Bill Text: NJ S1253 | 2012-2013 | Regular Session | Introduced
Bill Title: Requires SHBP and SHEBP to cover treatment for alcoholism, other substance-use disorders, and non biologically-based mental illnesses under same terms and conditions as for other diseases or illnesses.*
Spectrum: Partisan Bill (Democrat 22-1)
Status: (Vetoed) 2013-08-19 - Absolute Veto, Received in the Senate [S1253 Detail]
Download: New_Jersey-2012-S1253-Introduced.html
Sponsored by:
Senator JOSEPH F. VITALE
District 19 (Middlesex)
SYNOPSIS
Revises statutory mental health coverage requirements and requires all health insurers and SHBP to cover treatment for alcoholism and other substance-use disorders under same terms and conditions as for other diseases or illnesses.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning health care coverage for mental health services and alcoholism and other substance-use disorders and revising parts of the statutory law.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. Section 1 of P.L.1999, c.106 (C.17:48-6v) is amended to read as follows:
1. a. Every individual and group hospital service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act shall provide coverage for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the contract.
In addition, if the hospital service corporation contract provides coverage for a disorder that is included in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders and is not a biologically-based mental illness, the contract shall provide coverage for that disorder under the same terms and conditions as provided for any other sickness under the contract; however, coverage for treatment of alcoholism and other substance-use disorders shall be subject to the provisions of section 1 of P.L.1977, c.115 (C.17:48-6a).
"Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder or autism. "Same terms and conditions" means that the hospital service corporation cannot apply different copayments, deductibles, or benefit limits, including day or visit limits or annual or lifetime dollar limits, to biologically-based or other mental health benefits, as applicable, than those applied to other medical or surgical benefits.
b. Nothing in this section shall be construed to change the manner in which a hospital service corporation determines:
(1) whether a mental health
care service meets the medical
necessity standard as established by the hospital service corporation; or
(2) which providers shall be entitled to reimbursement for providing services for mental illness under the contract.
c. The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium.
(cf: P.L.1999, c.106, s.1)
2. Section 2 of P.L.1999, c.106 (C.17:48A-7u) is amended to read as follows:
2. a. Every individual and group medical service corporation contract that provides hospital or medical expense benefits that is delivered, issued, executed, or renewed in this State pursuant to P.L.1940, c.74 (C.17:48A-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act shall provide coverage for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the contract.
In addition, if the medical service corporation contract provides coverage for a disorder that is included in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders and is not a biologically-based mental illness, the contract shall provide coverage for that disorder under the same terms and conditions as provided for any other sickness under the contract; however, coverage for treatment of alcoholism and other substance-use disorders shall be subject to the provisions of section 1 of P.L.1977, c.117 (C.17:48A-7a).
"Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder or autism. "Same terms and conditions" means that the medical service corporation cannot apply different copayments, deductibles, or benefit limits, including day or visit limits or annual or lifetime dollar limits, to biologically-based or other mental health benefits, as applicable, than those applied to other medical or surgical benefits.
b. Nothing in this section shall be construed to change the manner in which a medical service corporation determines:
(1) whether a mental health care service meets the medical necessity standard as established by the medical service corporation; or
(2) which providers shall be entitled to reimbursement for providing services for mental illness under the contract.
c. The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium.
(cf: P.L.1999, c.106, s.2)
3. Section 3 of P.L.1999, c.106 (C.17:48E-35.20) is amended to read as follows:
3. a. Every individual and group health service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1985, c.236 (C.17:48E-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act shall provide coverage for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the contract.
In addition, if the health service corporation contract provides coverage for a disorder that is included in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders and is not a biologically-based mental illness, the contract shall provide coverage for that disorder under the same terms and conditions as provided for any other sickness under the contract; however, coverage for treatment of alcoholism and other substance-use disorders shall be subject to the provisions of section 34 of P.L.1985, c.236 (C.17:48E-34).
"Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder or autism. "Same terms and conditions" means that the health service corporation cannot apply different copayments, deductibles, or benefit limits, including day or visit limits or annual or lifetime dollar limits, to biologically-based or other mental health benefits, as applicable, than those applied to other medical or surgical benefits.
b. Nothing in this section shall be construed to change the manner in which the health service corporation determines:
(1) whether a mental health care service meets the medical necessity standard as established by the health service corporation; or
(2) which providers shall be entitled to reimbursement for providing services for mental illness under the contract.
c. The provisions of this section shall apply to all contracts in
which the health service corporation has reserved the right to change the premium.
(cf: P.L.1999, c.106, s.3)
4. Section 4 of P.L.1999, c.106 (C.17B:26-2.1s) is amended to read as follows:
4. a. Every individual health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 26 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act shall provide coverage for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the contract.
In addition, if the individual health insurance policy provides coverage for a disorder that is included in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders and is not a biologically-based mental illness, the policy shall provide coverage for that disorder under the same terms and conditions as provided for any other sickness under the policy; however, coverage for treatment of alcoholism and other substance-use disorders shall be subject to the provisions of section 1 of P.L.1977, c.118 (C.17B:26-2.1).
"Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder or autism. "Same terms and conditions" means that the insurer cannot apply different copayments, deductibles, or benefit limits, including day or visit limits or annual or lifetime dollar limits, to biologically-based or other mental health benefits, as applicable, than those applied to other medical or surgical benefits.
b. Nothing in this section shall be construed to change the manner in which the insurer determines:
(1) whether a mental health care service meets the medical necessity standard as established by the insurer; or
(2) which providers shall be entitled to reimbursement for providing services for mental illness under the policy.
c. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.
(cf: P.L.1999, c.106, s.4)
5. Section 5 of P.L.1999, c.106 (C.17B:27-46.1v) is amended to read as follows:
5. a. Every group health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act shall provide benefits for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the policy.
In addition, if the group health insurance policy provides coverage for a disorder that is included in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders and is not a biologically-based mental illness, the policy shall provide coverage for that disorder under the same terms and conditions as provided for any other sickness under the policy; however, coverage for treatment of alcoholism and other substance-use disorders shall be subject to the provisions of section 1 of P.L.1977, c.116 (C.17B:27-46.1).
"Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder or autism. "Same terms and conditions" means that the insurer cannot apply different copayments, deductibles, or benefit limits, including day or visit limits or annual or lifetime dollar limits, to biologically-based or other mental health benefits, as applicable, than those applied to other medical or surgical benefits.
b. Nothing in this section shall be construed to change the manner in which the insurer determines:
(1) whether a mental health care service meets the medical necessity standard as established by the insurer; or
(2) which providers shall be entitled to reimbursement for providing services for mental illness under the policy.
c. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.
