Bill Text: NJ A4267 | 2016-2017 | Regular Session | Introduced
Bill Title: Requires certain health benefits plans to provide coverage for outpatient behavioral health care services.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2016-10-20 - Introduced, Referred to Assembly Financial Institutions and Insurance Committee [A4267 Detail]
Download: New_Jersey-2016-A4267-Introduced.html
Sponsored by:
Assemblywoman VALERIE VAINIERI HUTTLE
District 37 (Bergen)
SYNOPSIS
Requires certain health benefits plans to provide coverage for outpatient behavioral health care services.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning health insurance coverage for behavioral health care services and revising and supplementing various parts of statutory law.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. Section 1 of P.L.1977, c.115 (C.17:48-6a) is amended to read as follows:
1. a. 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, after the effective date of [this act] P.L. , c. (pending before the Legislature as this bill), unless [such] that contract provides benefits to any subscriber or other covered person [covered thereunder] for [expenses incurred in connection with the treatment of alcoholism] behavioral health care services when [such treatment is] those services are [prescribed] deemed medically necessary by a [doctor of medicine] health care provider. [Such] Except as provided in subsections c. and d. of this section, benefits shall be provided to the same extent as for any other sickness under the contract.
b. Every contract shall include [such] benefits for [the treatment of alcoholism] behavioral health care services as [are hereinafter set forth] follows:
[a.] (1) [Inpatient or outpatient] Outpatient care in a [licensed hospital] health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
[b.] (2) [Treatment] Outpatient treatment at a State-licensed detoxification facility [licensed pursuant to P.L.1975, c.305];
[c. Confinement] (3) Participation as an [inpatient or] outpatient at a licensed, certified, or [state approved] State-approved residential treatment facility or behavioral health care facility [, under a program which meets minimum standards of care equivalent to those prescribed by the Joint Commission on Hospital Accreditation];
(4) Office visits with a health care provider; and
(5) Treatment at home and community-based service facilities.
Treatment or [confinement] participation at any facility, hospital, or office 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 under the contract], hospital, or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section.
d. The medical necessity determination by the health care provider as specified pursuant to subsection a. of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the contract.
e. For the purposes of this section:
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
"health care provider" means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage and family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
"medical necessity" means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.
f. 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.1977, c.115, s.1)
2. Section 1 of P.L.1977, c.117 (C.17:48A-7a) is amended to read as follows:
1. a. 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, after the effective date of [this act] P.L. , c. (pending before the Legislature as this bill), unless [such] that contract provides benefits to any subscriber or other covered person [covered thereunder] for [expenses incurred in connection with the treatment of alcoholism] behavioral health care services when [such treatment is] those services are [prescribed] deemed medically necessary by a [doctor of medicine] health care provider. [Such] Except as provided in subsections c. and d. of this section, benefits shall be provided to the same extent as for any other sickness under the contract.
b. Every contract shall include [such] benefits for [the treatment of alcoholism] behavioral health care services as [are hereinafter set forth] follows:
[a.] (1) [Inpatient or outpatient] Outpatient care in a [licensed hospital] health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
[b.] (2) [Treatment] Outpatient treatment at a State-licensed detoxification facility [licensed pursuant to P.L.1975, c.305];
[c. Confinement] (3) Participation as an [inpatient or] outpatient at a licensed, certified, or [state approved] State-approved residential treatment facility or behavioral health care facility [, under a program which meets minimum standards of care equivalent to those prescribed by the Joint Commission on Hospital Accreditation];
(4) Office visits with a health care provider; and
(5) Treatment at home and community-based service facilities.
