Bill Text: NJ S448 | 2016-2017 | Regular Session | Introduced
Bill Title: Requires health insurers, SHBP, and SEHBP health benefits coverage for eating disorders.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2016-03-18 - Reviewed by the Pension and Health Benefits Commission Recommend to not enact [S448 Detail]
Download: New_Jersey-2016-S448-Introduced.html
STATE OF NEW JERSEY
217th LEGISLATURE
PRE-FILED FOR INTRODUCTION IN THE 2016 SESSION
Sponsored by:
Senator DIANE B. ALLEN
District 7 (Burlington)
SYNOPSIS
Requires health insurers, SHBP, and SEHBP health benefits coverage for eating disorders.
CURRENT VERSION OF TEXT
Introduced Pending Technical Review by Legislative Counsel.
An Act concerning health benefits coverage for eating disorders and supplementing various parts of the statutory law.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. a. Every hospital service corporation contract that provides hospital or medical expense benefits and is 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, shall provide benefits to any person covered thereunder for expenses incurred for the diagnosis and treatment of eating disorders.
b. Coverage shall be in accordance with a treatment plan, and shall be limited to medically necessary treatment that is provided by a licensed treating physician, psychiatrist, psychologist, professional counselor, clinical social worker, or marriage and family therapist, acting pursuant to the authority granted under their license and within their lawful scope of practice.
c. The treatment plan shall, upon request, be provided to the hospital service corporation and shall contain all the elements necessary to pay claims, including, but not limited to, a diagnosis, proposed treatment by type, frequency and duration, and the anticipated outcomes stated as goals.
d. Coverage of the treatment of eating disorders may be subject to other general exclusions and limitations of the contract that are not in conflict with the provisions of this section, such as coordination of benefits, and utilization review of health care services, which includes reviews of medical necessity and care management.
e. A medical necessity determination and a decision regarding care management for the treatment of eating disorders shall:
(1) be made with consideration given to the overall medical and mental health needs of the individual with an eating disorder;
(2) not be based solely on weight; and
(3) take into consideration the most recent Practice Guideline for the Treatment of Patients with Eating Disorders adopted by the American Psychiatric Association and current standards based upon the medical literature generally recognized as authoritative in the medical community.
f. Benefits shall be provided to the same extent as for any other medical condition under the contract.
g. The provisions of this section shall apply to all contracts in which the health service corporation has reserved the right to change the premium.
h. For the purposes of this section, "eating disorder" means pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder, and any other eating disorder contained in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.
2. a. Every medical service corporation contract that provides hospital or medical expense benefits and is 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, shall provide benefits to any person covered thereunder for expenses incurred for the diagnosis and treatment of eating disorders.
b. Coverage shall be in accordance with a treatment plan, and shall be limited to medically necessary treatment that is provided by a licensed treating physician, psychiatrist, psychologist, professional counselor, clinical social worker, or marriage and family therapist, acting pursuant to the authority granted under their license and within their lawful scope of practice.
c. The treatment plan shall, upon request, be provided to the medical service corporation and shall contain all the elements necessary to pay claims, including, but not limited to, a diagnosis, proposed treatment by type, frequency and duration, and the anticipated outcomes stated as goals.
d. Coverage of the treatment of eating disorders may be subject to other general exclusions and limitations of the contract that are not in conflict with the provisions of this section, such as coordination of benefits, and utilization review of health care services, which includes reviews of medical necessity and care management.
e. A medical necessity determination and a decision regarding care management for the treatment of eating disorders shall:
(1) be made with consideration given to the overall medical and mental health needs of the individual with an eating disorder;
(2) not be based solely on weight; and
(3) take into consideration the most recent Practice Guideline for the Treatment of Patients with Eating Disorders adopted by the American Psychiatric Association and current standards based upon the medical literature generally recognized as authoritative in the medical community.
f. Benefits shall be provided to the same extent as for any other medical condition under the contract.
g. The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium.
h. For the purposes of this section, "eating disorder" means pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder, and any other eating disorder contained in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.