(cf: P.L.1999, c.106, s.5)
6. Section 6 of P.L.1999, c.106 (C.17B:27A-7.5) is amended to read as follows:
6. a. Every individual health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.) or approved for issuance or renewal in this State on or after the effective date of this act shall provide benefits for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the health benefits plan.
In addition, if the health benefits plan provides benefits for a disorder that is included in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders and is not a biologically-based mental illness, the plan shall provide benefits for that disorder under the same terms and conditions as provided for any other sickness under the plan; however, coverage for treatment of alcoholism and other substance-use disorders shall be subject to the provisions of section 14 of P.L. , c. (C. )(pending before the Legislature as this bill).
"Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder or autism. "Same terms and conditions" means that the plan cannot apply different copayments, deductibles, or benefit limits, including day or visit limits or annual or lifetime dollar limits, to biologically-based or other mental health benefits, as applicable, than those applied to other medical or surgical benefits.
b. Nothing in this section shall be construed to change the manner in which the carrier determines:
(1) whether a mental health care service meets the medical necessity standard as established by the carrier; or
(2) which providers shall be entitled to reimbursement for providing services for mental illness under the plan.
c. The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.
(cf: P.L.1999, c.106, s.6)
7. Section 7 of P.L.1999, c.106 (C.17B:27A-19.7) is amended to read as follows:
7. a. Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) or approved for issuance or renewal in this State on or after the effective date of this act shall provide benefits for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the health benefits plan.
In addition, if the health benefits plan provides benefits for a disorder that is included in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders and is not a biologically-based mental illness, the plan shall provide benefits for that disorder under the same terms and conditions as provided for any other sickness under the plan; however, coverage for treatment of alcoholism and other substance-use disorders shall be subject to the provisions of section 15 of P.L. , c. (C. )(pending before the Legislature as this bill).
"Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder or autism. "Same terms and conditions" means that the plan cannot apply different copayments, deductibles, or benefit limits, including day or visit limits or annual or lifetime dollar limits, to biologically-based or other mental health benefits, as applicable, than those applied to other medical or surgical benefits.
b. Nothing in this section shall be construed to change the manner in which the carrier determines:
(1) whether a mental health care service meets the medical necessity standard as established by the carrier; or
(2) which providers shall be entitled to reimbursement for providing services for mental illness under the health benefits plan.
c. The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.
(cf: P.L.1999, c.106, s.7)
8. Section 8 of P.L.1999, c.106 (C.26:2J-4.20) is amended to read as follows:
8. a. Every [enrollee agreement] contract delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of [Health and Senior Services] Banking and Insurance, on or after the effective date of this act shall provide health care services for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the [agreement] contract.
In addition, if the contract provides health care services for a disorder that is included in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders and is not a biologically-based mental illness, the contract shall provide health care services for that disorder under the same terms and conditions as provided for any other sickness under the contract; however, coverage for treatment of alcoholism and other substance-use disorders shall be subject to the provisions of section 16 of P.L. , c. (C. ) (pending before the Legislature as this bill).
"Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder or autism. "Same terms and conditions" means that the health maintenance organization cannot apply different copayments, deductibles, or health care services limits, including day or visit limits or annual or lifetime dollar limits, to biologically-based or other mental health care services, as applicable, than those applied to other medical or surgical health care services.
b. Nothing in this section shall be construed to change the manner in which a health maintenance organization determines:
(1) whether a mental health care service meets the medical necessity standard as established by the health maintenance organization; or
(2) which providers shall be entitled to reimbursement or to be participating providers, as appropriate, for mental health services under the [enrollee agreement] contract.
c. The provisions of this section shall apply to [enrollee agreements] contracts in which the health maintenance organization has reserved the right to change the premium.
(cf: P.L.1999, c.106, s.8)
9. Section 9 of P.L.1999, c.106 (C.34:11A-15) is amended to read as follows:
9. An employer in this State who provides health benefits coverage to his employees or their dependents for treatment of biologically-based or other mental illness shall annually, and upon request of an employee at other times during the year, notify his employees whether the employees' coverage for treatment of [biologically-based] mental illness is subject to the requirements of this act.
(cf: P.L.1999, c.106, s.9)
10. Section 1 of P.L.1977, c.117 (C.17:48A-7a) is amended to read as follows:
1. No group or individual contract providing hospital or medical expense benefits shall be delivered, issued, executed, or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, unless such contract provides benefits to any subscriber or other person covered thereunder for expenses incurred in connection with the treatment of alcoholism and other substance-use disorders when such treatment is [prescribed by a doctor of medicine] ordered by a physician, licensed clinical alcohol and drug counselor or other appropriately trained, licensed health care professional based upon a diagnosis of alcoholism or other substance-use disorder as provided in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders and an assessment of the appropriate level of treatment placement that utilizes the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate. Such benefits shall be provided [to the same extent] under the same terms and conditions as provided for any other [sickness] disease or illness under the contract.
"Treatment of alcoholism and other substance-use disorders" includes, but is not limited to, any of the following items or services provided for treatment of alcoholism or other substance-use disorders: inpatient or outpatient treatment, including detoxification, screening and assessment, case management, medication management, psychiatric consultations and individual, group and family counseling, and relapse prevention; non-hospital residential treatment; and prevention services, including health education and individual and group counseling to encourage the reduction of risk factors for alcoholism or other substance-use disorders.
"Same terms and conditions" means that the medical service corporation cannot apply different copayments, deductibles, or benefit limits, including day or visit limits or annual or lifetime dollar limits, to alcoholism and other substance-use disorder treatment services than those applied to other medical or surgical expense benefits.
Every contract shall include such benefits for the treatment of alcoholism and other substance-use disorders as are hereinafter set forth:
a. Inpatient or outpatient care in a [licensed hospital] health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
b. Treatment at a detoxification facility licensed pursuant to [P.L.1975, c.305] section 8 of P.L.1975, c.305 (C.26:2B-14);
c. [Confinement as an inpatient or outpatient at a licensed, certified, or state approved residential treatment facility, under a program which meets minimum standards of care equivalent to those prescribed by the Joint Commission on Hospital Accreditation] Participation as an inpatient at a residential facility licensed by the Division of Mental Health and Addiction Services in the Department of Human Services or as an outpatient in a State-approved outpatient treatment facility that meets minimum standards of care as set forth by the Department of Human Services; and
d. Treatment provided by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional.
Treatment [or confinement] at any facility shall not preclude further or additional treatment at any other eligible facility; provided, however, that the benefit days used do not exceed the total number of benefit days provided for any other [sickness] disease or illness under the contract.