Treatment or [confinement] participation at any facility, hospital, or office 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 under the contract], hospital, or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section.
d. The medical necessity determination by the health care provider as specified pursuant to subsection a. of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the contract.
e. For the purposes of this section:
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
"health care provider" means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage and family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
"medical necessity" means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.
f. 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.1977, c.117, s.1)
3. Section 34 of P.L.1985, c.236 (C.17:48E-34) is amended to read as follows:
34. a. No group or individual contract providing [health service coverage] 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, on or after the effective date of P.L. , c. (pending before the Legislature as this bill), unless the contract provides benefits to any [subscriber] insured or other covered person [covered thereunder] for [expenses incurred in connection with the treatment of alcoholism] behavioral health care services when the [treatment is] services are [prescribed] deemed medically necessary by a [doctor of medicine] health care provider. [Benefits] Except as provided in subsections c. and d. of this section, benefits shall be provided to the same extent as for any other sickness under the contract.
b. Every contract shall include [such] benefits for [the treatment of alcoholism] behavioral health care services as [are hereinafter set forth] follows:
[a.] (1) [Inpatient or outpatient] Outpatient care in a [licensed hospital] health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
[b.] (2) [Treatment] Outpatient treatment at a State-licensed detoxification facility [licensed pursuant to P.L.1975, c.305];
[c. Confinement] (3) Participation as an [inpatient or] outpatient at a licensed, certified, or [state approved] State-approved residential treatment facility or behavioral health care facility [, under a program which meets minimum standards of care equivalent to those prescribed by the Joint Commission on Hospital Accreditation];
(4) Office visits with a health care provider; and
(5) Treatment at home and community-based service facilities.
Treatment or [confinement] participation at any facility, hospital, or office 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 under the contract], hospital, or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section.
d. The medical necessity determination by the health care provider as specified pursuant to subsection a. of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the contract.
e. For the purposes of this section:
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
"health care provider" means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage and family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
"medical necessity" means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.
f. 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.1985, c.236, s.34)
4. Section 1 of P.L.1977, c.118 (C.17B:26-2.1) is amended to read as follows:
1. a. No individual 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, after the effective date of [this act] P.L. , c. (pending before the Legislature as this bill), unless [such contract] that policy provides benefits to any [subscriber] insured or other covered person [covered thereunder] for [expenses incurred in connection with the treatment of alcoholism] behavioral health care services when [such treatment is] those services are [prescribed] deemed medically necessary by a [doctor of medicine] health care provider. [Such] Except as provided in subsections c. and d. of this section, benefits shall be provided to the same extent as for any other sickness under the [contract] policy.
b. Every contract shall include [such] benefits for [the treatment of alcoholism] behavioral health care services as [are hereinafter set forth] follows:
[a.] (1) [Inpatient or outpatient] Outpatient care in a [licensed hospital] health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
[b.] (2) [Treatment] Outpatient treatment at a State-licensed detoxification facility [licensed pursuant to P.L.1975, c.305];
[c. Confinement] (3) Participation as an [inpatient or] outpatient at a licensed, certified, or [state approved] State-approved residential treatment facility or behavioral health care facility [, under a program which meets minimum standards of care equivalent to those prescribed by the Joint Commission on Hospital Accreditation];
(4) Office visits with a health care provider; and
(5) Treatment at home and community-based service facilities.
Treatment or [confinement] participation at any facility, hospital, or office 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 under the contract], hospital, or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section.
d. The medical necessity determination by the health care provider as specified pursuant to subsection a. of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the policy.
e. For the purposes of this section:
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
"health care provider" means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage and family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
"medical necessity" means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.
f. 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.1977, c.118, s.1)
5. Section 1 of P.L.1977, c.116 (C.17B:27-46.1) is amended to read as follows:
1. a. 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, after the effective date of [this act] P.L. , c. (pending before the Legislature as this bill), unless [such contract] that policy provides benefits to any [subscriber] insured or other covered person [covered thereunder] for [expenses incurred in connection with the treatment of alcoholism] behavioral health care services when [such treatment is] those services are [prescribed] deemed medically necessary by a [doctor of medicine] health care provider. [Such] Except as provided in subsections c. and d. of this section, benefits shall be provided to the same extent as for any other sickness under the [contract] policy.
b. Every contract shall include [such] benefits for [the treatment of alcoholism] behavioral health care services as [are hereinafter set forth] follows:
[a.] (1) [Inpatient or outpatient] Outpatient care in a [licensed hospital] health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
[b.] (2) [Treatment] Outpatient treatment at a State-licensed detoxification facility [licensed pursuant to P.L.1975, c.305];
[c. Confinement] (3) Participation as an [inpatient or] outpatient at a licensed, certified, or [state approved] State-approved residential treatment facility or behavioral health care facility [, under a program which meets minimum standards of care equivalent to those prescribed by the Joint Commission on Hospital Accreditation];
(4) Office visits with a health care provider; and
(5) Treatment at home and community-based service facilities.