3. a. Every health service corporation contract that provides hospital or medical expense benefits and is 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, shall provide benefits to any person covered thereunder for expenses incurred for the diagnosis and treatment of eating disorders.
b. Coverage shall be in accordance with a treatment plan, and shall be limited to medically necessary treatment that is provided by a licensed treating physician, psychiatrist, psychologist, professional counselor, clinical social worker, or marriage and family therapist, acting pursuant to the authority granted under their license and within their lawful scope of practice.
c. The treatment plan shall, upon request, be provided to the health service corporation and shall contain all the elements necessary to pay claims, including, but not limited to, a diagnosis, proposed treatment by type, frequency and duration, and the anticipated outcomes stated as goals.
d. Coverage of the treatment of eating disorders may be subject to other general exclusions and limitations of the contract that are not in conflict with the provisions of this section, such as coordination of benefits, and utilization review of health care services, which includes reviews of medical necessity and care management.
e. A medical necessity determination and a decision regarding care management for the treatment of eating disorders shall:
(1) be made with consideration given to the overall medical and mental health needs of the individual with an eating disorder;
(2) not be based solely on weight; and
(3) take into consideration the most recent Practice Guideline for the Treatment of Patients with Eating Disorders adopted by the American Psychiatric Association and current standards based upon the medical literature generally recognized as authoritative in the medical community.
f. Benefits shall be provided to the same extent as for any other medical condition under the contract.
g. The provisions of this section shall apply to all contracts in which the health service corporation has reserved the right to change the premium.
h. For the purposes of this section, "eating disorder" means pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder, and any other eating disorder contained in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.
4. a. Every individual policy that provides hospital or medical expense benefits and is 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, shall provide benefits to any person covered thereunder for expenses incurred for the diagnosis and treatment of eating disorders.
b. Coverage shall be in accordance with a treatment plan, and shall be limited to medically necessary treatment that is provided by a licensed treating physician, psychiatrist, psychologist, professional counselor, clinical social worker, or marriage and family therapist, acting pursuant to the authority granted under their license and within their lawful scope of practice.
c. The treatment plan shall, upon request, be provided to the insurer and shall contain all the elements necessary to pay claims, including, but not limited to, a diagnosis, proposed treatment by type, frequency and duration, and the anticipated outcomes stated as goals.
d. Coverage of the treatment of eating disorders may be subject to other general exclusions and limitations of the policy that are not in conflict with the provisions of this section, such as coordination of benefits, and utilization review of health care services, which includes reviews of medical necessity and care management.
e. A medical necessity determination and a decision regarding care management for the treatment of eating disorders shall:
(1) be made with consideration given to the overall medical and mental health needs of the individual with an eating disorder;
(2) not be based solely on weight; and
(3) take into consideration the most recent Practice Guideline for the Treatment of Patients with Eating Disorders adopted by the American Psychiatric Association and current standards based upon the medical literature generally recognized as authoritative in the medical community.
f. Benefits shall be provided to the same extent as for any other medical condition under the policy.
g. The provisions of this section shall apply to all contracts in which the insurer has reserved the right to change the premium.
h. For the purposes of this
section, "eating disorder" means pica, rumination disorder,
avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa,
binge eating disorder, other specified feeding or eating disorder, and any
other eating disorder contained in the most recent version of the Diagnostic
and Statistical Manual of Mental Disorders published by the American
Psychiatric Association.
5. a. Every group policy that provides hospital or medical expense benefits and is 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, shall provide benefits to any person covered thereunder for expenses incurred for the diagnosis and treatment of eating disorders.
b. Coverage shall be in accordance with a treatment plan, and shall be limited to medically necessary treatment that is provided by a licensed treating physician, psychiatrist, psychologist, professional counselor, clinical social worker, or marriage and family therapist, acting pursuant to the authority granted under their license and within their lawful scope of practice.
c. The treatment plan shall, upon request, be provided to the insurer and shall contain all the elements necessary to pay claims, including, but not limited to, a diagnosis, proposed treatment by type, frequency and duration, and the anticipated outcomes stated as goals.
d. Coverage of the treatment of eating disorders may be subject to other general exclusions and limitations of the policy that are not in conflict with the provisions of this section, such as coordination of benefits, and utilization review of health care services, which includes reviews of medical necessity and care management.
e. A medical necessity determination and a decision regarding care management for the treatment of eating disorders shall:
(1) be made with consideration given to the overall medical and mental health needs of the individual with an eating disorder;
(2) not be based solely on weight; and
(3) take into consideration the most recent Practice Guideline for the Treatment of Patients with Eating Disorders adopted by the American Psychiatric Association and current standards based upon the medical literature generally recognized as authoritative in the medical community.
f. Benefits shall be provided to the same extent as for any other medical condition under the policy.
g. The provisions of this section shall apply to all contracts in which the insurer has reserved the right to change the premium.
h. For the purposes of this section, "eating disorder" means pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder, and any other eating disorder contained in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.