Nothing in this section shall be construed to prohibit the medical service corporation from determining if the treatment of alcoholism and other substance-use disorders is medically necessary; however, the medical service corporation shall, for this purpose, use the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate.
Nothing in this section shall be construed to change the manner in which the medical service corporation determines which health care providers shall be entitled to reimbursement for providing treatment services under the contract.
(cf: P.L.1977, c.117, s.1)
11. Section 34 of P.L.1985, c.236 (C.17:48E-34) is amended to read as follows:
34. No group or individual contract providing health service coverage shall be delivered, issued, executed, or renewed in this State, or approved for issuance or renewal in this State by the commissioner, on or after the effective date of this act, unless the contract provides benefits to any subscriber or other person covered thereunder for expenses incurred in connection with treatment of alcoholism and other substance-use disorders when the treatment is [prescribed by a doctor of medicine] ordered by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional based upon a diagnosis of alcoholism or other substance-use disorder as provided in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders and an assessment of the appropriate level of treatment placement that utilizes the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate. Benefits shall be provided [to the same extent] under the same terms and conditions as provided for any other [sickness] disease or illness under the contract.
"Treatment of alcoholism and other substance-use disorders" includes, but is not limited to, any of the following items or services provided for treatment of alcoholism or other substance-use disorders: inpatient or outpatient treatment, including detoxification, screening and assessment, case management, medication management, psychiatric consultations and individual, group and family counseling, and relapse prevention; non-hospital residential treatment; and prevention services, including health education and individual and group counseling to encourage the reduction of risk factors for alcoholism or other substance-use disorders.
"Same terms and conditions" means that the health service corporation cannot apply different copayments, deductibles, or benefit limits, including day or visit limits or annual or lifetime dollar limits, to alcoholism and other substance-use disorder treatment services than those applied to other medical or surgical expense benefits.
Every contract shall include benefits for the treatment of alcoholism and other substance-use disorders as follows:
a. Inpatient or outpatient care in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
b. Treatment at a detoxification facility licensed pursuant to section 8 of P.L.1975, c.305 (C.26:2B-14);
c. [Confinement as an inpatient or outpatient at a licensed, certified, or state approved residential treatment facility, under a program which meets minimum standards of care equivalent to those prescribed by the Joint Commission on Hospital Accreditation] Participation as an inpatient at a residential facility licensed by the Division of Mental Health and Addiction Services in the Department of Human Services or as an outpatient in a State-approved outpatient treatment facility that meets minimum standards of care as set forth by the Department of Human Services; and
d. Treatment provided by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional.
Treatment [or confinement] at any facility shall not preclude further or additional treatment at any other eligible facility, if the benefit days used do not exceed the total number of benefit days provided for any other [sickness] disease or illness under the contract.
Nothing in this section shall be construed to prohibit the health service corporation from determining if the treatment of alcoholism and other substance-use disorders is medically necessary; however, the health service corporation shall, for this purpose, use the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate.
Nothing in this section shall be construed to change the manner in which the health service corporation determines which health care providers shall be entitled to reimbursement for providing treatment services under the contract.
(cf: P.L.1985, c.236, s.34)
12. Section 1 of P.L.1977, c.118 (C.17B:26-2.1) is amended to read as follows:
1. No health insurance [contract] policy providing hospital or medical expense benefits shall be delivered, issued, executed, or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, unless such [contract] policy provides benefits to any [subscriber] insured or other person covered thereunder for expenses incurred in connection with the treatment of alcoholism and other substance-use disorders when such treatment is [prescribed by a doctor of medicine] ordered by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional based upon a diagnosis of alcoholism or other substance-use disorder as provided in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders and an assessment of the appropriate level of treatment placement that utilizes the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate. Such benefits shall be provided [to the same extent] under the same terms and conditions as provided for any other [sickness] disease or illness under the [contract] policy.
"Treatment of alcoholism and other substance-use disorders" includes, but is not limited to, any of the following items or services provided for treatment of alcoholism or other substance-use disorders: inpatient or outpatient treatment, including detoxification, screening and assessment, case management, medication management, psychiatric consultations and individual, group and family counseling, and relapse prevention; non-hospital residential treatment; and prevention services, including health education and individual and group counseling to encourage the reduction of risk factors for alcoholism or other substance-use disorders.
"Same terms and conditions" means that the insurer cannot apply different copayments, deductibles, or benefit limits, including day or visit limits or annual or lifetime dollar limits, to alcoholism and other substance-use disorder treatment services than those applied to other medical or surgical expense benefits.
Every [contract] policy shall include such benefits for the treatment of alcoholism and other substance-use disorders as are hereinafter set forth:
a. Inpatient or outpatient care in a [licensed hospital] health care facility licensed pursuant to P.L.1971, c.136 (C. 26:2H-1 et seq.);
b. Treatment at a detoxification facility licensed pursuant to [P.L.1975, c.305] section 8 of P.L.1975, c.305 (C.26:2B-14);
c. [Confinement as an inpatient or outpatient at a licensed, certified, or state approved residential treatment facility, under a program which meets minimum standards of care equivalent to those prescribed by the Joint Commission on Hospital Accreditation] Participation as an inpatient at a residential facility licensed by the Division of Mental Health and Addiction Services in the Department of Human Services or as an outpatient in a State-approved outpatient treatment facility that meets minimum standards of care as set forth by the Department of Human Services; and
d. Treatment provided by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional.
Treatment [or confinement] at any facility shall not preclude further or additional treatment at any other eligible facility; provided, however, that the benefit days used do not exceed the total number of benefit days provided for any other [sickness] disease or illness under the [contract] policy.
Nothing in this section shall be construed to prohibit the insurer from determining if the treatment of alcoholism and other substance-use disorders is medically necessary; however, the insurer shall, for this purpose, use the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate.
Nothing in this section shall be construed to change the manner in which the insurer determines which health care providers shall be entitled to reimbursement for providing treatment services under the policy.
(cf: P.L.1977, c.118, s.1)
13. Section 1 of P.L.1977, c.116 (C.17B:27-46.1) is amended to read as follows:
1. No group health insurance [contract] policy providing hospital or medical expense benefits shall be delivered, issued, executed, or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, unless such [contract] policy provides benefits to any [subscriber] insured or other person covered thereunder for expenses incurred in connection with the treatment of alcoholism and other substance-use disorders when such treatment is [prescribed by a doctor of medicine] ordered by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional based upon a diagnosis of alcoholism or other substance-use disorder as provided in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders and an assessment of the appropriate level of treatment placement that utilizes the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate. Such benefits shall be provided [to the same extent] under the same terms and conditions as provided for any other [sickness] disease or illness under the [contract] policy.