Treatment or [confinement] participation at any facility, hospital, or office 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 under the contract], hospital, or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section.
d. The medical necessity determination by the health care provider as specified pursuant to subsection a. of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the policy.
e. For the purposes of this section:
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
"health care provider" means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage and family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
"medical necessity" means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.
f. 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.1977, c.116, s.1)
6. (New section) a. An 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 coverage for behavioral health care services when the services are deemed medically necessary by a health care provider. Except as provided in subsections c. and d. of this section, the benefits shall be provided to the same extent as for any other sickness under the health benefits plan.
b. Every health benefits plan shall include benefits for behavioral health care services as follows:
(1) Outpatient care in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
(2) Outpatient treatment at a State-licensed detoxification facility;
(3) Participation as an outpatient at a licensed, certified, or State-approved residential treatment facility or behavioral health care facility;
(4) Office visits with a health care provider; and
(5) Treatment at home and community-based service facilities.
Treatment or participation at any facility, hospital, or office shall not preclude further or additional treatment at any other eligible facility, hospital, or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section.
d. The medical necessity determination by the health care provider as specified pursuant to subsection a. of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the contract.
e. For the purposes of this section:
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
"health care provider" means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage and family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
"medical necessity" means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.
f. The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.
7. (New section) a. A 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 coverage for behavioral health care services when the services are deemed medically necessary by a health care provider. Except as provided in subsections c. and d. of this section, the benefits shall be provided to the same extent as for any other sickness under the health benefits plan.
b. Every health benefits plan shall include benefits for behavioral health care services as follows:
(1) Outpatient care in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
(2) Outpatient treatment at a State-licensed detoxification facility;
(3) Participation as an outpatient at a licensed, certified, or State-approved residential treatment facility or behavioral health care facility;
(4) Office visits with a health care provider; and
(5) Treatment at home and community-based service facilities.
Treatment or participation at any facility, hospital, or office shall not preclude further or additional treatment at any other eligible facility, hospital, or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section.
d. The medical necessity determination by the health care provider as specified pursuant to subsection a. of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the contract.
e. For the purposes of this section:
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
"health care provider" means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage and family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
"medical necessity" means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.
f. The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.
8. (New section) a. A certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of this act unless the health maintenance organization provides health care services to any enrollee or other covered person for behavioral health care services when the services are deemed medically necessary by a health care provider. Except as provided in subsections c. and d. of this section, the health care services shall be provided to the same extent as for any other sickness under the contract.
b. Every health benefits plan shall include benefits for behavioral health care services as follows:
(1) Outpatient care in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
(2) Outpatient treatment at a State-licensed detoxification facility;
(3) Participation as an outpatient at a licensed, certified, or State-approved residential treatment facility or behavioral health care facility;
(4) Office visits with a health care provider; and
(5) Treatment at home and community-based service facilities.
Treatment or participation at any facility, hospital, or office shall not preclude further or additional treatment at any other eligible facility, hospital, or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section.
d. The medical necessity determination by the health care provider as specified pursuant to subsection a. of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the contract.
e. For the purposes of this section:
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
"health care provider" means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage and family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
"medical necessity" means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.
f. The provisions of this section shall apply to all contracts for health care services in which the health maintenance organization has reserved the right to change the schedule of charges.