6. a. An individual health benefits plan that provides hospital or medical expense benefits and is 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, shall provide benefits to any person covered thereunder for expenses incurred for the diagnosis and treatment of eating disorders.
b. Coverage shall be in accordance with a treatment plan, and shall be limited to medically necessary treatment that is provided by a licensed treating physician, psychiatrist, psychologist, professional counselor, clinical social worker, or marriage and family therapist, acting pursuant to the authority granted under their license and within their lawful scope of practice.
c. The treatment plan shall, upon request, be provided to the insurer and shall contain all the elements necessary to pay claims, including, but not limited to, a diagnosis, proposed treatment by type, frequency and duration, and the anticipated outcomes stated as goals.
d. Coverage of the treatment of eating disorders may be subject to other general exclusions and limitations of the health benefits plan that are not in conflict with the provisions of this section, such as coordination of benefits, and utilization review of health care services, which includes reviews of medical necessity and care management.
e. A medical necessity determination and a decision regarding care management for the treatment of eating disorders shall:
(1) be made with consideration given to the overall medical and mental health needs of the individual with an eating disorder;
(2) not be based solely on weight; and
(3) take into consideration the most recent Practice Guideline for the Treatment of Patients with Eating Disorders adopted by the American Psychiatric Association and current standards based upon the medical literature generally recognized as authoritative in the medical community.
f. Benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.
g. The provisions of this section shall apply to all contracts in which the insurer has reserved the right to change the premium.
h. For the purposes of this section, "eating disorder" means pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder, and any other eating disorder contained in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.
7. a. A small employer health benefits plan that provides hospital or medical expense benefits and is 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, shall provide benefits to any person covered thereunder for expenses incurred for the diagnosis and treatment of eating disorders.
b. Coverage shall be in accordance with a treatment plan, and shall be limited to medically necessary treatment that is provided by a licensed treating physician, psychiatrist, psychologist, professional counselor, clinical social worker, or marriage and family therapist, acting pursuant to the authority granted under their license and within their lawful scope of practice.
c. The treatment plan shall, upon request, be provided to the insurer and shall contain all the elements necessary to pay claims, including, but not limited to, a diagnosis, proposed treatment by type, frequency and duration, and the anticipated outcomes stated as goals.
d. Coverage of the treatment of eating disorders may be subject to other general exclusions and limitations of the health benefits plan that are not in conflict with the provisions of this section, such as coordination of benefits, and utilization review of health care services, which includes reviews of medical necessity and care management.
e. A medical necessity determination and a decision regarding care management for the treatment of eating disorders shall:
(1) be made with consideration given to the overall medical and mental health needs of the individual with an eating disorder;
(2) not be based solely on weight; and
(3) take into consideration the most recent Practice Guideline for the Treatment of Patients with Eating Disorders adopted by the American Psychiatric Association and current standards based upon the medical literature generally recognized as authoritative in the medical community.
f. Benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.
g. The provisions of this section shall apply to all contracts in which the insurer has reserved the right to change the premium.
h. For the purposes of this section, "eating disorder" means pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder, and any other eating disorder contained in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.
8. a. A certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued on or after the effective date of this act for a health maintenance organization that provides health care services, unless the health maintenance organization also provides benefits to any person covered thereunder for expenses incurred for the diagnosis and treatment of eating disorders.
b. Coverage shall be in accordance with a treatment plan, and shall be limited to medically necessary treatment that is provided by a licensed treating physician, psychiatrist, psychologist, professional counselor, clinical social worker, or marriage and family therapist, acting pursuant to the authority granted under their license and within their lawful scope of practice.
c. The treatment plan shall, upon request, be provided to the health maintenance organization and shall contain all the elements necessary to pay claims, including, but not limited to, a diagnosis, proposed treatment by type, frequency and duration, and the anticipated outcomes stated as goals.
d. Coverage of the treatment of eating disorders may be subject to other general exclusions and limitations of the contract that are not in conflict with the provisions of this section, such as coordination of benefits, and utilization review of health care services, which includes reviews of medical necessity and care management.
e. A medical necessity determination and a decision regarding care management for the treatment of eating disorders shall:
(1) be made with consideration given to the overall medical and mental health needs of the individual with an eating disorder;
(2) not be based solely on weight; and
(3) take into consideration the most recent Practice Guideline for the Treatment of Patients with Eating Disorders adopted by the American Psychiatric Association and current standards based upon the medical literature generally recognized as authoritative in the medical community.
f. Benefits shall be provided to the same extent as for any other medical condition under the contract.
g. The provisions of this section shall apply to all contracts in which the health maintenance organization has reserved the right to change the premium.
h. For the purposes of this section, "eating disorder" means pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder, and any other eating disorder contained in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.