"Treatment of alcoholism and other substance-use disorders" includes, but is not limited to, any of the following items or services provided for treatment of alcoholism or other substance-use disorders: inpatient or outpatient treatment, including detoxification, screening and assessment, case management, medication management, psychiatric consultations and individual, group and family counseling, and relapse prevention; non-hospital residential treatment; and prevention services, including health education and individual and group counseling to encourage the reduction of risk factors for alcoholism or other substance-use disorders.
"Same terms and conditions" means that the insurer cannot apply different copayments, deductibles, or benefit limits, including day or visit limits or annual or lifetime dollar limits, to alcoholism and other substance-use disorder treatment services than those applied to other medical or surgical expense benefits.
Every [contract] policy shall include such benefits for the treatment of alcoholism and other substance-use disorders as are hereinafter set forth:
a. Inpatient or outpatient care in a [licensed hospital] health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
b. Treatment at a detoxification facility licensed pursuant to [P.L.1975, c. 305] section 8 of P.L.1975, c.305 (C.26:2B-14);
c. [Confinement as an inpatient or outpatient at a licensed, certified, or state approved residential treatment facility, under a program which meets minimum standards of care equivalent to those prescribed by the Joint Commission on Hospital Accreditation] Participation as an inpatient at a residential facility licensed by the Division of Mental Health and Addiction Services in the Department of Human Services or as an outpatient in a State-approved outpatient treatment facility that meets minimum standards of care as set forth by the Department of Human Services; and
d. Treatment provided by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional.
Treatment [or confinement] at any facility shall not preclude further or additional treatment at any other eligible facility; provided, however, that the benefit days used do not exceed the total number of benefit days provided for any other [sickness] disease or illness under the [contract] policy.
Nothing in this section shall be construed to prohibit the insurer from determining if the treatment of alcoholism and other substance-use disorders is medically necessary; however, the insurer shall, for this purpose, use the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate.
Nothing in this section shall be construed to change the manner in which the insurer determines which health care providers shall be entitled to reimbursement for providing treatment services under the policy.
(cf: P.L.1977, c.116, s.1)
14. (New section) Every individual health benefits plan that provides hospital or medical expense benefits, and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), on or after the effective date of this act, shall provide coverage for expenses incurred in connection with the treatment of alcoholism and other substance-use disorders when such treatment is ordered by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional based upon a diagnosis of alcoholism or other substance-use disorder as provided in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders and an assessment of the appropriate level of treatment placement that utilizes the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate. Such benefits shall be provided under the same terms and conditions as provided for any other disease or illness under the plan.
"Treatment of alcoholism and other substance-use disorders" includes, but is not limited to, any of the following items or services provided for treatment of alcoholism or other substance-use disorders: inpatient or outpatient treatment, including detoxification, screening and assessment, case management, medication management, psychiatric consultations and individual, group and family counseling, and relapse prevention; non-hospital residential treatment; and prevention services, including health education and individual and group counseling to encourage the reduction of risk factors for alcoholism or other substance-use disorders.
"Same terms and conditions" means that the carrier cannot apply different copayments, deductibles, or benefit limits, including day or visit limits or annual or lifetime dollar limits, to alcoholism and other substance-use disorder treatment services than those applied to other medical or surgical expense benefits.
Every plan shall include such benefits for the treatment of alcoholism and other substance-use disorders as are hereinafter set forth:
a. Inpatient or outpatient care in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
b. Treatment at a detoxification facility licensed pursuant to section 8 of P.L.1975, c.305 (C.26:2B-14);
c. Participation as an inpatient at a residential facility licensed by the Division of Mental Health and Addiction Services in the Department of Human Services or as an outpatient in a State-approved outpatient treatment facility that meets minimum standards of care as set forth by the Department of Human Services; and
d. Treatment provided by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional.
Treatment at any facility shall not preclude further or additional treatment at any other eligible facility; provided, however, that the benefit days used do not exceed the total number of benefit days provided for any other disease or illness under the plan.
Nothing in this section shall be construed to remove the carrier's right to review the medical necessity of services rendered to treat alcoholism and other substance-use disorders. As used in this section, "medical necessity" shall have the same meaning as provided in the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate.
Nothing in this section shall be construed to change the manner in which the carrier determines which health care providers shall be entitled to reimbursement for providing treatment services under the contract.
15. (New section) Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), on or after the effective date of this act, shall provide coverage for expenses incurred in connection with treatment of alcoholism and other substance-use disorders when such treatment is ordered by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional based upon a diagnosis of alcoholism or other substance-use disorder as provided in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders and an assessment of the appropriate level of treatment placement that utilizes the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate. Such benefits shall be provided under the same terms and conditions as provided for any other disease or illness under the plan.
"Treatment of alcoholism and other substance-use disorders" includes, but is not limited to, any of the following items or services provided for treatment of alcoholism or other substance-use disorders: inpatient or outpatient treatment, including detoxification, screening and assessment, case management, medication management, psychiatric consultations and individual, group and family counseling, and relapse prevention; non-hospital residential treatment; and prevention services, including health education and individual and group counseling to encourage the reduction of risk factors for alcoholism or other substance-use disorders.
"Same terms and conditions" means that the carrier cannot apply different copayments, deductibles, or benefit limits, including day or visit limits or annual or lifetime dollar limits, to alcoholism and other substance-use disorder treatment services than those applied to other medical or surgical expense benefits.
Every plan shall include such benefits for the treatment of alcoholism and other substance-use disorders as are hereinafter set forth:
a. Inpatient or outpatient care in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
b. Treatment at a detoxification facility licensed pursuant to section 8 of P.L.1975, c.305 (C.26:2B-14);
c. Participation as an inpatient at a residential facility licensed by the Division of Mental Health and Addiction Services in the Department of Human Services or as an outpatient in a State-approved outpatient treatment facility that meets minimum standards of care as set forth by the Department of Human Services; and
d. Treatment provided by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional.
Treatment at any facility shall not preclude further or additional treatment at any other eligible facility; provided, however, that the benefit days used do not exceed the total number of benefit days provided for any other disease or illness under the plan.
Nothing in this section shall be construed to prohibit the health maintenance organization from determining if the treatment of alcoholism and other substance-use disorders is medically necessary; however, the health maintenance organization shall, for this purpose, use the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate.
Nothing in this section shall be construed to change the manner in which the health maintenance organization determines which health care providers shall be entitled to reimbursement for providing treatment services under the contract.