9. (New section) a. The State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act provides hospital or medical expense benefits for behavioral health care services when the services are deemed medically necessary by a health care provider. Except as provided in subsections c. and d. of this section, the benefits shall be provided to the same extent as for any other sickness under the contract.
b. Every contract shall include benefits for behavioral health care services as follows:
(1) Outpatient care in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
(2) Outpatient treatment at a State-licensed detoxification facility;
(3) Participation as an outpatient at a licensed, certified, or State-approved residential treatment facility or behavioral health care facility;
(4) Office visits with a health care provider; and
(5) Treatment at home and community-based service facilities.
Treatment or participation at any facility, hospital, or office shall not preclude further or additional treatment at any other eligible facility, hospital, or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section.
d. The medical necessity determination by the health care provider as specified pursuant to subsection a. of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the contract.
e. For the purposes of this section:
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
"health care provider" means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage and family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
"medical necessity" means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.
10. (New section) a. The School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act provides hospital or medical expense benefits for behavioral health care services when the services are deemed medically necessary by a health care provider. Except as provided in subsections c. and d. of this section, the benefits shall be provided to the same extent as for any other sickness under the contract.
b. Every contract shall include benefits for behavioral health care services as follows:
(1) Outpatient care in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
(2) Outpatient treatment at a State-licensed detoxification facility;
(3) Participation as an outpatient at a licensed, certified, or State-approved residential treatment facility or behavioral health care facility;
(4) Office visits with a health care provider; and
(5) Treatment at home and community-based service facilities.
Treatment or participation at any facility, hospital, or office shall not preclude further or additional treatment at any other eligible facility, hospital, or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section.
d. The medical necessity determination by the health care provider as specified pursuant to subsection a. of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the contract.
e. For the purposes of this section:
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
"health care provider" means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage and family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
"medical necessity" means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.
11. P.L.1999, c.106 (C.17:48-6v, C.17:48A-7u, C.17:48E-35.20, C.17B:26-2.1s, C.17B:27-46.1v, C.17B:27A-7.5, C.17B:27A-19.7, C.26:2J-4.20 and C.34:11A-15) is repealed.
12. This act shall take effect on the 60th day after enactment and shall apply to all contracts and policies delivered, issued, executed or renewed on or after that date.
STATEMENT
This bill requires hospital, medical and health service corporations, commercial insurers, health maintenance organizations, health benefits plans issued pursuant to the New Jersey Individual Health Coverage and Small Employer Health Benefits Programs, the State Health Benefits Program, and the School Employees' Health Benefits Program, to provide coverage, without utilization management review, for outpatient behavioral health care services when those services are deemed medically necessary by a physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage or family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
The bill amends several statutes, initially enacted in 1977 and 1985, which require hospital, medical and health service corporations, and individual and group health insurers to provide coverage for the treatment of alcoholism. The bill expands that coverage to include coverage for "behavioral health care services," which is defined as procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
The bill also extends the required behavioral health coverage to health maintenance organizations, the individual and small employer insurance programs, the State Health Benefits Program, and the School Employees' Health Benefits Program, which were not included in the 1977 and 1985 statutes.
Specifically, the bill requires that the coverage for behavioral health care services include:
· outpatient care in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
· treatment at a State-licensed detoxification facility;
· participation as an outpatient at a licensed, certified, or State-approved residential treatment facility or behavioral health care facility;
· office visits with a health care provider; and
· treatment at home and community-based service facilities.
Treatment or participation at any facility, hospital or office shall not preclude further or additional treatment at any other eligible facility, hospital or office.
The bill further provides that, notwithstanding any law or regulation to the contrary, the benefits provided pursuant to the bill shall not be subject to any utilization management review or medical necessity determination other than the determination of medical necessity by a health care provider.
The medical necessity determination as specified shall control both the nature and duration of treatment. However, the bill also provides that this coverage may be subject to limits relating to the use of participating providers and facilities as provided in the contract.
The bill also defines "medical necessity" as health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.
The bill also repeals P.L.1999, c.106, which requires mental health parity, meaning coverage under the same terms and conditions as provided for any other sickness, for "biologically-based mental illnesses." As the bill requires coverage, without utilization management review, for behavioral health care services, including for all mental health and emotional disorders, P.L.1999, c.106 is superseded by the provisions of this bill.
