covered by group health insurance or a school blanket
health insurance policy. Group health insurance is insurance that you obtain through an employer or through an association, such as a chamber
of commerce. A school blanket health insurance policy covers students enrolled in a college or university who purchase their insurance through
the school.
If you are enrolled in Healthy New York or Child Health Plus, or you are covered under or purchase your own insurance directly from an insurance
company, the benefits of Timothy's Law do not apply to you.
When does my coverage begin?
Timothy's Law took effect on January 1, 2007 and applies to policies and contracts issued, amended, or renewed after that date. This means, for example,
that if your health insurance policy renews on May 1, 2007, then the mental health benefits provided under Timothy's Law will go into effect on May 1.
Back to Top
What benefits are covered?
The types of benefits to which you may be entitled depend primarily upon the size of your employer. Employees of both large employers (50+ employees)
and small employers (50 employees or fewer) are entitled to care for mental, nervous, or emotional disorders, for no less than thirty days of inpatient
care and twenty visits of outpatient care per year.
Inpatient care must be provided in a hospital defined under the Mental Hygiene Law. The inpatient care does not include time spent in a residential treatment
facility. You may replace one inpatient day for two visits in a partial hospitalization program.
The 20 visits of outpatient treatment must be provided in a facility issued an operating certificate by the Commissioner of Mental Health, a facility
operated by the office of Mental Health or by a psychiatrist, psychologist, social worker, or a professional corporation or university faculty practice corporation.
What cost-sharing must apply?
The deductibles, copayments and coinsurance applied to these benefits may be no greater than those applied to other benefits under the contract.
For example, if your policy has a $500 inpatient copayment, the policy may impose a $500 copayment for an inpatient mental health stay. If your policy
has a $40 copayment for office specialist visits, then the policy may impose a $40 copayment for an outpatient mental health visit.
Back to Top
What additional benefits must large employers provide?
If your policy is issued to a group with more than 50 employees, then in addition to the above-described thirty days of inpatient care and twenty
days of outpatient care, you are entitled to mental health benefits for the following biologically based mental illnesses comparable to your level of
coverage for other health benefits under the policy:
- Schizophrenia/psychotic disorders
- Major depression
- Bipolar disorder
- Delusional disorders
- Panic Disorder
- Obsessive Compulsive Disorders
- Bulimia
- Anorexia
In addition, children with serious emotional disturbances are entitled to benefits that are comparable to other benefits under the policy. To qualify
for this benefit, the child must be under the age of 18 with diagnoses of attention deficit disorder, disruptive behavior disorders, or pervasive development
disorders with one or more of the following:
- Serious suicidal symptoms or other life-threatening self-destructive behaviors;
- Significant psychotic symptoms (hallucinations, delusion, bizarre behaviors);
- Behavior caused by emotional disturbances that placed the child at risk of causing personal injury or significant property damage or;
- Behavior caused by emotional disturbances that placed the child at substantial risk of removal from the household.
The deductibles, copayments and coinsurance applied to these benefits may be no greater than those applied to other benefits under the contract.
For example, if you are receiving treatment on an outpatient basis for major depression, and your copayment for a specialist such as a dermatologist
is $30 per visit, then you may be required to pay no more than $30 for a visit to a specialist who is treating your depression.
Small employers must be offered the opportunity to purchase this type of coverage although they are not required to offer this coverage to their employees.
Prior authorization:
Your health plan may require you to obtain prior authorization from them before you receive treatment.
Back to Top