16. (New section) Every contract for health care services, which is delivered, issued, executed, or renewed in this State by the Division of Mental Health and Addiction Services in the Department of Human Services or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide health care services for treatment of alcoholism and other substance-use disorders when such treatment is ordered by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional based upon a diagnosis of alcoholism or other substance-use disorder as provided in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders and an assessment of the appropriate level of treatment placement that utilizes the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate. Such health care services shall be provided under the same terms and conditions as provided for any other disease or illness under the contract.
"Treatment of alcoholism and other substance-use disorders" includes, but is not limited to, any of the following items or services provided for treatment of alcoholism or other substance-use disorders: inpatient or outpatient treatment, including detoxification, screening and assessment, case management, medication management, psychiatric consultations and individual, group and family counseling, and relapse prevention; non-hospital residential treatment; and prevention services, including health education and individual and group counseling to encourage the reduction of risk factors for alcoholism or other substance-use disorders.
"Same terms and conditions" means that the health maintenance organization cannot apply different copayments, deductibles, or benefit limits, including day or visit limits or annual or lifetime dollar limits, to alcoholism and other substance-use disorder treatment services than those applied to other health care services.
Every contract shall include such health care services for the treatment of alcoholism and other substance-use disorders as are hereinafter set forth:
a. Inpatient or outpatient care in a health care facility licensed pursuant to P.L.1971, c. 136 (C.26:2H-1 et seq.);
b. Treatment at a detoxification facility licensed pursuant to section 8 of P.L.1975, c.305 (C.26:2B-14);
c. Participation as an inpatient at a residential facility licensed by the Division of Mental Health and Addiction Services in the Department of Human Services or as an outpatient in a State-approved outpatient treatment facility that meets minimum standards of care as set forth by the Department of Human Services; and
d. Treatment provided by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional.
Treatment at any facility shall not preclude further or additional treatment at any other eligible facility; provided, however, that the benefit days used do not exceed the total number of benefit days provided for any other disease or illness under the contract.
Nothing in this section shall be construed to prohibit the carrier from determining if the treatment of alcoholism and other substance-use disorders is medically necessary; however, the carrier shall, for this purpose, use the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate.
Nothing in this section shall be construed to change the manner in which the carrier determines which health care providers shall be entitled to reimbursement for providing treatment services under the health benefits plan.
17. (New section) An employer in this State who provides health benefits coverage to his employees or their dependents for treatment of alcoholism or other substance-use disorders shall annually, and upon request of an employee at other times during the year, notify his employees whether the employees' coverage for treatment of alcoholism or other substance-use disorders is subject to the requirements of section 1 of P.L.1977, c.115 (C.17:48-6a), section 1 of P.L.1977, c.116 (C.17B:27-46.1); section 1 of P.L.1977, c.117 (C.17:48A-7a), section 1 of P.L.1977, c.118 (C.17B:26-2.1), section 34 of P.L.1985, c.236 (C.17:48E-34), or sections 14 through 16 of P.L. , c. (C. ) (pending before the Legislature as this bill).
18. Section 5 of P.L.1961, c.49 (C.52:14-17.29) is amended to read as follows:
5. (A) The contract or contracts purchased by the commission pursuant to subsection b. of section 4 of P.L.1961, c.49 (C.52:14-17.28) shall provide separate coverages or policies as follows:
(1) Basic benefits which shall include:
(a) Hospital benefits, including outpatient;
(b) Surgical benefits;
(c) Inpatient medical benefits;
(d) Obstetrical benefits; and
(e) Services rendered by an extended care facility or by a home health agency and for specified medical care visits by a physician during an eligible period of such services, without regard to whether the patient has been hospitalized, to the extent and subject to the conditions and limitations agreed to by the commission and the carrier or carriers.
Basic benefits shall be substantially equivalent to those available on a group remittance basis to employees of the State and their dependents under the subscription contracts of the New Jersey "Blue Cross" and "Blue Shield" Plans. Such basic benefits shall include benefits for:
(i) Additional days of inpatient medical service;
(ii) Surgery elsewhere than in a hospital;
(iii) X-ray, radioactive isotope therapy and pathology services;
(iv) Physical therapy services;
(v) Radium or radon therapy services;
and the extended basic benefits shall be subject to the same conditions and limitations, applicable to such benefits, as are set forth in "Extended Outpatient Hospital Benefits Rider," Form 1500, 71(9-66), and in "Extended Benefit Rider" (as amended), Form MS 7050J(9-66) issued by the New Jersey "Blue Cross" and "Blue Shield" Plans, respectively, and as the same may be amended or superseded, subject to filing by the Commissioner of Banking and Insurance; and
(2) Major medical expense benefits which shall provide benefit payments for reasonable and necessary eligible medical expenses for hospitalization, surgery, medical treatment and other related services and supplies to the extent they are not covered by basic benefits. The commission may, by regulation, determine what types of services and supplies shall be included as "eligible medical services" under the major medical expense benefits coverage as well as those which shall be excluded from or limited under such coverage. Benefit payments for major medical expense benefits shall be equal to a percentage of the reasonable charges for eligible medical services incurred by a covered employee or an employee's covered dependent, during a calendar year as exceed a deductible for such calendar year of $100.00 subject to the maximums hereinafter provided and to the other terms and conditions authorized by this act. The percentage shall be 80% of the first $2,000.00 of charges for eligible medical services incurred subsequent to satisfaction of the deductible and 100% thereafter. There shall be a separate deductible for each calendar year for (a) each enrolled employee and (b) all enrolled dependents of such employee. Not more than $1,000,000.00 shall be paid for major medical expense benefits with respect to any one person for the entire period of such person's coverage under the plan, whether continuous or interrupted except that this maximum may be reapplied to a covered person in amounts not to exceed $2,000.00 a year. Maximums of $10,000.00 per calendar year and $20,000.00 for the entire period of the person's coverage under the plan shall apply to eligible expenses incurred because of [mental illness or functional nervous disorders] any mental illness or functional nervous disorder that is not included in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, and such may be reapplied to a covered person, [except as provided] in accordance with the provisions of P.L.1999, c.441 (C.52:14-17.29d et al.). The same provisions shall apply for retired employees and their dependents. Under the conditions agreed upon by the commission and the carriers as set forth in the contract, the deductible for a calendar year may be satisfied in whole or in part by eligible charges incurred during the last three months of the prior calendar year.
Any service determined by regulation of the commission to be an "eligible medical service" under the major medical expense benefits coverage which is performed by a duly licensed practicing psychologist within the lawful scope of his practice shall be recognized for reimbursement under the same conditions as would apply were such service performed by a physician.