9. a. The State Health Benefits Commission shall ensure that every contract purchased on or after the effective date of this act that provides hospital or medical expense benefits shall provide benefits to any person covered thereunder for expenses incurred for the diagnosis and treatment of eating disorders.
b. Coverage shall be in accordance with a treatment plan, and shall be limited to medically necessary treatment that is provided by a licensed treating physician, psychiatrist, psychologist, professional counselor, clinical social worker, or marriage and family therapist, acting pursuant to the authority granted under their license and within their lawful scope of practice.
c. The treatment plan shall, upon request, be provided to the carrier and shall contain all the elements necessary to pay claims, including, but not limited to, a diagnosis, proposed treatment by type, frequency and duration, and the anticipated outcomes stated as goals.
d. Coverage of the treatment of eating disorders may be subject to other general exclusions and limitations of the contract that are not in conflict with the provisions of this section, such as coordination of benefits, and utilization review of health care services, which includes reviews of medical necessity and care management.
e. A medical necessity determination and a decision regarding care management for the treatment of eating disorders shall:
(1) be made with consideration given to the overall medical and mental health needs of the individual with an eating disorder;
(2) not be based solely on weight; and
(3) take into consideration the most recent Practice Guideline for the Treatment of Patients with Eating Disorders adopted by the American Psychiatric Association and current standards based upon the medical literature generally recognized as authoritative in the medical community.
f. Benefits shall be provided to the same extent as for any other medical condition under the contract.
g. For the purposes of this section, "eating disorder" means pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder, and any other eating disorder contained in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.
10. a. The School Employees' Health Benefits Commission shall ensure that every contract purchased on or after the effective date of this act that provides hospital or medical expense benefits shall provide benefits to any person covered thereunder for expenses incurred for the diagnosis and treatment of eating disorders.
b. Coverage shall be in accordance with a treatment plan, and shall be limited to medically necessary treatment that is provided by a licensed treating physician, psychiatrist, psychologist, professional counselor, clinical social worker, or marriage and family therapist, acting pursuant to the authority granted under their license and within their lawful scope of practice.
c. The treatment plan shall, upon request, be provided to the carrier and shall contain all the elements necessary to pay claims, including, but not limited to, a diagnosis, proposed treatment by type, frequency and duration, and the anticipated outcomes stated as goals.
d. Coverage of the treatment of eating disorders may be subject to other general exclusions and limitations of the contract that are not in conflict with the provisions of this section, such as coordination of benefits, and utilization review of health care services, which includes reviews of medical necessity and care management.
e. A medical necessity determination and a decision regarding care management for the treatment of eating disorders shall:
(1) be made with consideration given to the overall medical and mental health needs of the individual with an eating disorder;
(2) not be based solely on weight; and
(3) take into consideration the most recent Practice Guideline for the Treatment of Patients with Eating Disorders adopted by the American Psychiatric Association and current standards based upon the medical literature generally recognized as authoritative in the medical community.
f. Benefits shall be provided to the same extent as for any other medical condition under the contract.
g. For the purposes of this section, "eating disorder" means pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder, and any other eating disorder contained in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.
11. This act shall take effect on the 90th day next following enactment.
STATEMENT
This bill requires hospital, medical, and health service corporations, individual, small employer and large group health insurers, health maintenance organizations, the State Health Benefits Program, and the School Employees' Health Benefits Program to provide coverage for the diagnosis and treatment of eating disorders.
The bill requires coverage to be in accordance with a treatment plan, and limits coverage to medically necessary treatment that is provided by a licensed treating physician, psychiatrist, psychologist, professional counselor, clinical social worker, or marriage and family therapist, acting pursuant to the authority granted under their license and within their lawful scope of practice.
The treatment plan must, upon request, be provided to the insurer and shall contain all the elements necessary to pay claims, including, but not limited to, a diagnosis, proposed treatment by type, frequency and duration, and the anticipated outcomes stated as goals.
The bill also provides that coverage of the treatment of eating disorders may be subject to other general exclusions and limitations of the contract or policy that are not in conflict with the provisions of the bill, such as coordination of benefits, and utilization review of health care services, which includes reviews of medical necessity and care management.
Further, the bill requires medical necessity determinations and decisions regarding care management for the treatment of eating disorders to:
(1) be made with consideration given to the overall medical and mental health needs of the individual with an eating disorder;
(2) not be based solely on weight; and
(3) take into consideration the most recent Practice Guideline for the Treatment of Patients with Eating Disorders adopted by the American Psychiatric Association and current standards based upon the medical literature generally recognized as authoritative in the medical community.
The bill requires that benefits be provided to the same extent as for any other medical condition under the contract or policy.
Finally, the bill defines "eating disorder" to mean pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder, and any other eating disorder contained in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.