(B) The contract or contracts purchased by the commission pursuant to subsection c. of section 4 of P.L.1961, c.49 (C.52:14-17.28) shall include coverage for services and benefits that are at a level that is equal to or exceeds the level of services and benefits set forth in this subsection, provided that such services and benefits shall include only those that are eligible medical services and not those deemed experimental, investigative or otherwise not eligible medical services. The determination of whether services or benefits are eligible medical services shall be made by the commission consistent with the best interests of the State and participating employers, employees, and dependents. The following list of services is not intended to be exclusive or to require that any limits or exclusions be exceeded.
Covered services shall include:
(1) Physician services, including:
(a) Inpatient services, including:
(i) medical care including consultations;
(ii) surgical services and services related thereto; and
(iii) obstetrical services including normal delivery, cesarean section, and abortion.
(b) Outpatient/out-of-hospital services, including:
(i) office visits for covered services and care;
(ii) allergy testing and related diagnostic/therapy services;
(iii) dialysis center care;
(iv) maternity care;
(v) well child care;
(vi) child immunizations/lead screening;
(vii) routine adult physicals including pap, mammography, and prostate examinations; and
(viii) annual routine obstetrical/gynecological exam.
(2) Hospital services, both inpatient and outpatient, including:
(a) room and board;
(b) intensive care and other required levels of care;
(c) semi-private room;
(d) therapy and diagnostic services;
(e) surgical services or facilities and treatment related thereto;
(f) nursing care;
(g) necessary supplies, medicines, and equipment for care; and
(h) maternity care and related services.
(3) Other facility and services, including:
(a) approved treatment centers for medical emergency/accidental injury;
(b) approved surgical center;
(c) hospice;
(d) chemotherapy;
(e) diagnostic x-ray and lab tests;
(f) ambulance;
(g) durable medical equipment;
(h) prosthetic devices;
(i) foot orthotics;
(j) diabetic supplies and education; and
(k) oxygen and oxygen administration.
(4) All services for which coverage is required pursuant to P.L.1961, c.49 (C.52:14-17.25 et seq.), as amended and supplemented. Benefits under the contract or contracts purchased as authorized by the State Health Benefits Program shall include those for mental health services subject to limits and exclusions consistent with the provisions of the New Jersey State Health Benefits Program Act.
(C) The contract or contracts purchased by the commission pursuant to subsection c. of section 4 of P.L.1961, c.49 (C.52:14-17.28) shall include the following provisions regarding reimbursements and payments:
(1) In the successor plan, the co-payment for doctor's office visits shall be $10 per visit with a maximum out-of-pocket of $400 per individual and $1,000 per family for in-network services for each calendar year. The out-of-network deductible shall be $100 per individual and $250 per family for each calendar year, and the participant shall receive reimbursement for out-of-network charges at the rate of 80% of reasonable and customary charges, provided that the out-of-pocket maximum shall not exceed $2,000 per individual and $5,000 per family for each calendar year.
(2) In the State managed care plan that is required to be included in a contract entered into pursuant to subsection c. of section 4 of P.L.1961, c.49 (C.52:14-17.28), the co-payment for doctor's office visits shall be $15 per visit. The participant shall receive reimbursement for out-of-network charges at the rate of 70% of reasonable and customary charges. The in-network and out-of-network limits, exclusions, maximums, and deductibles shall be substantially equivalent to those in the NJ PLUS plan in effect on June 30, 2007, with adjustments to that plan pursuant to a binding collective negotiations agreement or pursuant to action by the commission, in its sole discretion, to apply such adjustments to State employees for whom there is no majority representative for collective negotiations purposes.
(3) "Reasonable and customary charges" means charges based upon the 90th percentile of the usual, customary, and reasonable (UCR) fee schedule determined by the Health Insurance Association of America or a similar nationally recognized database of prevailing health care charges.
(D) Benefits under the contract or contracts purchased as authorized by this act may be subject to such limitations, exclusions, or waiting periods as the commission finds to be necessary or desirable to avoid inequity, unnecessary utilization, duplication of services or benefits otherwise available, including coverage afforded under the laws of the United States, such as the federal Medicare program, or for other reasons.
Benefits under the contract or contracts purchased as authorized by this act shall include those for the treatment of alcoholism or other substance-use disorders where such treatment is [prescribed] ordered by a physician [and shall also include treatment while confined in or as an outpatient of a licensed hospital or residential treatment program which meets minimum standards of care equivalent to those prescribed by the Joint Commission on Hospital Accreditation. No benefits shall be provided beyond those stipulated in the contracts held by the State Health Benefits Commission] , licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional based upon a diagnosis of alcoholism or other substance-use disorder as provided in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders and an assessment of the appropriate level of treatment placement that utilizes the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate. The benefits shall be provided in accordance with the provisions of section 21 of P.L. , c. (C. ) (pending before the Legislature as this bill).
(E) The rates charged for any contract purchased under the authority of this act shall reasonably and equitably reflect the cost of the benefits provided based on principles which in the judgment of the commission are actuarially sound. The rates charged shall be determined by the carrier on accepted group rating principles with due regard to the experience, both past and contemplated, under the contract. The commission shall have the right to particularize subgroups for experience purposes and rates. No increase in rates shall be retroactive.
(F) The initial term of any contract purchased by the commission under the authority of this act shall be for such period to which the commission and the carrier may agree, but permission may be made for automatic renewal in the absence of notice of termination by the commission. Subsequent terms for which any contract may be renewed as herein provided shall each be limited to a period not to exceed one year.
(G) A contract purchased by the commission pursuant to subsection b. of section 4 of P.L.1961, c.49 (C.52:14-17.28) shall contain a provision that if basic benefits or major medical expense benefits of an employee or of an eligible dependent under the contract, after having been in effect for at least one month in the case of basic benefits or at least three months in the case of major medical expense benefits, is terminated, other than by voluntary cancellation of enrollment, there shall be a 31-day period following the effective date of termination during which such employee or dependent may exercise the option to convert, without evidence of good health, to converted coverage issued by the carriers on a direct payment basis. Such converted coverage shall include benefits of the type classified as "basic benefits" or "major medical expense benefits" in subsection (A) hereof and shall be equivalent to the benefits which had been provided when the person was covered as an employee. The provision shall further stipulate that the employee or dependent exercising the option to convert shall pay the full periodic charges for the converted coverage which shall be subject to such terms and conditions as are normally prescribed by the carrier for this type of coverage.
(H) The commission may purchase a contract or contracts to provide drug prescription and other health care benefits or authorize the purchase of a contract or contracts to provide drug prescription and other health care benefits as may be required to implement a duly executed collective negotiations agreement or as may be required to implement a determination by a public employer to provide such benefit or benefits to employees not included in collective negotiations units.
(I) The commission shall take action as necessary, in cooperation with the School Employees' Health Benefits Commission established pursuant to section 33 of P.L.2007, c.103 (C.52:14-17.46.3), to effectuate the purposes of the School Employees' Health Benefits Program Act as provided in sections 31 through 41 of P.L.2007, c.103 (C.52:14-17.46.1 through C.52:14-17.46.11) and to enable the School Employees' Health Benefits Commission to begin providing coverage to participants pursuant to the School Employees' Health Benefits Program Act as of July 1, 2008.
(J) Beginning January 1, 2012, the State Health Benefits Plan Design Committee shall provide to employees the option to select one of at least three levels of coverage each for family, individual, individual and spouse, and individual and dependent, or equivalent categories, for each plan offered by the program differentiated by out of pocket costs to employees including co-payments and deductibles. Notwithstanding any other provision of law to the contrary, the committee shall have the sole discretion to set the amounts for maximums, co-pays, deductibles, and other such participant costs for all plans in the program. The committee shall also provide for a high deductible health plan that conforms with Internal Revenue Code Section 223.
There shall be appropriated annually for each State fiscal year, through the annual appropriations act, such amounts as shall be necessary as funding by the State as an employer, or as otherwise required, with regard to employees or retirees who have enrolled in a high deductible health plan that conforms with Internal Revenue Code Section 223.
(cf: P.L.2011, c.78, s.47)
19. Section 1 of P.L.1999, c.441 (C.52:14-17.29d) is amended to read as follows:
1. As used in this act:
"Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness including, but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder or autism.
"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation or health maintenance organization authorized to issue health benefits plans in this State.
"Same terms and conditions" means that a carrier cannot apply different copayments, deductibles, or benefit limits, including day or visit limits or annual or lifetime dollar limits, to biologically-based or other mental health benefits, as applicable, than those applied to other medical or surgical benefits.
(cf: P.L.1999, c.441, s.1)
20. Section 2 of P.L.1999, c.441 (C.52:14-17.29e) is amended to read as follows:
2. a. The State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits shall provide coverage for biologically-based mental illness under the same terms and conditions as provided for any other [sickness] disease or illness under the contract.
In addition, the State Health Benefits Commission shall ensure that every such contract, which provides coverage for a disorder that is included in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders and is not a biologically-based mental illness, shall provide coverage for that disorder under the same terms and conditions as provided for any other disease or illness under the contract.
b. Nothing in this section shall be construed to change the manner in which a carrier determines:
(1) whether a mental health care service meets the medical necessity standard as established by the carrier; or
(2) which providers shall be entitled to reimbursement for providing services for mental illness under the contract.
c. The commission shall provide notice to employees regarding the coverage required by this section in accordance with this subsection and regulations promulgated by the Commissioner of Health and Senior Services pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). The notice shall be in writing and prominently positioned in any literature or correspondence and shall be transmitted at the earliest of: (1) the next mailing to the employee; (2) the yearly informational packet sent to the employee; or (3) July 1, 2000. The commission shall also ensure that the carrier under contract with the commission, upon receipt of information that a covered person is receiving treatment for a biologically-based or other mental illness, shall promptly notify that person of the coverage required by this section.
(cf: P.L.1999, c.441, s.2)
21. (New section) The State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of P.L. , c. (C. )( pending before the Legislature as this bill) provides hospital or medical expense benefits for the treatment of alcoholism and other substance-use disorders under the same terms and conditions as provided for any other disease or illness under the contract.
"Treatment of alcoholism and other substance-use disorders" includes, but is not limited to, any of the following items or services provided for treatment of alcoholism or other substance-use disorders: inpatient or outpatient treatment, including detoxification, screening and assessment, case management, medication management, psychiatric consultations and individual, group and family counseling, and relapse prevention; non-hospital residential treatment; and prevention services, including health education and individual and group counseling to encourage the reduction of risk factors for alcoholism or other substance-use disorders.
"Same terms and conditions" means that a carrier cannot apply different copayments, deductibles, or benefit limits, including day or visit limits or annual or lifetime dollar limits, to alcoholism and other substance-use disorder treatment services than those applied to other medical or surgical expense benefits.
Every contract shall include such benefits for the treatment of alcoholism and other substance-use disorders as are hereinafter set forth:
a. Inpatient or outpatient care in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
b. Treatment at a detoxification facility licensed pursuant to section 8 of P.L.1975, c.305 (C.26:2B-14);
c. Participation as an inpatient at a residential facility licensed by the Division of Mental Health and Addiction Services in the Department of Human Services or as an outpatient in a State-approved outpatient treatment facility that meets minimum standards of care as set forth by the Department of Human Services; and
d. Treatment provided by a physician, licensed clinical alcohol and drug counselor or other appropriately trained, licensed health care professional.
Treatment at any facility shall not preclude further or additional treatment at any other eligible facility; provided, however, that the benefit days used do not exceed the total number of benefit days provided for any other disease or illness under the contract.
Nothing in this section shall be construed to prohibit the State Health Benefits Commission from determining if the treatment of alcoholism and other substance-use disorders is medically necessary; however, the commission shall, for this purpose, use the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate.
Nothing in this section shall be construed to change the manner in which the State Health Benefits Commission determines which health care providers shall be entitled to reimbursement for providing treatment services under the contract.
22. Section 1 of P.L.1977, c.115 (C.17:48-6a) is amended to read as follows:
1. No group or individual contract providing hospital or medical expense benefits shall be delivered, issued, executed, or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, unless such contract provides benefits to any subscriber or other person covered thereunder for expenses incurred in connection with the treatment of alcoholism and other substance-use disorders when such treatment is [prescribed by a doctor of medicine] ordered by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional based upon a diagnosis of alcoholism or other substance-use disorder as provided in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders and an assessment of the appropriate level of treatment placement that utilizes the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate. Such benefits shall be provided [to the same extent] under the same terms and conditions as provided for any other [sickness] disease or illness under the contract.
"Treatment of alcoholism and other substance-use disorders" includes, but is not limited to, any of the following items or services provided for treatment of alcoholism or other substance-use disorders: inpatient or outpatient treatment, including detoxification, screening and assessment, case management, medication management, psychiatric consultations and individual, group and family counseling, and relapse prevention; non-hospital residential treatment; and prevention services, including health education and individual and group counseling to encourage the reduction of risk factors for alcoholism or other substance-use disorders.
"Same terms and conditions" means that the medical service corporation cannot apply different copayments, deductibles, or benefit limits, including day or visit limits or annual or lifetime dollar limits, to alcoholism and other substance-use disorder treatment services than those applied to other medical or surgical expense benefits.
Every contract shall include such benefits for the treatment of alcoholism and other substance-use disorders as are hereinafter set forth:
a. Inpatient or outpatient care in a [licensed hospital] health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
b. Treatment at a detoxification facility licensed pursuant to [P.L.1975, c.305] section 8 of P.L.1975, c.305 (C.26:2B-14);
c. [Confinement as an inpatient or outpatient at a licensed, certified, or state approved residential treatment facility, under a program which meets minimum standards of care equivalent to those prescribed by the Joint Commission on Hospital Accreditation] Participation as an inpatient at a residential facility licensed by the Division of Mental Health and Addiction Services in the Department of Human Services or as an outpatient in a State-approved outpatient treatment facility that meets minimum standards of care as set forth by the Department of Human Services; and
d. Treatment provided by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional.
Treatment [or confinement] at any facility shall not preclude further or additional treatment at any other eligible facility; provided, however, that the benefit days used do not exceed the total number of benefit days provided for any other [sickness] disease or illness under the contract.
Nothing in this section shall be construed to prohibit the hospital service corporation from determining if the treatment of alcoholism and other substance-use disorders is medically necessary; however, the hospital service corporation shall, for this purpose, use the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate.
Nothing in this section shall be construed to change the manner in which the hospital service corporation determines which health care providers shall be entitled to reimbursement for providing treatment services under the contract.
(cf: P.L.1977, c.115, s.1)
23. This act shall take effect on the 90th day after enactment and shall apply to policies or contracts issued or renewed on or after the effective date.
STATEMENT
This bill provides for expanded health insurance coverage for treatment of mental and nervous disorders and alcoholism and other substance-use disorders.
Mental Health Coverage: The bill expands the mental health coverage provisions of P.L.1999, c.106 and P.L.1999, c.441 to require that if a health insurer provides coverage for a disorder that is included in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (currently, the DSM-IV) and is not a biologically-based mental illness, the insurer shall provide coverage for that disorder under the same terms and conditions as provided for any other sickness under the policy. Health insurers include hospital, medical and health service corporations, individual and small employer and large group commercial health insurers and health maintenance organizations. These provisions would also apply to the State Health Benefits Program.
The mental health "parity" coverage requirement is currently limited to biologically-based mental illness, which is defined as a "mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness including, but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder, and pervasive developmental disorder or autism."
The DSM-IV is published by the American Psychiatric Association and is the principal diagnostic reference used by mental health professionals in the United States. The DSM-IV includes a broader range of mental and nervous disorders than biologically-based mental illnesses.
The bill clarifies the definition of "same terms and conditions," and makes it consistent with the definition of that term as provided in the sections of the bill concerning benefits for treatment of alcoholism and substance-use disorders. The revised definition provides that an insurer cannot apply different copayments, deductibles, or benefit limits, "including day or visit limits or annual or lifetime dollar limits," to mental health benefits than the insurer applies to other medical or surgical benefits.
The provisions of P.L.1999, c.106 and P.L.1999, c.441, which provide that the mental health parity requirements in those laws shall not be construed to change the manner in which the carrier determines whether a mental health care services meets the medical necessity standard as established by the carrier, or which providers shall be entitled to reimbursement for providing services under the policy or contract, shall also apply to the expanded mental health coverage in this bill.
Coverage for Treatment of Alcoholism and Other Substance-use Disorders: The bill also requires health insurers, as well as the State Health Benefits Program, to provide coverage for treatment of alcoholism and other substance-use disorders under the same terms and conditions as for other diseases or illnesses.
Specifically, the bill revises the existing statutory requirement to provide coverage for treatment of alcoholism that applies to hospital, medical and health service corporations, commercial health insurers and the State Health Benefits Program (but currently not to individual and small employer health benefits plans and health maintenance organizations), to add coverage for treatment of other substance-use disorders and to specify the types of benefits that must be covered. The bill extends the requirement to provide coverage for treatment of alcoholism to those health insurers which are not already mandated by State law to provide such coverage, and includes the requirement to provide coverage for treatment of other substance-use disorders.
The bill provides that:
· Benefits shall be provided when the treatment is ordered by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional based upon a diagnosis of alcoholism or other substance-use disorder as provided in the latest edition of the DSM (currently, the DSM-IV) and an assessment of the appropriate level of treatment placement that utilizes the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate.
· "Treatment of alcoholism and other substance-use disorders" is defined to include, but not be limited to, any of the following items or services provided for treatment of alcoholism and other substance-use disorders: inpatient or outpatient treatment, including detoxification, screening and assessment, case management, medication management, psychiatric consultations and individual, group, and family counseling, and relapse prevention; non-hospital residential treatment; and prevention services, including health education and individual and group counseling to encourage the reduction of risk factors for alcoholism or other substance-use disorders.
· "Same terms and conditions" is defined to mean that the insurer cannot apply different copayments, deductibles, or benefit limits, including day or visit limits or annual or lifetime dollar limits, to alcoholism and other substance-use disorders treatment services than those applied to other medical or surgical expense benefits.
· All health insurance contracts or policies shall provide the following benefits:
-- inpatient or outpatient care in a licensed health care facility;
-- treatment at a State-licensed detoxification facility;
--participation as an inpatient at a State-licensed residential facility or as an outpatient in a State-approved outpatient treatment facility that meets minimum standards of care as set forth by the Department of Human Services; and
--treatment provided by a physician, licensed clinical alcohol and drug counselor, or other appropriately trained, licensed health care professional.
· Treatment at any facility shall not preclude further or additional treatment at any other eligible facility if the benefit days used do not exceed the total number of benefit days provided for any other disease or illness under the contract or policy.
· The provisions of the bill shall not be construed to:
--prohibit an insurer from determining if the treatment of alcoholism and other substance-use disorders is medically necessary; however, the insurer shall, for this purpose, use the most recent patient placement criteria adopted by the American Society of Addiction Medicine, or such other generally accepted clinical criteria as may be subsequently determined by the Commissioner of Banking and Insurance, by regulation, to be more appropriate; and
--change the manner in which the insurer determines which health care providers shall be entitled to reimbursement for providing treatment services under the policy or contract.
The bill takes effect on the 90th day after the date of enactment and will apply to health insurance contracts and policies issued or renewed on or after that date.
